BOEING 777-200ERAsiana Airlines
San Francisco, CA, USA · 2013-07-06·HL7742
What happened
NTSB summary, verbatimThe 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.
Photographs
193the aircraft, and what the investigators foundPhotographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.
Probable cause
the Board's determinationThe 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.
Occurrence sequence
1 stepsNTSB coding · CICTT taxonomy- 1 · ApproachControlled flight into terr/obj (CFIT)defining event
Findings
7 causal · 8 contributing- CAUSEPersonnel issues › Action/decision › Action › Incorrect action performance — Flight crew
- CAUSEPersonnel issues › Action/decision › Action › Delayed action — Flight crew
- CAUSEPersonnel issues › Psychological › Attention/monitoring › Monitoring equip/instruments — Flight crew
- CAUSEAircraft › Aircraft systems › Auto flight system › Auto throttle system — Related operating info
- CAUSEPersonnel issues › Action/decision › Info processing/decision › Understanding/comprehension — Flight crew
- CAUSEPersonnel issues › Experience/knowledge › Training › Training with equipment — Pilot
- CAUSEPersonnel issues › Physical › Alertness/Fatigue › Circadian rhythms or jetlag — Flight crew
- FACTORNot determined › Not determined › (general) — Unknown/Not determined
- FACTORAircraft › Aircraft systems › Equipment/furnishings › Escape slide — Capability exceeded
- FACTOROrganizational issues › Management › Policy/procedure › Adequacy of policy/proc — Emergency services
- FACTOROrganizational issues › Management › Policy/procedure › Availability of policy/proc — Emergency services
- FACTORAircraft › Aircraft systems › Equipment/furnishings › Passenger compartment equip — Not used/operated
- FACTOROrganizational issues › Management › Resources › Availability of personnel — Emergency services
- FACTOROrganizational issues › Support/oversight/monitoring › Training — Emergency services
- FACTOREnvironmental issues › Operating environment › Communication system — Not specified
Safety recommendations
27 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Require Boeing to develop enhanced 777 training that will improve flight crew understanding of autothrottle modes and automatic activation system logic through improved documentation, courseware, and instructor training.
TO THE FEDERAL AVIATION ADMINISTRATION: Once the enhanced Boeing 777 training has been developed, as requested in Safety Recommendation A-14-37, require operators and training providers to provide this training to 777 pilots.
TO THE FEDERAL AVIATION ADMINISTRATION: Require Boeing to revise its 777 Flight Crew Training Manual stall protection demonstration to include an explanation and demonstration of the circumstances in which the autothrottle does not provide low speed protection.
TO THE FEDERAL AVIATION ADMINISTRATION: Once the revision to the Boeing 777 Flight Crew Training Manual has been completed, as requested in Safety Recommendation A-14-39, require operators and training providers to incorporate the revised stall protection demonstration in their training.
TO THE FEDERAL AVIATION ADMINISTRATION: Convene an expert panel (including members with expertise in human factors, training, and flight operations) to evaluate methods for training flight crews to understand the functionality of automated systems for flightpath management, identify the most effective training methods, and revise training guidance for operators in this area.
TO THE FEDERAL AVIATION ADMINISTRATION: Convene a special certification design review of how the Boeing 777 automatic flight control system controls airspeed and use the results of that evaluation to develop guidance that will help manufacturers improve the intuitiveness of existing and future interfaces between flight crews and autoflight systems.
TO THE FEDERAL AVIATION ADMINISTRATION: Task a panel of human factors, aviation operations, and aircraft design specialists, such as the Avionics Systems Harmonization Working Group, to develop design requirements for context-dependent low energy alerting systems for airplanes engaged in commercial operations.
TO THE FEDERAL AVIATION ADMINISTRATION: Conduct research that examines the injury potential to occupants in accidents with significant lateral forces, and if the research deems it necessary, implement regulations to mitigate the hazards identified.
TO THE FEDERAL AVIATION ADMINISTRATION: Conduct research to identify the mechanism that produces high thoracic spinal injuries in commercial aviation accidents, and if the research deems it necessary, implement regulations to mitigate the hazards identified.
TO THE FEDERAL AVIATION ADMINISTRATION: Analyze, in conjunction with slide/raft manufacturers, the information obtained in this accident investigation and evaluate the adequacy of slide and slide/raft certification standards and test methods specified in Federal Aviation Administration regulations and guidance materials. If appropriate, modify certification standards and test methods for future slide and slide/raft design based on the results of this evaluation.
TO THE FEDERAL AVIATION ADMINISTRATION: Work with the Aircraft Rescue and Firefighting Working Group and equipment manufacturers to develop and distribute more specific policies and guidance about when, how, and where to use the high-reach extendable turret’s unique capabilities.
TO THE FEDERAL AVIATION ADMINISTRATION: Once the minimum staffing level has been developed by the Aircraft Rescue and Firefighting (ARFF) Working Group, as requested in Safety Recommendation A-14-60, amend 14 Code of Federal Regulations 139.319(j) to require a minimum ARFF staffing level that would allow exterior firefighting and rapid entry into an airplane to perform interior firefighting and rescue of passengers and crewmembers.
TO THE FEDERAL AVIATION ADMINISTRATION: Work with the Aircraft Rescue and Firefighting (ARFF) Working Group to develop and distribute policy guidance and training materials to ensure that all airport and mutual aid firefighting officers placed in command at the scene of an aircraft accident have at least a minimum level of ARFF training.
TO THE FEDERAL AVIATION ADMINISTRATION: Issue a CertAlert to all Part 139 airports to distribute the information contained in the Federal Aviation Administration’s (FAA) legal interpretation of 14 Code of Federal Regulations 139.319 that requires all personnel assigned to aircraft rescue and firefighting duties to meet the initial and recurrent training and live-fire drill requirements and clarify how the FAA will enforce this regulation.
TO THE FEDERAL AVIATION ADMINISTRATION: Conduct a special inspection of San Francisco International Airport’s emergency procedures manual and work closely with the airport to ensure that the airport meets its obligations under Part 139.325.
TO ASIANA AIRLINES, INC.: Reinforce, through your pilot training programs, flight crew adherence to standard operating procedures involving making inputs to the operation of autoflight system controls on the Boeing 777 mode control panel and the performance of related callouts.
TO ASIANA AIRLINES, INC.: Revise your flight instructor operating experience (OE) qualification criteria to ensure that all instructor candidates are supervised and observed by a more experienced instructor during OE or line training until the new instructor demonstrates proficiency in the instructor role.
TO ASIANA AIRLINES, INC.: Issue guidance in the Boeing 777 Pilot Operating Manual that after disconnecting the autopilot on a visual approach, if flight director guidance is not being followed, both flight director switches should be turned off.
TO ASIANA AIRLINES, INC.: Modify your automation policy to provide for more manual flight, both in training and in line operations, to improve pilot proficiency.
TO THE BOEING COMPANY: Revise the Boeing 777 Flight Crew Operating Manual to include a specific statement that when the autopilot is off and both flight director switches are turned off, the autothrottle mode goes to speed (SPD) mode and maintains the mode control panel-selected speed.
TO THE BOEING COMPANY: Using the guidance developed by the low energy alerting system panel created in accordance with Safety Recommendation A-14-43, develop and evaluate a modification to Boeing wide-body automatic flight control systems to help ensure that the aircraft energy state remains at or above the minimum desired energy condition during any portion of the flight.
TO THE AIRCRAFT RESCUE AND FIREFIGHTING WORKING GROUP: Work with the Federal Aviation Administration and equipment manufacturers to develop and distribute more specific policies and guidance about when, how, and where to use the high-reach extendable turret’s unique capabilities.
TO THE AIRCRAFT RESCUE AND FIREFIGHTING WORKING GROUP: Work with medical and medicolegal professional organizations to develop and distribute guidance on task prioritization for responding aircraft rescue and firefighting (ARFF) personnel that includes recommended best practices to avoid striking or rolling over seriously injured or deceased persons with ARFF vehicles in a mass casualty situation.
TO THE AIRCRAFT RESCUE AND FIREFIGHTING WORKING GROUP: Develop a minimum aircraft rescue and firefighting staffing level that would allow exterior firefighting and rapid entry into an airplane to perform interior firefighting and rescue of passengers and crewmembers.
TO THE AIRCRAFT RESCUE AND FIREFIGHTING WORKING GROUP: Develop and distribute, in conjunction with the Federal Aviation Administration, guidance and training materials to ensure that all airport and mutual aid firefighting officers placed in command at the scene of an aircraft accident have at least a minimum level of aircraft rescue and firefighting training.
TO THE CITY OF SAN FRANCISCO: Routinely integrate the use of all San Francisco Fire Department medical and firefighting vehicles in future disaster drills and preparatory exercises.
TO THE CITY OF SAN FRANCISCO: Implement solutions to the communications deficiencies identified in ICF International’s after-action report as soon as practicable.
Sequence of events
24 timed eventsfrom the FDR factual report · claude-fable-5-1 (in-session)- 11:17:38 PDTdescentp.7Aircraft 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
- 11:18:46 PDTdescentp.7Autopilot pitch mode changed to Altitude Capture, autothrottle to Speed; aircraft leveled at 9,000 ft (selected altitude)
- 11:19:28 PDTdescentp.7Selected 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
- 11:21:00 PDTdescentp.8Selected altitude changed to 4,000 ft; descent continued with pitch mode FLCH and autothrottle Hold
- 11:21:03 PDTdescentp.8Speed brakes extended for about 54 seconds
- 11:22:11 PDTapproachp.8Localizer 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
- 11:23:02 PDTapproachp.8Selected 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
- 11:23:57 PDTapproachp.8Autopilot 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
- 11:24:53 PDTapproachp.8Gear handle selected down, about 3 minutes before impact
- 11:25:45 PDTapproachp.8Selected altitude changed from about 1,800 ft to about 3,000 ft; radio altitude about 2,350 ft
- 11:26:05 PDTapproachp.8Flap handle set to detent 20
- 11:26:25 PDTapproachp.8At 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
- 11:26:29 PDTapproachp.9Autopilot disengaged; flight director began displaying pitch-up commands toward the selected altitude
- 11:26:30 PDTapproachp.9Flap 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)
- 11:26:37 PDTapproachp.9At about 1,400 ft radio altitude, airspeed approximately 170 knots; selected airspeed changed to 137 knots
- 11:26:45 PDTapproachp.9At 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
- 11:26:55 PDTfinal approachp.9At about 1,000 ft radio altitude, airspeed approximately 149 knots
- 11:27:05 PDTfinal approachp.9Descent 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
- 11:27:15 PDTfinal approachp.9At about 500 ft radio altitude, airspeed approximately 134 knots, 3 knots below the selected airspeed
- 11:27:31 PDTfinal approachp.9Stall protection function activated, reaching a peak value about 15 seconds later
- 11:27:43 PDTfinal approachp.9Seven seconds before impact, thrust levers moved forward and autothrottle changed from Hold to Thrust; radio altitude about 125 ft, airspeed approximately 112 knots
- 11:27:47 PDTfinal approachp.9About 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
- 11:27:50 PDTimpactp.10All three acceleration parameters spiked, indicating initial impact; both engines N1 approximately 92% and increasing; airspeed approximately 106 knots
- 11:28:01 PDTimpactp.10Recording continued for approximately 11 seconds after impact, ending about 11:28:01
NTSB analysis
from the final reportThe 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.