ASIANA AIRLINES FLIGHT 214

DATE : JULY 6 T H 2 013 / S ITE : S AN FRAN S ISC O IN TE RN AT ION AL

AIRP ORT

ACCIDENT INFORMATION
FLIGHT FROM INCHEON INTERNATIONAL -> SAN FRANSISCO INTERNATIONAL
DATE: 6TH JULY 2013
OPERATOR: ASIANA AIRLINES / CALLSIGN: HL7742 / BOEING 777-200 ER
PAX: 291 / CREW: 16 / INJURIES: 187(NON FATAL) & 3(FATAL) / SURVIVORS 304
CAPTAIN: 12,387 Hrs (3220 Hrs -777 A/C)
COPILOT: 9,793 Hrs
COPILOT HAD CONTROLS UNDER CAPTAINS SUPERVISION

ACCIDENT SUMMARY
Asiana Airlines Flight 214 was a
scheduled transpacific passenger flight
from Incheon International Airport near
Seoul, South Korea, to San Francisco
International Airport (SFO) in the
United States. On the morning of
Saturday, July 6, 2013, the Boeing 777200ER aircraft operating the flight
crashed on final approach into SFO. Of
the 307 people aboard, three passengers
died. Another 187 individuals were
injured, 49 of them seriously. Among
the injured were three flight attendants
who were thrown onto the runway
while still strapped in their seats when
the tail section broke off after striking
the seawall short of the runway.

THE CRASH
On July 6, 2013, Flight OZ214 took off from Incheon International Airport at 08:04 UTC, 34
minutes after its scheduled departure time. It was scheduled to land at San Francisco International
Airport (SFO) at 18:04 UTC.
The flight was cleared for a visual approach to runway 28L and told to maintain a speed of 180
knots (330 km/h; 210 mph) until the aircraft was 5 miles (8.0 km) from the runway. A tower
controller acknowledged the second call from the crew when the plane was 1.5 miles (2.4 km)
away, and gave clearance to land.
The weather was very good, the latest METAR reported light wind, 10 miles (16 km) visibility,
no precipitation, and no forecast or reports of wind shear. The pilots performed a visual
approach assisted by the runway's precision approach path indicator (PAPI).

At 19:28UTC, HL7742 crashed short ofrunway 28 L'sthreshold. Thelanding

gearand then the tail struck the seawall that projects intoSan Francisco Bay.
Both engines and thetail section separated from the aircraft. The main
landing gear, the first part of the aircraft to hit the seawall, "separated
cleanly from [the] aircraft as designed".The vertical and both horizontal
stabilizers fell on the runway before the threshold.
The remainder of thefuselageand wings rotated counter-clockwise
approximately 330 degrees. It came to rest to the left of the runway, 2,400
feet (730m) from the initial point of impact at the seawall.
The fire was traced to a ruptured oil tank above the right engine. The leaking
oil fell onto the hot engine and ignited. The fire was not fed byjet fuel.

INVESTIGATION REPORT
The flight was vectored for a visual approach to runway 28L and intercepted the final approach
course about 14 nautical miles (nm) from the threshold at an altitude slightly above the desired 3
glide path. This set the flight crew up for a straight-in visual approach;
After the flight crew accepted an air traffic control instruction to maintain 180 knots to 5 nm from
the runway, the flight crew mismanaged the airplane's descent, which resulted in the airplane being
well above the desired 3 glide path when it reached the 5 nm point. The flight crew's difficulty in
managing the airplane's descent continued as the approach continued.
In an attempt to increase the airplane's descent rate and capture the desired glide path, the pilot flying
(PF) selected an autopilot (A/P) mode (flight level change speed [FLCH SPD]) that instead resulted in
the auto flight system initiating a climb because the airplane was below the selected altitude.

The PF disconnected the A/P and moved the thrust levers to idle, which caused the auto throttle (A/T) to
change to the HOLD mode, a mode in which the A/T does not control airspeed. The PF then pitched the
airplane down and increased the descent rate. Neither the PF, nor the pilot monitoring (PM), nor the observer
noted the change in A/T mode to HOLD.
As the airplane reached 500 ft above airport elevation, the point at which Asiana's procedures dictated that
the approach must be stabilized, the precision approach path indicator (PAPI) would have shown the flight
crew that the airplane was slightly above the desired glide path.
The airspeed, which had been decreasing rapidly, had just reached the proper approach speed of 137 knots.
However, the thrust levers were still at idle, and the descent rate was about 1,200 ft per minute, well above
the descent rate of about 700 fpm needed to maintain the desired glide path.
Those were two indications that the approach was not stabilized. Based on these two indications, the flight
crew should have determined that the approach was unstabilized and initiated a go-around, but they did not
do so.

As the approach continued, it became increasingly unstabilized as the airplane

descended below the desired glide path.
The PAPI displayed three and then four red lights, indicating the continuing
descent below the glide path. The decreasing trend in airspeed continued, and
about 200 ft, the flight crew became aware of the low airspeed and low path
conditions but did not initiate a go-around until the airplane was below 100 ft, at
which point the airplane did not have the performance capability to accomplish a
go-around. The flight crew's insufficient monitoring of airspeed indications
during the approach resulted from expectancy, increased workload, fatigue, and
automation reliance.

CAUSE OF ACCIDENT
The National Transportation Safety Board determines that the probable cause of this accident was
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 glide path and airspeed tolerances.
Contributing to the accident were,
The flight crew's nonstandard communication and coordination regarding the use of the auto
throttle and autopilot flight director systems

The flight crew did not consistently adhere to Asiana's SOPs involving
selections and callouts pertaining to the auto flight system's mode control panel.
The pilot flying's inadequate training on the planning and executing of visual
approaches
The pilot monitoring/instructor pilot's inadequate supervision of the pilot flying
Flight crew fatigue, which likely degraded their performance.

POINTS TO REMEMBER
STICK TO STANDARD OPERATING PROCEDURES. KNOW ALL YOU
PROCEDURES THOROUGH.
TAKE ADEQUEATE REST TO AVOID FATIGUE.
PROPER CRM TECHNIQUE.
ALWAYS MONITOR YOUR GAUGES AND INSTRUMENTS.
KNOWLEDGE ABOUT AIRCRAFT AND SYSTEMS.

THANK YOU