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.
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 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.
Boeing 777-200 · HL7742 — 5,208,552 samples, 260 parameters, 00:38:09.0 to 11:28:01.6.
| Parameter | Max | at | Min | at | Final | at |
|---|---|---|---|---|---|---|
| Pressure altitude ft | 40,952.0 | 10:57:10.2 | -1,905.0 | 11:28:00.2 | 131.0 | 11:28:01.2 |
| Computed airspeed kts | 306.5 | 01:20:13.9 | 30.0 | 00:38:09.9 | 31.5 | 11:28:00.9 |
| Pitch attitude deg | 54.0 | 11:28:01.5 | -4.0 | 11:26:58.5 | 54.0 | 11:28:01.5 |
| Roll attitude deg | 14.4 | 01:09:05.3 | -27.4 | 00:56:02.3 | 0.0 | 11:28:01.3 |
| Vertical acceleration g | 9.0 | 11:28:01.3 | -0.9 | 11:27:50.5 | 5.0 | 11:28:01.5 |
| Engine 1 N1 %RPM | 98.4 | 11:27:51.6 | 0.0 | 00:38:09.6 | 0.0 | 11:28:00.6 |
| Engine 2 N1 %RPM | 100.0 | 11:27:54.1 | 0.0 | 00:38:09.1 | 29.9 | 11:28:01.1 |
| Time | Event | Page |
|---|---|---|
| 11:17:38 PDT | Aircraft descended through 10,000 ft at about 210 knots, 10 minutes 12 seconds before impact; flaps up, gear up, gross weight approximately 425,000 lb; autothrottle in Thrust mode, autopilot in Flight Level Change pitch mode | 7 |
| 11:18:46 PDT | Autopilot pitch mode changed to Altitude Capture, autothrottle to Speed; aircraft leveled at 9,000 ft (selected altitude) | 7 |
| 11:19:28 PDT | Selected altitude changed to 6,000 ft; about 4 seconds later pitch mode to FLCH, autothrottle to Thrust, and a series of 4 left turns began over the next four and a half minutes onto the final approach heading; thrust lever angles decreased to about 34 degrees over six seconds, then autothrottle mode changed to Hold | 7 |
| 11:21:00 PDT | Selected altitude changed to 4,000 ft; descent continued with pitch mode FLCH and autothrottle Hold | 8 |
| 11:21:03 PDT | Speed brakes extended for about 54 seconds | 8 |
| 11:22:11 PDT | Localizer mode Armed; localizer intercept indicated at 11:22:28; selected altitude to about 3,000 ft at 11:22:48; localizer capture at 11:22:51 | 8 |
| 11:23:02 PDT | Selected altitude set to about 1,800 ft; flap handle to detent 1 at 11:23:10; selected airspeed reduced from 212 to 172 knots over 35 seconds from 11:23:16; flap handle to detent 5 at 11:23:45 | 8 |
| 11:23:57 PDT | Autopilot pitch mode changed to Vertical Speed and autothrottle to Speed; airspeed about 195 knots, selected 172 knots; recorded vertical speed about -400 ft/min, selected -1000 ft/min | 8 |
| 11:24:53 PDT | Gear handle selected down, about 3 minutes before impact | 8 |
| 11:25:45 PDT | Selected altitude changed from about 1,800 ft to about 3,000 ft; radio altitude about 2,350 ft | 8 |
| 11:26:05 PDT | Flap handle set to detent 20 | 8 |
| 11:26:25 PDT | At about 1,600 ft radio altitude, pitch mode changed from Vertical Speed to FLCH and autothrottle from Speed to Thrust; the aircraft began a climb toward the selected 3,000 ft with a slight thrust increase and pitch up | 8 |
| 11:26:29 PDT | Autopilot disengaged; flight director began displaying pitch-up commands toward the selected altitude | 9 |
| 11:26:30 PDT | Flap handle set to detent 30; two seconds later autothrottle changed from Thrust to Hold after thrust lever angles returned to about 34 degrees (about 1,475 ft radio altitude) | 9 |
| 11:26:37 PDT | At about 1,400 ft radio altitude, airspeed approximately 170 knots; selected airspeed changed to 137 knots | 9 |
| 11:26:45 PDT | At about 1,240 ft radio altitude the captain's flight director switch was selected off while the first officer's remained on, and they stayed so to the end; the AFDS mode did not change again | 9 |
| 11:26:55 PDT | At about 1,000 ft radio altitude, airspeed approximately 149 knots | 9 |
| 11:27:05 PDT | Descent rate momentarily -1776 ft/min, the highest in the last 2.5 minutes; from here it gradually decreased to -608 ft/min at impact while pitch attitude increased until stick shaker activation | 9 |
| 11:27:15 PDT | At about 500 ft radio altitude, airspeed approximately 134 knots, 3 knots below the selected airspeed | 9 |
| 11:27:31 PDT | Stall protection function activated, reaching a peak value about 15 seconds later | 9 |
| 11:27:43 PDT | Seven seconds before impact, thrust levers moved forward and autothrottle changed from Hold to Thrust; radio altitude about 125 ft, airspeed approximately 112 knots | 9 |
| 11:27:47 PDT | About 3 seconds before impact: lowest airspeed of the approach, approximately 103 knots; stick shaker activated; N1 increasing through 50%; pitch about 12 degrees, the highest of the last 2.5 minutes | 9 |
| 11:27:50 PDT | All three acceleration parameters spiked, indicating initial impact; both engines N1 approximately 92% and increasing; airspeed approximately 106 knots | 10 |
| 11:28:01 PDT | Recording continued for approximately 11 seconds after impact, ending about 11:28:01 | 10 |
412 transcribed utterances from 10:42:27.9 to 11:28:00.2, 22 sources. Final entries:
| 11:27:54.3 | CAM | [sound of quadruple chime] |
| 11:27:55.4 | INT-? | ah what's happening over there? |
| 11:27:55.9 | CAM | [sound of quadruple chime] |
| 11:27:57.8 | CAM | [sound of quadruple chime] |
| 11:28:00.2 | CAM | {sound of quadruple chime] End of Transcript 11:28:01.9 [end of recording] |
Docket: data.ntsb.gov/Docket/?NTSBNumber=DCA13MA120. This brief is an analytical aid assembled from public records; it is not an investigative finding.