Asiana Accident at San Francisco 6 July 2013 (Asiana Flight 214, Boeing 777 HL7742)
There are a host of human factors, automation, crashworthiness, survivability and emergency response lessons from this 2013 accident.
Wreckage of Asiana, Flight 214, a Boeing 777, HL7742,at SFO (Credit: NTSB)
The National Transportation Safety Board (NTSB) held a Board Meeting in Washington on 24 June 2014 to finalise their conclusions on this landing accident to Asiana Flight 214, Boeing 777 HL7742 at San Francisco International Airport.
- Acting Chairman’s Opening Statement
- IIC Opening Presentation – Bill English, Investigator-in-Charge
- Operational Factors Presentation – Roger Cox, Operations Group Chairman
- Human Performance Presentation – Dr. William Bramble, Senior Human Performance Investigator
- Survival Factors Presentation – Jason Fedok, Survival Factors Group Chairman
- Acting Chairman’s Closing Statement
A summary can be found here. The full report is here.
NTSB Probable Cause:
….the flight crew’s mismanagement of the airplane’s descent during the visual approach, the PF’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 PF’s inadequate training on the planning and execution of visual approaches;
(4) the PM/instructor pilot’s inadequate supervision of the PF; and
(5) flight crew fatigue, which likely degraded their performance.
Aviation Week & Space Technology highlighted one significant recommendation, the call for a special certification review, a rare measure for an in-service aircraft.
Other Safety Resources
- Investigation into Jet Airways B777 VT-JEK Serious Incident at Heathrow
- Singapore Airlines B777 41t Fuel Discrepancy Incident
- B777 in Autoland Mode Left Runway When Another Aircraft Interfered With the Localiser Signal
- Forgotten Fasteners – Serious Incidents
- UPDATE 6 February 2020: Emirates B777 Runway Impact During Attempted Go-Around, 3 August 2016, Dubai: Accident Report
- UPDATE 3 July 2020: Fatigue Featured in Anchorage Alaska Air Ambulance Accident
- UPDATE 3 July 2020: New surveillance, eyewitness footage of Asiana Flight 214 crash released
The clips, obtained by The Desk…include a previously-unknown eyewitness video shot by a crane operator moments after the jet crashed on runway 28L. In the video, the operator could be heard describing the incident as it unfolded to a nearby worker.
https://youtu.be/7gBO1rxhH8g
https://youtu.be/MQsaeR-Zkd8
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