On the morning of July 6, 2013, an Asiana Airlines Boeing 777 operated Flight 214 from Seoul to San Francisco. However, due to flight crew mismanagement on the final approach, the aircraft stalled and crashed in San Francisco, marking the first fatal crash of the Boeing 777 since the aircraft type entered service in 1995.
Boeing 777-200ER with registration HL7742 operated Asiana flight OZ214 from Incheon International Airport, South Korea to San Francisco International Airport, USA. Flight 214’s crew consisted of Captain Lee Jeong-min, who had a total of 12,307 flight hours, including 3,208 hours in the Boeing 777. The 49-year-old captain filled the dual roles of control/instructor captain and commanding pilot. He was accompanied by Captain Lee Kang-kuk, who had a total of 9,684 flight hours but only 33 flight hours on the type.
Captain Kuk received his first operational experience (IOE) training and was halfway through Asiana’s IOE requirements. During the crash, Captain Kuk was the Pilot Flying (PF) while Captain Min was the Pilot Supervising (PM).
Also on board the plane were detachment first officer Bong Dong-won and detachment captain Lee Jong-joo. At the time of the incident, the relieving F/O was observing from the jump seat in the cockpit, while the relieving Captain was occupying a business class seat in the passenger cabin. On board the aircraft were 291 passengers and 16 crew members, including 12 flight attendants.
That day Captain Kuk landed at San Francisco International Airport for the first time and was supervised by Captain Min, who was on his first flight as an instructor.
Approaching San Francisco
Captain Min continued uneventfully, reporting that he observed no problems with Captain Kuk’s abilities during the takeoff, climb, and cruising portions of the flight. Visual meteorological conditions prevailed and an IFR flight plan was submitted.
Flight 214 was aligned for a visual approach to San Francisco runway 28L and intercepted the final approach course approximately 14 nautical miles from the threshold at an altitude slightly higher than the desired 3° glideslope. This put the flight crew in position for a direct visual approach. However, after accepting the instruction from air traffic control to keep 180 knots within 5 nm of the runway, the flight crew made a critical error in controlling the aircraft’s descent, causing it to be well above the 5 nm point when it reached the 5 nm point desired glide path.
Despite the flight crew’s difficulties in correcting the aircraft’s altitude and acquiring the desired glideslope, they continued on the approach, but had difficulty managing the descent while the approach continued. To increase the rate of descent of the aircraft and capture the desired glideslope, the pilot flying (PF) selected an autopilot (A/P) (altitude rate of change) mode. [FLCH SPD]), but instead of descending, the automatic flight system initiated a climb since the aircraft was below the selected altitude. This caused the PF to disconnect the A/P and idle the throttles, causing the autothrottle (A/T) to enter HOLD mode, a mode in which the A/T does not control airspeed.
The PF then pitched the aircraft down and increased the rate of descent, but none of the crew members noticed the A/T mode change to HOLD.
By the time the aircraft reached 500 feet above airport altitude, Flight 214 was slightly over the desired glideslope and the approach was not being stabilized because the rate of descent was well above the required rate. Also, the airspeed had just reached the correct approach speed of 137 knots, but the throttles were still idle and the rate of descent was well in excess of the rate required to maintain the desired glideslope. Based on this information, the flight crew should have initiated a go-around, but did not do so.
As the approach continued, it became increasingly unstable as the aircraft descended below the desired glideslope. as indicated by the Precision Approach Path Indicator (PAPI) showing three and then four red lights. Despite the decreasing airspeed trend and the flight crew’s awareness of the low airspeed and trajectory conditions at about 200 feet, they did not initiate a go-around until the aircraft was below 100 feet, giving it insufficient capability to achieve a go-around.
Inadequate monitoring of airspeed indicators by the flight crew during approach was caused by a variety of factors including anticipation, increased workload, fatigue and reliance on automation. Flight 214 was less than a minute from the runway when some passengers realized something was wrong with the plane being too low.
Copilot Min: speed, speed
Copilot Min: Walk around
Copilot Min: Go around, go around
When the crew decided to fly around with the aircraft level too low due to insufficient performance, the main landing gear and rear fuselage hit the seawall. As a result, the tail unit broke off at the rear pressure bulkhead. The Boeing 777 skidded down the runway, lifted partially in the air, rotated about 330° and hit the ground one last time.
evacuation, deaths and injuries
Flight 214’s impact forces exceeded certification limits, causing two slides/rafts in the cabin to inflate and injuring two flight attendants. Six occupants were ejected from the aircraft during the impact sequence.
Among them were two fatally injured passengers and four critically injured flight attendants who were wearing their restraint belts but were ejected due to the destruction of the aft galley where they were seated. The two passengers who were ejected were not wearing their seat belts and would probably have survived had they been wearing them.
As the aircraft came to a standstill, a fire broke out in the severed right engine, which was positioned off the right side of the fuselage. One of the flight attendants spotted the fire and quickly began evacuating. Remarkably, 98% of the passengers were able to evacuate themselves. However, as the fire progressed and spread across the fuselage, firefighters had to board the plane to rescue five passengers who could not be evacuated and sustained injuries. Unfortunately, one of those passengers later died. Despite this tragedy, it is important to note that 99% of the occupants survived the accident.
Ten inmates (8 adults and 2 children) in critical condition were taken to San Francisco General Hospital and a few to Stanford Medical Center. Nine hospitals in the area admitted a total of 182 injured people.
Almost half of the flight’s passengers, 141 people, were Chinese citizens. Among those Chinese passengers were 70 students and teachers who were en route to a summer camp in the United States. Unfortunately, the three passengers who died in the incident belonged to the group from Jiangshan High School heading to West Valley Camp.
Aircraft damage and findings
The fuselage of the Boeing 777-200ER shattered into pieces after the empennage hit the seawall just short of the runway. This impact resulted in the separation of the tail section and right engine. The plane then turned and skidded down the runway before coming to a stop.
The right engine, located on the wing that struck the seawall, was severely damaged and caught fire after the plane stalled. The left engine and landing gear were also damaged. In addition, the interior of the aircraft was severely damaged by the impact forces.
Overall, the aircraft was classified as hull damage due to the extent of damage sustained. Asiana Flight 214 was the first fatal Boeing 777 crash.
The investigation into the accident was led by the National Transportation Safety Board (NTSB). The investigation concluded that the probable cause of this accident was the flight crew’s mismanagement of the descent of the aircraft during the visual approach, the inadvertent deactivation of automatic airspeed control by the PF, insufficient airspeed monitoring by the flight crew, and the flight crew’s late decision was a go-around after realizing the aircraft was below acceptable glideslope and airspeed tolerances.
The NTSB investigation identified the following contributing factors:
- The complexity of the autothrottle and autopilot flight control systems was inadequately described in Boeing documentation and Asiana pilot training, increasing the likelihood of mode errors.
- The non-standard communication and coordination of the flight crew regarding the use of the autothrottle and autopilot flight control systems.
- The insufficient training of the PF in the planning and execution of visual approaches.
- Insufficient monitoring of the PF by the PM/instructor pilot.
- Flight crew fatigue, which likely affected their performance.
Critical mismanagement of the plane’s descent and lack of attention to A/T mode ultimately led to the devastating crash of Flight 214.
After the crash, San Francisco International Airport was closed for five hours, diverting incoming flights to other nearby airports. In response to the incident, Asiana Airlines announced that it would discontinue flight numbers 214 and 213 and instead operate new flights between Incheon International Airport and San Francisco International Airport under callsigns OZ212 and OZ211, respectively.
In addition, the Korean airline pledged to improve training for pilots learning to operate new types of aircraft and improve crew communication and fatigue management to prevent similar incidents in the future.
On August 12, 2013, Asiana announced initial payouts to crash survivors of $10,000, stating that the survivors “need money to go to the hospital or for transportation, so we’re giving them the $10,000 first.” Dollar”. According to Asiana spokeswoman Lee Hyo Min, the families of the deceased were paid more than $10,000 in initial compensation.
This NTSB investigation also resulted in the formulation of safety recommendations for several organizations, including the FAA, Asiana Airlines, Boeing, the Aircraft Rescue and Firefighting Working Group, and the City and County of San Francisco.
South Korea’s Transportation Ministry officials ordered Korean Air and Asiana to inspect the engines and landing gear of all 48 of their 777 model aircraft. The officials also said the government will conduct special inspections at the eight Korean airlines.
Feature image: NTSB