Asiana Airlines Flight 214
   HOME

TheInfoList



OR:

Asiana Airlines Flight 214 was a scheduled transpacific passenger flight originating from
Incheon International Airport Incheon International Airport is the main international airport serving Seoul, the capital of South Korea. It is also one of the largest and busiest airports in the world. This airport opened for business on 29 March 2001, to replace the old ...
near
Seoul Seoul, officially Seoul Special Metropolitan City, is the capital city, capital and largest city of South Korea. The broader Seoul Metropolitan Area, encompassing Seoul, Gyeonggi Province and Incheon, emerged as the world's List of cities b ...
, South Korea, to
San Francisco International Airport San Francisco International Airport is the primary international airport for the San Francisco Bay Area in the U.S. state of California. Owned and operated by the City and County of San Francisco, the airport has a San Francisco mailing ...
near
San Francisco San Francisco, officially the City and County of San Francisco, is a commercial, Financial District, San Francisco, financial, and Culture of San Francisco, cultural center of Northern California. With a population of 827,526 residents as of ...
, California, United States. On the morning of July 6, 2013, the
Boeing 777-200ER The Boeing 777, commonly referred to as the Triple Seven, is an American long-range wide-body airliner developed and manufactured by Boeing Commercial Airplanes. The 777 is the world's largest twinjet and the most-built wide-body airliner. ...
operating the flight crashed on final approach into
San Francisco International Airport San Francisco International Airport is the primary international airport for the San Francisco Bay Area in the U.S. state of California. Owned and operated by the City and County of San Francisco, the airport has a San Francisco mailing ...
in the United States. Of the 307 people on board, 3 of them were killed; another 187 occupants were injured, 49 of them seriously. Among the seriously injured were four flight attendants who were thrown onto the runway while still strapped in their seats when the tail section broke off after striking the
seawall A seawall (or sea wall) is a form of coastal defense constructed where the sea, and associated coastal processes, impact directly upon the landforms of the coast. The purpose of a seawall is to protect areas of human habitation, conservation, ...
short of the runway. This was the first fatal crash of a Boeing 777 since the aircraft type entered service in 1995, and the first fatal crash of a passenger airliner on U.S. soil since the crash of
Colgan Air Flight 3407 Colgan Air Flight 3407 was a scheduled passenger flight from Newark, New Jersey, to Buffalo, New York, on February 12, 2009. Approaching Buffalo, the aircraft, a Bombardier Q400, entered an aerodynamic stall from which it did not recover and ...
in 2009. The investigation by the U.S.
National Transportation Safety Board The National Transportation Safety Board (NTSB) is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and inci ...
(NTSB) concluded that the accident was caused by the flight crew's mismanagement of the airplane's final approach. Deficiencies in Boeing's documentation of complex flight control systems and in
Asiana Airlines Asiana Airlines Inc. ( ) is a South Korean airline headquartered in Seoul.Home
." Asiana Airlines. Retrieved 13 September 2 ...
' pilot training were also cited as contributory factors.


Background


Aircraft

The Boeing 777-28EER involved, MSN 29171, registered as HL7742, was powered by two Pratt and Whitney PW4090 engines. The aircraft was manufactured in 2006 and was delivered to
Asiana Airlines Asiana Airlines Inc. ( ) is a South Korean airline headquartered in Seoul.Home
." Asiana Airlines. Retrieved 13 September 2 ...
on March 7, 2006. At the time of the accident, the plane had accumulated 37,120 flight hours and 5,388 takeoff-and-landing cycles. This was the 777's first fatal accident, second crash (after British Airways Flight 38), and third
hull loss A hull loss is an aviation accident that damages the aircraft beyond economic repair, resulting in a total loss. The term also applies to situations where the aircraft is missing, the search for its wreckage is terminated, or the wreckage is ...
since it began operating commercially in 1995.


Crew and passengers


Crew

The
aircrew Aircrew are personnel who operate an aircraft while in flight. The composition of a flight's crew depends on the type of aircraft, plus the flight's duration and purpose. Commercial aviation Flight deck positions In commercial aviatio ...
consisted of three captains and one first officer. Captain Lee Jeong-min, 49 years old, was in the right seat (first officer position) and filled the dual role of a check/instructor captain. As
pilot in command The pilot in command (PIC) of an aircraft is the person aboard an aircraft who is ultimately responsible for its operation and safety during flight. This would be the captain in a typical two- or three- pilot aircrew, or "pilot" if there is only ...
, he was responsible for the safe operation of the flight. He had 12,387 hours of flying experience, of which 3,220 hours were in a 777. This was his first flight as an instructor. Lee Kang-kook, 45 years old, was in the left seat (captain position) and was the
pilot flying In commercial aviation with a two-person flight crew, the pilot flying (PF) is the pilot operating the flight controls of the aircraft. The other pilot is referred to as the pilot monitoring (PM) or pilot not flying (PNF). Before a flight departs, ...
. He was receiving his initial operating experience (IOE) training and was halfway through Asiana's IOE requirements. He had 9,793 hours of flying experience, of which 43 were in a 777 over nine flights operating the controls under the supervision of the instructor captain in the right seat. At the time of the crash, relief first officer Bong Dong-won, 40 years old, was observing from the cockpit
jump seat A jump seat (sometimes spelled jumpseat) is an auxiliary seat in an automobile, train or aircraft, typically folding or spring-loaded to collapse out of the way when not used. The term originated in the United States c. 1860 for a movable car ...
. He had 4,557 hours of flying experience, of which 715 hours were in a 777. Relief Captain Lee Jong-joo, 52 years old, occupied a business-class seat in the passenger cabin. After the crash, Bong Dong-won received medical treatment for a cracked rib; none of the other pilots needed hospital care. Four
flight attendant A flight attendant is a member of the aircrew whose primary responsibility is ensure the safety of passengers in the cabin of an aircraft across all stages of flight. Their secondary duty is to see to the comfort of passengers. Flight attenda ...
s seated at the rear were ejected from the aircraft when the tail section broke off, but they survived. Twelve flight attendants were on board, ten South Korean and two Thai. Six flight attendants received physical and emotional treatment. The other six returned to South Korea.


Passengers

Wang Linjia and Ye Mengyuan, both Chinese nationals, were found dead outside the aircraft soon after the crash after having been ejected from the plane during the crash. Neither victim were wearing their seatbelts. Experts concluded Wang and Ye likely would have survived the plane crash had they been wearing their seatbelts. On July 19, 2013, the San Mateo County Coroner's office initially determined that Ye was still alive when she was run over by a
rescue vehicle A rescue vehicle is a specialized vehicle designed to transport and provide the equipment necessary for technical rescue. Vehicles carry an array of special equipment such as the jaws of life, wooden Cribbing (rescue), cribbing, Electric gene ...
and was killed from the resulting traumas. However, additional investigations later concluded Ye was already dead from severe injuries being ejected from the aircraft. A third passenger, Liu Yipeng, died of her injuries at
San Francisco General Hospital The Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) is a public hospital in San Francisco, California, under the purview of the city's Department of Public Health. It serves as the only Level I trauma c ...
six days after the accident. Liu had been wearing her seatbelt while seated in 42A, which is on the last row of passenger seats on the left side of the aircraft, immediately ahead of door 4L. During the crash, the back of Liu's seat rotated back and against the floor, leaving her exposed. Her injuries were likely the result of having been struck by door 4L, which separated during the airplane's final impact. Ten people in critical condition were admitted at San Francisco General Hospital and a few were sent to Stanford Medical Center. Nine hospitals in the area admitted a total of 182 injured people. San Francisco Fire Department chief Joanne Hayes-White, after checking with two intake points at the airport, told reporters that all on board had been accounted for. Of the passengers, 141 (almost half) were Chinese citizens. More than 90 of them had boarded Asiana Airlines Flight 362 from
Shanghai Pudong International Airport Shanghai Pudong International Airport is one of the two international airports serving Shanghai, China. Pudong Airport serves both international flights and a smaller number of domestic flights, while the city's other major airport, Shanghai ...
, connecting to Flight 214 at Incheon. Incheon serves as a major connecting point between China and North America. In July 2013, Asiana Airlines operated between Incheon (Seoul) and 21 cities in mainland China. Seventy students and teachers traveling to the United States for
summer camp A summer camp, also known as a sleepaway camp or residential camp, is a supervised overnight program for children conducted during the summer vacation from school in many countries. Children and adolescents who attend summer residential camps ...
were among the Chinese passengers. Thirty of the students and teachers were from
Shanxi Shanxi; Chinese postal romanization, formerly romanised as Shansi is a Provinces of China, province in North China. Its capital and largest city of the province is Taiyuan, while its next most populated prefecture-level cities are Changzhi a ...
, and the others were from
Zhejiang ) , translit_lang1_type2 = , translit_lang1_info2 = ( Hangzhounese) ( Ningbonese) (Wenzhounese) , image_skyline = 玉甑峰全貌 - panoramio.jpg , image_caption = View of the Yandang Mountains , image_map = Zhejiang i ...
. Five of the teachers and 29 of the students were from Jiangshan High School in Zhejiang; they were traveling together. Thirty-five of the students were to attend a West Valley Christian School summer camp. The Shanxi students originated from
Taiyuan Taiyuan; Mandarin pronunciation: (Jin Chinese, Taiyuan Jin: /tʰai˦˥ ye˩˩/) is the capital of Shanxi, China. Taiyuan is the political, economic, cultural and international exchange center of Shanxi Province. It is an industrial base foc ...
, with 22 students and teachers from the Taiyuan Number Five Secondary School and 14 students and teachers from the Taiyuan Foreign Language School. The three passengers who died were in the Jiangshan High School group to West Valley camp.


Accident

On July 6, 2013, Flight OZ214 took off from
Incheon International Airport Incheon International Airport is the main international airport serving Seoul, the capital of South Korea. It is also one of the largest and busiest airports in the world. This airport opened for business on 29 March 2001, to replace the old ...
(ICN) at 5:04 p.m. KST (08:04
UTC Coordinated Universal Time (UTC) is the primary time standard globally used to regulate clocks and time. It establishes a reference for the current time, forming the basis for civil time and time zones. UTC facilitates international communica ...
), 34 minutes after its scheduled departure time. It was scheduled to land at
San Francisco International Airport San Francisco International Airport is the primary international airport for the San Francisco Bay Area in the U.S. state of California. Owned and operated by the City and County of San Francisco, the airport has a San Francisco mailing ...
(SFO) at 11:04 a.m. PDT (18:04 UTC). The flight was uneventful until its landing. The instrument landing system's (ILS) vertical guidance (glide slope) on Runway 28L was unavailable, as it had been taken out of service on June 1. A notice to airmen to that effect had been issued. Therefore, a precision ILS approach to the runway was not possible. The flight was cleared for a
visual approach In aviation, a visual approach is an approach to a runway at an airport conducted under instrument flight rules (IFR) but where the pilot proceeds by visual reference and clear of clouds to the airport. The pilot must at all times have either th ...
to Runway 28L at 11:21 a.m. PDT and was told to maintain a speed of until the aircraft was from the runway. At 11:26 a.m., Northern California TRACON ("NorCal Approach") handed the flight off to San Francisco tower. A tower controller acknowledged the second call from the crew at 11:27 a.m. when the plane was away and gave clearance to land. The weather was very good; the latest
METAR METAR is a format for reporting weather information. A METAR weather report is predominantly used by aircraft pilots, and by meteorologists, who use aggregated METAR information to assist in weather forecasting. Raw METAR is highly standardize ...
reported light wind,
visibility In meteorology, visibility is the measure of the distance at which an object or light can be clearly discerned. It depends on the Transparency and translucency, transparency of the surrounding air and as such, it is unchanging no matter the amb ...
(the maximum it can report), no precipitation, and no forecast or reports of
wind shear Wind shear (; also written windshear), sometimes referred to as wind gradient, is a difference in wind speed and/or direction over a relatively short distance in the atmosphere. Atmospheric wind shear is normally described as either vertical ...
. The pilots performed a
visual approach In aviation, a visual approach is an approach to a runway at an airport conducted under instrument flight rules (IFR) but where the pilot proceeds by visual reference and clear of clouds to the airport. The pilot must at all times have either th ...
assisted by the runway's
precision approach path indicator A precision approach path indicator (PAPI) is a system of Electric light, lights on the side of an airport runway threshold that provides visual descent (aircraft), descent guidance information during final approach. It is generally located on ...
(PAPI). Preliminary analysis indicated that the plane's approach was too slow and too low. Eighty-two seconds before impact, at an altitude of about , the autopilot was turned off, the throttles were set to idle, and the plane was operated manually during final descent. NTSB chairman Deborah Hersman stated the pilots did not "set the aircraft for an auto-land situation ... They had been cleared for a visual approach and they were hand-flying the airplane", adding: "During the approach there were statements made in the cockpit first about being above the glide path, then about being on the glide path, then later reporting about being below the glide path. All of these statements were made as they were on the approach to San Francisco..." Based on preliminary data from the flight data recorder (FDR), the NTSB found that the plane's airspeed on final approach had fallen well below its target approach speed. A preliminary review of FAA radar return data did not show an abnormally steep descent curve, although the crew did recognize that they began high on the final approach. At a height of , eight seconds before impact, the airspeed had dropped to . According to initial reports from the cockpit crew, the plane's autothrottle was set for the correct reference speed, but until the runway's precision approach path indicator (PAPI) showed them significantly below the glide path, the pilots were unaware that the autothrottle was failing to maintain that speed. The instructor pilot stated that the PAPI indicated a deviation below the glide path at approximately above ground level, and he attempted to correct it at that time. Between , the instructor pilot also reported a lateral deviation that the crew attempted to correct. Seven seconds before impact, one pilot called for an increase in speed. The FDR showed the throttles were advanced from idle at that time. The instructor pilot reported that he had called for an increase in speed, but that the pilot flying had already advanced the throttles by the time that he reached for the throttles. The sound of the
stick shaker Stick, sticks or the stick may refer to: Thin elongated objects * Twig or branch * Walking stick, a device to facilitate balancing while walking * Shepherd's crook * Shillelagh * Swagger stick * Digging stick * Swizzle stick, used to stir drinks ...
(warning of imminent stall) could be heard four seconds before impact on the cockpit voice recorder. Airspeed reached a minimum of (34 knots below the target speed) three seconds before impact, with engines at 50% power and increasing. The co-pilot called for a go-around 1.5 seconds before impact. At impact, airspeed had increased to . At 11:28 a.m., the plane crashed short of Runway 28L's threshold. The
landing gear Landing gear is the undercarriage of an aircraft or spacecraft that is used for taxiing, takeoff or landing. For aircraft, it is generally needed for all three of these. It was also formerly called ''alighting gear'' by some manufacturers, s ...
and tail struck the seawall that projects into
San Francisco Bay San Francisco Bay (Chochenyo language, Chochenyo: 'ommu) is a large tidal estuary in the United States, U.S. state of California, and gives its name to the San Francisco Bay Area. It is dominated by the cities of San Francisco, California, San ...
. The left engine and the tail section separated from the aircraft. The NTSB noted that the main landing gear, the first part of the aircraft to hit the seawall, "separated cleanly from heaircraft as designed" to protect the wing fuel tank structure. The vertical and both horizontal stabilizers fell on the runway before the threshold. The remainder of the
fuselage The fuselage (; from the French language, French ''fuselé'' "spindle-shaped") is an aircraft's main body section. It holds Aircrew, crew, passengers, or cargo. In single-engine aircraft, it will usually contain an Aircraft engine, engine as wel ...
and wings rotated counter-clockwise approximately 330 degrees as the plane slid westward. Video showed it pivoting about the wing and the nose while sharply inclined to the ground. It came to rest to the left of the runway, from the initial point of impact at the seawall. After a minute or so, a dark plume of smoke was observed rising from the wreckage. 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 by
jet fuel Jet fuel or aviation turbine fuel (ATF, also abbreviated avtur) is a type of aviation fuel designed for use in aircraft powered by Gas turbine, gas-turbine engines. It is colorless to straw-colored in appearance. The most commonly used fuels for ...
. All three fire handles were extended; these operate safety equipment intended to extinguish fires on the aircraft (a handle for each engine and the
auxiliary power unit An auxiliary power unit (APU) is a device on a vehicle that provides energy for functions other than propulsion. They are commonly found on large aircraft and naval ships as well as some large land vehicles. Aircraft APUs generally produce 115&n ...
). The speedbrake lever was down, showing that it was not being used. Two
evacuation slide An evacuation slide is an inflatable slide used to evacuate an aircraft quickly. An escape slide is required on all commercial (passenger carrying) aircraft where the door sill height is such that, in the event of an evacuation, passengers would ...
s were deployed on the left side of the airliner and used for evacuation. Despite damage to the aircraft, "many ... were able to walk away on their own." The slides for the first and second doors on the right side of the aircraft (doors 1R and 2R) deployed inside the aircraft during the crash, pinning the flight attendants seated nearby. According to
NBC The National Broadcasting Company (NBC) is an American commercial broadcast television and radio network serving as the flagship property of the NBC Entertainment division of NBCUniversal, a subsidiary of Comcast. It is one of NBCUniversal's ...
reports in September 2013, the U.S. government had been concerned about the reliability of evacuation slides for decades: "Federal safety reports and government databases reveal that the NTSB has recommended multiple improvements to escape slides and that the Federal Aviation Administration has collected thousands of complaints about them." Two months before the accident at SFO, the FAA issued an airworthiness directive ordering inspection of the slide-release mechanism on certain Boeing 777 aircraft in order to detect and correct corrosion that might interfere with slide deployment. This was the third fatal crash in Asiana's 25-year history.


Survivor and eyewitness accounts

Several passengers recalled noticing the plane's unusual proximity to the water on final approach, which caused water to thrust upward as the engines were spooling up in the final seconds before impact. In the initial moments after the crash, the cockpit crew told flight attendants to delay evacuating the aircraft as they were communicating with the tower. A flight attendant seated at the second door on the left side (door 2L) observed fire outside the aircraft near row 10 and informed the cockpit crew, and the evacuation order was then given, approximately 90 seconds after the aircraft had come to rest. Flight attendants told NTSB investigators that there was no fire inside the cabin when the evacuation began. The crew also helped several passengers who were unable to escape on their own, and a pilot carried out one passenger with an injured leg. One flight attendant said that many Chinese passengers who sat at the back of the plane near the third exit were not aware of the evacuation. During the evacuation, a pilot used an extinguisher on a fire that had penetrated from the exterior to the inside of the cabin. During the crash, two of the evacuation slides inflated into the cabin. One slide blocked the forward right exit and nearly suffocated a flight attendant before being deflated by a pilot with an
axe An axe (; sometimes spelled ax in American English; American and British English spelling differences#Miscellaneous spelling differences, see spelling differences) is an implement that has been used for thousands of years to shape, split, a ...
from the cockpit. The second chute expanded toward the center of the aircraft near the fire. It trapped a second flight attendant until a pilot deflated it with a
table knife A table knife is an item of cutlery with a single cutting edge, and a blunt end – part of a table setting. Table knives are typically of moderate sharpness only, designed to cut prepared and cooked food. History In early periods in the We ...
. Some passengers sitting at the rear of the aircraft escaped through the hole left by the missing tail section. Eyewitnesses to the crash included the cockpit crew and many passengers on board
United Airlines United Airlines, Inc. is a Major airlines of the United States, major airline in the United States headquartered in Chicago, Chicago, Illinois that operates an extensive domestic and international route network across the United States and six ...
Flight 885, a
Boeing 747-400 The Boeing 747-400 is a large, long-range wide-body airliner produced by Boeing Commercial Airplanes, an advanced variant of the initial Boeing 747. The ''Advanced Series 300'' was announced at the September 1984 Farnborough Airshow, target ...
that was holding on Taxiway F, next to the runway. Others saw it from the terminal and near the airport. At least one person recorded it on video. Writing on the Professional Pilots Rumour Network internet forum, the first officer of UA 885 described what he saw: Passengers and others praised the flight attendants' conduct after the crash. Lee Yoon-hye, the aircraft's cabin manager (the chief flight attendant) was the last to leave the burning plane. San Francisco fire chief Hayes-White praised Lee's courage, saying, "She wanted to make sure that everyone was off. ... She was a hero." A firefighter who entered the cabin said that the back of the plane had suffered structural damage, but that the seats near the front "were almost pristine" before the cabin fire.


Investigation

The National Transportation Safety Board (NTSB) sent a team of 20 to the scene to investigate. On July 7, 2013, NTSB investigators recovered the
flight data recorder A flight recorder is an electronic recording device placed in an aircraft for the purpose of facilitating the investigation of aviation accidents and incidents. The device may often be referred to colloquially as a "black box", an outdated nam ...
and
cockpit voice recorder A flight recorder is an electronic recording device placed in an aircraft for the purpose of facilitating the investigation of aviation accidents and incidents. The device may often be referred to colloquially as a "black box", an outdated nam ...
and transported them to
Washington, D.C. Washington, D.C., formally the District of Columbia and commonly known as Washington or D.C., is the capital city and federal district of the United States. The city is on the Potomac River, across from Virginia, and shares land borders with ...
, for analysis. Additional parties to the investigation include the
Federal Aviation Administration The Federal Aviation Administration (FAA) is a Federal government of the United States, U.S. federal government agency within the United States Department of Transportation, U.S. Department of Transportation that regulates civil aviation in t ...
, airframe manufacturer
Boeing The Boeing Company, or simply Boeing (), is an American multinational corporation that designs, manufactures, and sells airplanes, rotorcraft, rockets, satellites, and missiles worldwide. The company also provides leasing and product support s ...
, engine manufacturer
Pratt & Whitney Pratt & Whitney is an American aerospace manufacturer with global service operations. It is a subsidiary of RTX Corporation (formerly Raytheon Technologies). Pratt & Whitney's aircraft engines are widely used in both civil aviation (especially ...
, and the Korean
Aviation and Railway Accident Investigation Board The Aviation and Railway Accident Investigation Board (ARAIB, ) is an agency of the South Korean government that investigates aviation and railway accidents, subservient to the Ministry of Land, Infrastructure and Transport (MOLIT) and headquart ...
(ARAIB). ARAIB's technical adviser is Asiana Airlines. Hersman said that the NTSB conducted a four-hour interview with each pilot, adding that the pilots were open and cooperative. She said both pilots at the controls had ample rest before they left South Korea and during the flight when they were relieved by the backup crew. All three pilots told NTSB investigators that they were relying on the 777's automated devices for speed control during final descent. The relief first officer also stated to NTSB investigators that he had called out " sink rate" to call attention to the rate at which the plane was descending during the final approach. This "sink rate" warning was repeated several times during the last minute of the descent. ARAIB tested the pilots for drug use four weeks after the accident; the tests proved negative. The NTSB's investigative team completed the examination of the airplane wreckage and runway. The wreckage was removed to a secure storage location at San Francisco International Airport. The Airplane Systems, Structures, Powerplants, Airplane Performance, and Air Traffic Control investigative groups completed their on-scene work. The Flight Data Recorder and Cockpit Voice Recorder groups completed their work in Washington. The Survival Factors/Airport group completed their interviews of the
first responders A first responder is a person with specialized training who is among the first to arrive and provide assistance or incident resolution at the scene of an emergency. First responders typically include law enforcement officers (commonly known as ...
. The next phase of the investigation included additional interviews, examination of the evacuation slides and other airplane components, and a more detailed analysis of the airplane's performance. Based on a preliminary review of FDR data, the NTSB stated there was no anomalous behavior of the engines, the autopilot, the flight director, or the autothrottle. The autothrottle control was found to be in the "armed" position during documentation of cockpit levers and switches, differing from both the "on" and "off" positions. Furthermore, the pilot flying's flight director was ''deactivated'' whereas the instructor pilot's was ''activated''. Significantly, deactivating neither or both flight directors enables and ''forces'' an autothrottle "wake-up" whereas deactivating only one flight director ''inhibits'' an autothrottle "wake-up". Hersman said: "In this flight, in the last 2.5 minutes of the flight, from data on the flight data recorder we see multiple autopilot modes and multiple autothrottle modes ... We need to understand what those modes were, if they were commanded by pilots, if they were activated inadvertently, if the pilots understood what the mode was doing." Hersman has repeatedly emphasized it is the pilot's responsibility to monitor and maintain correct approach speed and that the crew's actions in the cockpit are the primary focus of the investigation. The final report into the crash was released on June 24, 2014. The NTSB found that the "Mismanagement of Approach and Inadequate Monitoring of Airspeed led to the Crash of Asiana flight 214". The NTSB determined that the flight crew mismanaged the initial approach and that the airplane was well above the desired glidepath. In response, the captain selected an inappropriate autopilot mode (FLCH, or Flight Level Change) which resulted in the autothrottle no longer controlling airspeed. The aircraft then descended below the desired glidepath with the crew unaware of the decreasing airspeed. The attempted go-around was conducted below 100 feet, by which time it was too late. Over-reliance on automation and lack of systems understanding by the pilots were cited as major factors contributing to the accident. The NTSB further determined that the pilot's faulty mental model of the airplane's automation logic led to his inadvertent deactivation of automatic airspeed control. In addition, Asiana's automation policy emphasized the full use of all automation and did not encourage manual flight during line operations. The flight crew's mismanagement of the airplane's vertical profile during the initial approach led to a period of increased workload that reduced the monitoring pilot's awareness of the flying pilot's actions around the time of the unintended deactivation of automatic airspeed control. Insufficient flight crew monitoring of airspeed indications during the approach likely resulted from expectancy, increased workload, fatigue, and automation reliance. Lack of compliance with
standard operating procedure A standard operating procedure (SOP) is a set of step-by-step instructions compiled by an organization to help workers carry out routine operations. SOPs aim to achieve efficiency, quality output, and uniformity of performance, while reducing mis ...
s and crew resource management were cited as additional factors. The NTSB reached the following final conclusion:


NTSB use of social media

Shortly after the accident, the US National Transportation Safety Board (NTSB) used Twitter and YouTube to inform the public about the investigation and quickly publish quotes from press conferences. NTSB first tweeted about Asiana 214 less than one hour after the crash. One hour after that, the NTSB announced via Twitter that officials would hold a press conference at Reagan Airport Hangar 6 before departing for San Francisco. Less than 12 hours after the crash, the NTSB released a photo showing investigators conducting their first site assessment. On June 24, 2014, the NTSB published to YouTube a narrated accident sequence animation.


Air Line Pilots Association

On July 9, 2013, the
Air Line Pilots Association The Air Line Pilots Association, International (ALPA) is the largest pilot union in the world, representing more than 79,000 pilots from 42 US and Canadian airlines. ALPA was founded on 27 July 1931 and is a member of the AFL-CIO and the Canadian ...
(ALPA) criticized the NTSB for releasing "incomplete, out-of-context information" that gave the impression that
pilot error In aviation, pilot error generally refers to an action or decision made by a Aircraft pilot#Airline, pilot that is a substantial contributing factor leading to an Aviation accidents and incidents, aviation accident. It also includes a pilot ...
was entirely to blame. NTSB Chairman Hersman responded: "The information we're providing is consistent with our procedures and processes ... One of the hallmarks of the NTSB is our transparency. We work for the traveling public. There are a lot of organizations and groups that have advocates. We are the advocate for the traveling public. We believe it's important to show our work and tell people what we are doing." Answering ALPA's criticism, NTSB spokeswoman Kelly Nantel also said the agency routinely provided factual updates during investigations. "For the public to have confidence in the investigative process, transparency and accuracy are critical", Nantel said. On July 11, 2013, in a follow-up press release without criticizing the NTSB, ALPA gave a general warning against speculation.


South Korean investigation

The South Korean government announced in a Ministry of Land, Infrastructure and Transport (MOLIT) statement that it would investigate whether the crew followed procedures and how they were trained.


Aftermath

The airport was closed for five hours after the crash. Flights destined for San Francisco were diverted to
Oakland Oakland is a city in the East Bay region of the San Francisco Bay Area in the U.S. state of California. It is the county seat and most populous city in Alameda County, with a population of 440,646 in 2020. A major West Coast port, Oakland is ...
, San Jose,
Sacramento Sacramento ( or ; ; ) is the capital city of the U.S. state of California and the seat of Sacramento County. Located at the confluence of the Sacramento and American Rivers in Northern California's Sacramento Valley, Sacramento's 2020 p ...
,
Los Angeles Los Angeles, often referred to by its initials L.A., is the List of municipalities in California, most populous city in the U.S. state of California, and the commercial, Financial District, Los Angeles, financial, and Culture of Los Angeles, ...
, Portland (OR), and Seattle–Tacoma. By 3:30 p.m. PDT, runway 1L/19R and runway 1R/19L (both of which run perpendicular across the runway of the accident) were reopened; runway 10L/28R (parallel to the runway of the accident) remained closed for more than 24 hours. The accident runway, 10R/28L, reopened on July 12 after being repaired. In August 2013, Asiana renumbered its Seoul-San Francisco route with the flight OZ212, on a retimed scheduled departure of 8:40 pm, using an
Airbus A350-900 The Airbus A350 is a flight length, long-range, wide-body twin-engine airliner developed and produced by Airbus. The initial A350 design proposed in 2004, in response to the Boeing 787 Dreamliner, would have been a development of the Airbu ...
aircraft; the July 6 accident OZ214 had a scheduled 4:40 pm departure using a Boeing 777-200ER. In the U.S., drug and alcohol tests are standard after air accidents, but this is not a requirement for pilots of foreign-registered aircraft, and the pilots were not tested immediately after the accident. The lack of alcohol testing received much public attention and was critically discussed by various media and politicians after the accident. Shortly after the accident, Congresswoman
Jackie Speier Karen Lorraine Jacqueline Speier ( ; born May 14, 1950) is an American lawyer and politician who served as the U.S. representative for , serving in Congress from 2008 to 2023. A member of the Democratic Party, Speier represented much of the terr ...
stated that she would consider legislation to improve airline safety by requiring increased pilot training and mandatory drug and alcohol testing for international crews. The crash damaged Asiana's reputation and that of South Korea's aviation industry following years of apparent improvements after a series of aircraft disasters in the 1980s and early 1990s. Asiana shares fell by 5.8% on the first day of trading after the crash.


Response from Asiana Airlines

In the hours after the accident, Asiana Airlines CEO Yoon Young-doo said his airline had ruled out mechanical failure as the cause of the crash. Later, he defended the flight crew, calling them "very experienced and competent pilots". On July 9, Yoon apologized directly to the parents of the two victims, then flew aboard Flight 214 to San Francisco, the same route as the crashed aircraft, to meet with NTSB officials. Asiana gave flights to San Francisco to the families of the victims. Asiana Airlines announced on July 29, 2013, that it would retire flight numbers 214 and 213 on August 12, 2013. Flights from Incheon to San Francisco and the return leg would thenceforth operate as OZ212 and OZ211, respectively. Asiana Airlines officials said the airline would improve training for its pilots: in particular, for pilots learning to fly different types of aircraft, and in various skills such as making visual approaches and flying on autopilot. Asiana officials also said they would seek to improve communications skills among crew members, introduce a system to manage "fatigue risk", set up separate maintenance teams for Boeing and Airbus planes, and improve safety management systems. On August 12, 2013, Asiana Airlines announced initial payouts to crash survivors of US$10,000, ($ in ) stating the survivors "need money to go to hospital or for transportation so we are giving them the $10,000 first", Asiana spokeswoman Lee Hyo Min said in a telephone interview. "Even if they are not hurt or they don't go to hospital, we will still give them this money". "The carrier may pay more after the U.S. National Transportation Safety Board completes its investigation into the accident. The families of those who died were paid more than $10,000 as an initial compensation", Lee said, without providing a specific figure.


Response from the South Korean government

South Korean transport ministry officials ordered
Korean Air Korean Air Lines Co., Ltd. (KAL; ) is the flag carrier of South Korea and its largest airline based on fleet size, international destinations, and international flights. It is owned by the Hanjin, Hanjin Group. The present-day Korean Air tra ...
and Asiana to check engines and landing equipment on all 48 of their model 777 aircraft and announced that the government would conduct special inspections on the nation's eight carriers through August 25, 2013. "The measures could include
hanging Hanging is killing a person by suspending them from the neck with a noose or ligature strangulation, ligature. Hanging has been a standard method of capital punishment since the Middle Ages, and has been the primary execution method in numerou ...
rules on training flights if needed", Deputy Minister for Civil Aviation Choi Jeong-ho told reporters. The officials also said South Korea had no fatal air crashes between December 1999 and the July 2011 crash of an Asiana freighter.


Response from the San Francisco Fire Department

Helmet-recorded images showed that firefighters on scene saw some victims alive outside of the aircraft after being thrown from the plane. During their response, one firefighting vehicle ran over a girl who "was alive and lying outside the plane near one of its wings when the trucks ran over her." The firefighter driving the vehicle was reported to have said "She got run over... I mean, s— happens, you know?" Afterward the incident was reported by the firefighter to San Francisco Fire Department chief Joanne M. Hayes-White stating "Chief, there's a woman there who's been run over by one of our rigs." The chief asked if the victim had been crushed, to which the firefighter replied "like someone dropped a pumpkin." Chief Hayes-White initially made a public statement lauding her firefighters for having "worked as best as it possibly could have". After two days, Hayes-White addressed the incident and said that "public officials most certainly have a duty to tell the truth", and that "it would have been speculative and irresponsible to report something without having confirmation" during the first two days while the San Francisco police and National Transportation Safety Board conducted their investigation. The San Mateo County prosecutors did not file criminal charges against San Francisco firefighters for what they described as a "tragic accident". Hayes-White stated that the department's 2009 ban on video recording devices would be extended to include any devices mounted on helmets that record emergencies citing privacy concerns.


Lawsuits Involving Fire Department Response

On December 30, 2013, the "parents and successors" of the girl killed after being run over by a responding fire department vehicle filed a lawsuit against the San Francisco Police Department, and its chief at the time. The lawsuit was later dropped as part of a "confidential settlement" however "the city attorney's office said no money was paid to the family to dismiss their lawsuit." On May 9, 2014, the San Francisco Fire Department firefighter who drove the vehicle that ran over the girl in the above incident filed a lawsuit against the City and County of San Francisco alleging they were treated as a scapegoat by fire department command staff "to minimize and downplay broader failures within the SFFD esponse by pushing responsibility for the incident onto the individual. The lawsuit was later settled for $250,000. The firefighter was never criminally charged.


Lawsuits

On July 15, 2013, two Korean passengers filed a lawsuit against Asiana Airlines in a California federal court for "an extensive litany of errors and omissions" and improper crew training and supervision. On the same day, 83 passengers filed a petition for discovery in
Chicago Chicago is the List of municipalities in Illinois, most populous city in the U.S. state of Illinois and in the Midwestern United States. With a population of 2,746,388, as of the 2020 United States census, 2020 census, it is the List of Unite ...
, alleging a possible failure of the autothrottle system and malfunctioning
evacuation slide An evacuation slide is an inflatable slide used to evacuate an aircraft quickly. An escape slide is required on all commercial (passenger carrying) aircraft where the door sill height is such that, in the event of an evacuation, passengers would ...
s and
seat belts A seat belt, also known as a safety belt or spelled seatbelt, is a vehicle safety device designed to secure the driver or a passenger of a vehicle against harmful movement that may result during a collision or a sudden stop. A seat belt reduce ...
. An additional lawsuit against Asiana Airlines and Boeing Aircraft Company was filed on August 9, 2013. In addition to alleging product defects, the suits focus on the training provided to the Asiana crew. Seventy-two passengers reached an undisclosed settlement that was filed in United States Federal court on March 3, 2015. On the same day the ''Los Angeles Times'' reported that, "At least 60 lawsuits against the airline filed in the Northern District of California ... have not reached settlements", and "dozens of claims have been filed against the airline in China and South Korea and against Boeing in an Illinois state court." Asiana also initially announced it would file a defamation lawsuit against
KTVU KTVU (channel 2) is a television station licensed to Oakland, California, United States, serving the San Francisco Bay Area. It is owned and operated by the Fox Broadcasting Company, Fox network through its Fox Television Stations division along ...
for having aired the Asiana Airlines KTVU prank , but withdrew from that course of action two days later.


Legislative action

On July 30, 2013, an amendment to Transportation bill H.R. 2610 was adopted by voice vote for the transfer of $500,000 from the
Next Generation Air Transportation System The Next Generation Air Transportation System (NextGen) is the current U.S. Federal Aviation Administration (FAA) program to modernize the National Airspace System (NAS). The FAA began work on NextGen improvements in 2007 and plans to finish imp ...
account to the air safety account to study implementing a verbal warning system for low air speed.


Fines

On February 25, 2014, the
U.S. Department of Transportation The United States Department of Transportation (USDOT or DOT) is one of the executive departments of the U.S. federal government. It is headed by the secretary of transportation, who reports directly to the president of the United States a ...
fined Asiana Airlines US$500,000 for failing to keep victims and family of victims updated on the crash.


In popular culture


''Mayday'' TV series

'' Mayday: Air Crash Investigation'' mentioned Asiana Airlines Flight 214 in its Season 13 episode, "Getting Out Alive", as part of a series of accidents and discussion of how passengers were able to escape. A season 15 episode focused solely on the Flight 214 accident, titled "Terror in San Francisco", aired on January 13, 2016.


KTVU prank

San Francisco television station
KTVU KTVU (channel 2) is a television station licensed to Oakland, California, United States, serving the San Francisco Bay Area. It is owned and operated by the Fox Broadcasting Company, Fox network through its Fox Television Stations division along ...
fell victim to a prank which led news anchor Tori Campbell to report the names of the pilots as "Captain Sum Ting Wong", "Wi Tu Lo", "Ho Lee Fuk", and "Bang Ding Ow", in the immediate aftermath of the crash. Viewers quickly realized that these "names" were phonetic double entendres. The prank was described as racist and offensive, and led to the firing of three veteran KTVU producers. The names do not resemble
Korean name Korean names are names that place their origin in, or are used in, Korea. A Korean name in the modern era typically consists of a surname followed by a given name, with no middle names. A number of Korean terms for names exist. For full names, ...
s, and it has been suggested that they sound Chinese. The names have also been described as evoking the racist term " ching chong". That term, which is supposed to mock
Chinese people The Chinese people, or simply Chinese, are people or ethnic groups identified with Greater China, China, usually through ethnicity, nationality, citizenship, or other affiliation. Chinese people are known as Zhongguoren () or as Huaren () by ...
, has sometimes been directed to
East Asian people East Asian people (also East Asians) are the people from East Asia, which consists of China, Japan, Mongolia, North Korea, South Korea, and Taiwan. The total population of all countries within this region is estimated to be 1.677 billion and 21% ...
in general, which in effect falsely portrays East Asians as culturally and linguistically uniform. While the source of the joke names remains unclear, the NTSB admitted in a statement that a summer intern at the agency mistakenly confirmed the erroneous names to the news station when asked about them.


See also

* List of accidents and incidents involving commercial aircraft * British Airways Flight 38 *
Turkish Airlines Flight 1951 Turkish Airlines Flight 1951 (also known as the Poldercrash or the Schiphol Polderbaan incident) was a passenger flight that crashed during landing at Amsterdam Schiphol Airport, the Netherlands, on 25 February 2009, resulting in the deaths of ...
* Lion Air Flight 904 *
Malaysia Airlines Flight 370 Malaysia Airlines Flight 370 (MH370/MAS370) was an international passenger flight operated by Malaysia Airlines that disappeared from radar on 8 March 2014, while flying from Kuala Lumpur International Airport in Malaysia to its planned de ...
* Delta Air Lines Flight 723 * Singapore Airlines Flight 321 * Emirates Flight 521 * Sosoliso Airlines Flight 1145 *
Korean Air Flight 801 Korean Air Flight 801 (KE801, KAL801) was a scheduled international passenger flight operated by Korean Air, from Gimpo International Airport, Seoul to Antonio B. Won Pat International Airport, Guam. On August 6, 1997, the Boeing 747-300 operatin ...
* AIRES Flight 8250 * Asiana Airlines Flight 733 * Asiana Airlines Flight 162 *
1961 Ndola United Nations DC-6 crash On 18 September 1961, a DC-6 passenger aircraft of Transair Sweden operating for the United Nations (UN) crashed near Ndola, Northern Rhodesia (present-day Zambia). The crash resulted in the deaths of all people on board, including Dag Hamma ...
* Air Canada Flight 624 * UPS Airlines Flight 1354


Notes


References


External links

* *
National Transportation Safety Board The National Transportation Safety Board (NTSB) is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and inci ...

Aviation Accident Investigation – Asiana Airlines Flight 214
** // NTSB.gov
Investigation docket

Asiana 214 traffic with SFO Tower, July 6, 2013
(radio recording) * * {{Portal bar, Aviation, China, San Francisco Bay Area, South Korea, California Aviation accidents and incidents in the United States in 2013 2013 in San Francisco Accidents and incidents involving the Boeing 777 Airliner accidents and incidents in California Aircraft fires Asiana Airlines accidents and incidents Filmed deaths during aviation accidents and incidents South Korea–United States relations History of San Mateo County, California July 2013 in the United States Airliner accidents and incidents caused by pilot error San Francisco International Airport Airliner accidents and incidents caused by stalls Aviation accidents and incidents in 2013