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National Transportation Safety Board
Aviation Accident Final Report
Location:
San Francisco, CA
Accident Number:
DCA13MA120
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
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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
Auto throttle system - Related operating info (Factor)
Personnel issues
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)
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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
Airline Transport
Age:
45
Multi-engine Land
Seat Occupied:
Left
None
Restraint Used:
Airplane
Second Pilot Present:
Yes
None
Toxicology Performed:
Class 1 Without
Waivers/Limitations
Last Medical Exam:
09/14/2012
Yes
Last Flight Review or Equivalent:
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)
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Flight Instructor Information
Airline Transport
Age:
49
Multi-engine Land
Seat Occupied:
Right
None
Restraint Used:
Airplane
Second Pilot Present:
Yes
Airplane Multi-engine
Toxicology Performed:
No
Class 1 Without
Waivers/Limitations
Last Medical Exam:
09/05/2012
Yes
Last Flight Review or Equivalent:
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)
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Meteorological Information and Flight Plan
Conditions at Accident Site:
Visual Conditions
Condition of Light:
Observation Facility, Elevation:
SFO, 13 ft msl
Observation Time:
Distance from Accident Site:
Direction from Accident Site:
Lowest Cloud Condition:
Few / 1600 ft agl
Temperature/Dew Point:
Lowest Ceiling:
None
Visibility
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:
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
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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.