National Transportation Safety Board Aviation Accident Final Report Location: San Francisco, CA Accident Number: Date & Time: 07/06/2013, 1128 PDT Registration: HL7742 Aircraft: BOEING 777-200ER Aircraft Damage: Destroyed Defining Event: Controlled flight into terr/obj (CFIT) Injuries: 3 Fatal, 50 Serious, 137 Minor, 117 None Flight Conducted Under: Part 129: Foreign Analysis The Safety Board's full report is available at http://www.ntsb.gov/investigations/accidentreports/pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-14/01. On July 6, 2013, about 1128 Pacific daylight time, a Boeing 777-200ER, Korean registration HL7742, operating as Asiana Airlines flight 214, was on approach to runway 28L when it struck a seawall at San Francisco International Airport (SFO), San Francisco, California. Three of the 291 passengers were fatally injured; 40 passengers, 8 of the 12 flight attendants, and 1 of the 4 flight crewmembers received serious injuries. The other 248 passengers, 4 flight attendants, and 3 flight crewmembers received minor injuries or were not injured. The airplane was destroyed by impact forces and a postcrash fire. Flight 214 was a regularly scheduled international passenger flight from Incheon International Airport (ICN), Seoul, Korea, operating under the provisions of 14 Code of Federal Regulations (CFR) Part 129. Visual meteorological conditions (VMC) prevailed, and an instrument flight rules (IFR) flight plan was filed. Probable Cause and Findings The National Transportation Safety Board determines the probable cause(s) of this accident to be: The flight crew's mismanagement of the airplane's descent during the visual approach, the pilot flying's unintended deactivation of automatic airspeed control, the flight crew's inadequate monitoring of airspeed, and the flight crew's delayed execution of a go-around after they became aware that the airplane was below acceptable glidepath and airspeed tolerances. Contributing to the accident were (1) the complexities of the autothrottle and autopilot flight director systems that were inadequately described in Boeing's documentation and Asiana's pilot training, which increased the likelihood of mode error; (2) the flight crew's nonstandard communication and coordination regarding the use of the autothrottle and Page 1 of 6
autopilot flight director systems; (3) the pilot flying's inadequate training on the planning and executing of visual approaches; (4) the pilot monitoring/instructor pilot's inadequate supervision of the pilot flying; and (5) flight crew fatigue, which likely degraded their performance. Findings Aircraft Personnel issues Auto throttle system - Related operating info (Factor) Incorrect action performance - Flight crew (Cause) Delayed action - Flight crew (Cause) Monitoring equip/instruments - Flight crew (Cause) Understanding/comprehension - Flight crew (Factor) Training with equipment - Pilot (Factor) Circadian rhythms or jetlag - Flight crew (Factor) Page 2 of 6
Factual Information The Safety Board's full report is available at http://www.ntsb.gov/investigations/accidentreports/pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-14/01. On July 6, 2013, about 1128 Pacific daylight time, a Boeing 777-200ER, Korean registration HL7742, operating as Asiana Airlines flight 214, was on approach to runway 28L when it struck a seawall at San Francisco International Airport (SFO), San Francisco, California. Three of the 291 passengers were fatally injured; 40 passengers, 8 of the 12 flight attendants, and 1 of the 4 flight crewmembers received serious injuries. The other 248 passengers, 4 flight attendants, and 3 flight crewmembers received minor injuries or were not injured. The airplane was destroyed by impact forces and a postcrash fire. Flight 214 was a regularly scheduled international passenger flight from Incheon International Airport (ICN), Seoul, Korea, operating under the provisions of 14 Code of Federal Regulations (CFR) Part 129. Visual meteorological conditions (VMC) prevailed, and an instrument flight rules (IFR) flight plan was filed. History of Flight Approach Controlled flight into terr/obj (CFIT) (Defining event) Pilot Information Certificate: Airline Transport Age: 45 Airplane Rating(s): Multi-engine Land Seat Occupied: Left Other Aircraft Rating(s): None Restraint Used: Instrument Rating(s): Airplane Second Pilot Present: Yes Instructor Rating(s): None Toxicology Performed: Medical Certification: Class 1 Without Waivers/Limitations Last Medical Exam: 09/14/2012 Occupational Pilot: Yes Last Flight Review or Equivalent: Flight Time: 9684 hours (Total, all aircraft), 33 hours (Total, this make and model), 3729 hours (Pilot In Command, all aircraft), 57 hours (Last 90 days, all aircraft), 57 hours (Last 30 days, all aircraft) Page 3 of 6
Flight Instructor Information Certificate: Airline Transport Age: 49 Airplane Rating(s): Multi-engine Land Seat Occupied: Right Other Aircraft Rating(s): None Restraint Used: Instrument Rating(s): Airplane Second Pilot Present: Yes Instructor Rating(s): Airplane Multi-engine Toxicology Performed: No Medical Certification: Class 1 Without Waivers/Limitations Last Medical Exam: 09/05/2012 Occupational Pilot: Yes Last Flight Review or Equivalent: Flight Time: 12307 hours (Total, all aircraft), 3208 hours (Total, this make and model), 7510 hours (Pilot In Command, all aircraft), 211 hours (Last 90 days, all aircraft), 71 hours (Last 30 days, all aircraft) Aircraft and Owner/Operator Information Aircraft Manufacturer: BOEING Registration: HL7742 Model/Series: 777-200ER Aircraft Category: Airplane Year of Manufacture: Amateur Built: No Airworthiness Certificate: Transport Serial Number: 29171 Landing Gear Type: Retractable - Tricycle Seats: 312 Date/Type of Last Inspection: 07/01/2013, Conditional Certified Max Gross Wt.: 632500 lbs Time Since Last Inspection: Engines: 2 Turbo Fan Airframe Total Time: 37111 Hours Engine Manufacturer: Pratt and Whitney ELT: Installed, activated, did not aid in locating accident Engine Model/Series: PW4090 Registered Owner: Asiana Airlines Rated Power: 90000 lbs Operator: Asiana Airlines Air Carrier Operating Certificate: Foreign Air Carrier (129) Page 4 of 6
Meteorological Information and Flight Plan Conditions at Accident Site: Visual Conditions Condition of Light: Day Observation Facility, Elevation: SFO, 13 ft msl Observation Time: 1156 PDT Distance from Accident Site: Direction from Accident Site: Lowest Cloud Condition: Few / 1600 ft agl Temperature/Dew Point: 18 C / 10 C Lowest Ceiling: None Visibility 10 Miles Wind Speed/Gusts, Direction: 7 knots, 210 Visibility (RVR): Altimeter Setting: 29.82 inches Hg Visibility (RVV): Precipitation and Obscuration: No Obscuration; No Precipitation Departure Point: Seoul, CA (ICN) Type of Flight Plan Filed: IFR Destination: San Francisco, CA (SFO) Type of Clearance: IFR Departure Time: 1000 UTC Type of Airspace: Class B Airport Information Airport: San Francisco International (SFO) Runway Surface Type: Asphalt Airport Elevation: 13 ft Runway Surface Condition: Dry Runway Used: 28L IFR Approach: Visual Runway Length/Width: 11381 ft / 200 ft VFR Approach/Landing: Wreckage and Impact Information Crew Injuries: 10 Serious, 3 Minor, 3 None Aircraft Damage: Destroyed Passenger Injuries: 3 Fatal, 40 Serious, 134 Minor, 114 None Aircraft Fire: On-Ground Ground Injuries: N/A Aircraft Explosion: None Total Injuries: 3 Fatal, 50 Serious, 137 Minor, 117 None Latitude, Longitude: 37.613333, -122.363889 (est) Administrative Information Investigator In Charge (IIC): William R English Adopted Date: 02/03/2015 Additional Participating Persons: Floyd A James; Washington, DC Publish Date: 02/03/2015 Note: The NTSB traveled to the scene of this accident. Investigation Docket: http://dms.ntsb.gov/pubdms/search/docklist.cfm?mkey=87395 Page 5 of 6
The National Transportation Safety Board (NTSB), established in 1967, is an independent federal agency mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of any part of an NTSB report related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. Page 6 of 6