BOEING 777-200ER
San Francisco, CA — July 6, 2013
Event Information
| Date | July 6, 2013 |
| Event Type | ACC |
| NTSB Number | DCA13MA120 |
| Event ID | 20130707X83745 |
| Location | San Francisco, CA |
| Country | USA |
| Coordinates | 37.61333, -122.36389 |
| Airport | San Francisco International |
| Highest Injury | FATL |
Aircraft
| Make | BOEING |
| Model | 777-200ER |
| Category | AIR |
| FAR Part | 129 |
| Aircraft Damage | DEST |
Conditions
| Light Condition | DAYL |
| Weather | VMC |
Injuries
| Fatal | 3 |
| Serious | 50 |
| Minor | 137 |
| None | 117 |
| Total Injured | 190 |
Event Location
Probable Cause
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.
Full Narrative
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.
About This NTSB Record
This aviation event was investigated by the National Transportation Safety Board (NTSB). NTSB investigates all U.S. civil aviation accidents to determine probable cause and issue safety recommendations to prevent future accidents.