National Transportation Safety Board
Aviation Accident Final Report
Controlled flight into terr/obj
(CFIT)
3 Fatal, 50 Serious,
137 Minor, 117 None
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