Asiana Airlines Flight 214

Asiana Airlines Flight 214

The aircraft after the crash
Accident
Date	July 6, 2013 (2013-07-06)
Summary	Under investigation
Site	San Francisco International Airport 37°36′48″N 122°21′52″W
Aircraft
Aircraft type	Boeing 777-200ER
Operator	Asiana Airlines
Registration	HL7742
Flight origin	Incheon International Airport, South Korea
Destination	San Francisco International Airport, United States
Passengers	291
Crew	16
Fatalities	3
Injuries	181, about 13 critical
Survivors	304

Asiana Airlines Flight 214 was a scheduled transpacific passenger flight on July 6, 2013 from Incheon International Airport, South Korea, that crash-landed at its destination, San Francisco International Airport, United States. Of the 307 people (291 passengers and 16 crew) aboard the Asiana Airlines Boeing 777-200ER, two passengers died at the crash scene, and about 13 were critically injured. A third passenger died on July 12, while still in intensive care. 181 others were injured, including three flight attendants who were thrown in their seats onto the runway when the aircraft tail hit the sea wall in front of runway 28L. By order of the pilot in command, evacuation was delayed about 90 seconds after the aircraft came to rest beside the runway.

It was the second crash of a Boeing 777 (the first was British Airways Flight 38 in 2008) and the first fatal one since it began operating commercially in 1995.

Aircraft

HL7742, the aircraft involved in the accident, in July 2011

The Boeing 777-200ER, registration HL7742, was delivered to Asiana Airlines in March 2006. Powered by two Pratt & Whitney PW4090 engines, the airframe had about 36,000 flight hours and 5,000 cycles (takeoff-and-landing sets). The Boeing 777 has a good reputation for safety.

Crash

On July 6, 2013, Flight 214 took off from Incheon International Airport (ICN) outside Seoul at 5:04 p.m. KST (08:04 UTC), 34 minutes after its scheduled departure time. It was scheduled to land at San Francisco International Airport (SFO) at 11:04 a.m. PDT (18:04 UTC).

The flight was cleared for a visual approach to runway 28L at 11:21 a.m. PDT, and asked to maintain a speed of 180 knots until the aircraft was 5 miles from the runway. At 11:26 a.m., air traffic control was handed from the NorCal TRACON facility in Sacramento to San Francisco Tower. The crew made two attempts to contact the tower. Tower officials acknowledged the second contact at 11:27:10, when the plane was about 1.5 miles away, and gave clearance to land.

At 11:28 a.m., HL7742 crashed short of runway 28L's threshold. The landing gear and then the tail struck the seawall that projects into San Francisco Bay. Both engines and the tail section separated from the aircraft. The NTSB noted the main landing gear, the first part of the aircraft to hit the sea wall, "separated cleanly from [the] aircraft as designed". The vertical and both horizontal stabilizers fell on the runway before the threshold. The remainder of the fuselage and wings yawed about 330 degrees to the left and came to rest to the left of the runway about 2,000 feet (610 m) from the seawall.

 Runway 28L 

 Engine 

 Fuselage 
 and engine 

 Landing gear 

 Tail 

←

Approximate location of the wreckage. The arrow indicates the general direction of flight on approach before impact

The entire crash was captured on video by an onlooker. Eyewitnesses described a short-lived fireball, then a second large explosion minutes after the impact, with a dark plume of smoke rising from the fuselage. The fire was traced to a post-crash rupture of an oil tank above the right engine, when oil leaking from the ruptured tank fell onto the hot engine and ignited. The fire that engulfed the fuselage after it came to a stop was not "a fuel-fed fire," a spokesman added.

Some evacuation slides were deployed on one side of the plane, and were used to evacuate the aircraft. 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, pinning the flight attendant seated at each of the doors.

The instrument landing system's vertical guidance (glide slope) on runway 28L had been scheduled to be out of service beginning June 1 (and a Notice To Airmen (NOTAM) to that effect had been issued), meaning an ILS approach was not possible. Weather appeared to have been good (the latest METAR reported light wind, 10 miles;16 km visibility and no precipitation) and the aircraft performed a visual approach, assisted by the runway's precision approach path indicator (PAPI).

After the crash, employees of United Airlines, Asiana's partner in Star Alliance, provided help to survivors at the airport terminal and in area hospitals.

This was the third fatal crash in Asiana's 25-year history. It was the first fatal crash of a Boeing 777. It was also the first fatal passenger airliner crash in the United States since the Colgan Air Flight 3407 crash in 2009, and the first multiple-fatality crash in North America involving a major airline since the American Airlines Flight 587 crash in 2001 (fatal crashes since Flight 587 have involved regional carriers). It was the first widebody passenger aircraft crash in North America since Air France Flight 358 in 2005. The crash was the third hull loss of a Boeing 777, and the second of them to crash while on approach to landing, after British Airways Flight 38 that crashed at London Heathrow Airport in 2008.

The first officer who had been in the cockpit received medical treatment for a cracked rib; neither of the other pilots were admitted to the hospital.

Passengers and crew

Passengers and crew

Nationality	Passengers	Crew	Total
China	141	0	141
South Korea	77	14	91
United States	64	0	64
Canada	3	0	3
India	3	0	3
Thailand	0	2	2
France	1	0	1
Japan	1	0	1
Vietnam	1	0	1
Total	291	16	307

The cockpit crew comprised three captains and one first officer. One captain, Lee Jeong-min filled the dual role of a check/instructor captain and pilot in command, responsible for the safe operation of the flight. He was in the right seat (co-pilot position) at the time of the accident. Lee Jeong-min had 12,387 hours of flying experience (at the time of the accident) and 3,220 with the 777.

Captain Lee Kang-kook in the left seat (captain's position) was the pilot receiving his initial operating experience (IOE) training and was operating the controls under the direction of the instructor in the right seat. He had 9,793 flying hours, of which 43 were in a 777, and was about halfway through Asiana's IOE requirements. At the time of the crash, the relief first officer occupied the cockpit jump seat, and the relief captain occupied a seat in the passenger cabin.

This was Lee Kang-kook's first landing at San Francisco in this aircraft type although he had previously landed there in other aircraft including the Boeing 747. It was his ninth training flight in a 777 and Lee Jeong-min's first flight as an instructor. It was the first time the two pilots had flown together.

San Francisco Fire Department Chief Joanne Hayes-White confirmed that there were two deaths immediately after the crash; both were 16-year-old female Chinese passport holders with both bodies found outside the aircraft. One of them was hit by a fire truck while she was covered in fire-fighting foam. It remains unclear whether she was alive at the time; the coroner is yet to rule on cause of death. Three of the four flight attendants seated at the rear of the aircraft were ejected from the aircraft during the impact with the tail section breaking off, and survived. Ten people in critical condition were admitted to San Francisco General and about three to Stanford Medical Center. Nine hospitals in the area admitted a total of 182 injured. Hayes-White told a subsequent press conference that all on board had been accounted for after reconciliation of two intake points at the airport. On July 12, 2013, San Francisco General Hospital announced that a third passenger had died of her injuries. She was identified as a 15-year-old Chinese girl.

Seventy students and teachers traveling to the United States for summer camp were among the Chinese passengers. Thirty of the students and teachers were from Shanxi, and the others were from Zhejiang. Five of the teachers and 29 of the students were from Jiangshan High School in Zhejiang traveling together. Thirty-five of the students were to attend a West Valley Christian School summer camp. The Shanxi students originated from Taiyuan, with 22 students and teachers from the Taiyuan Number Five Secondary School and 14 students and teachers from the Taiyuan Foreign Language School. One teacher received minor injuries, and all three passengers who died were in the West Valley camp group.

Survivor and eyewitness accounts

The rear cabin, after the crash

The charred middle cabin, after the crash and fire

Several passengers recalled noticing the plane's unusual proximity to the Bay on final approach, which caused water to thrust upward as the engines were powered up in the final moments before impact.

In the initial moments after the crash, the cockpit crew told flight attendants to hold off 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, at which point the evacuation order was given, approximately 90 seconds after the aircraft came 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; 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.

Smoke rising from the crash site, as seen from Terminal 1

Partway through the evacuation process, the fire spread from the exterior of the aircraft into the interior and was extinguished by a co-pilot.

Two of the inflatable chutes expanded into the cabin rather than outwards. The first chute, which blocked the forward right exit, nearly suffocated a flight attendant and was deflated by a pilot with a crash axe from the flight deck. The second expanded toward the center of the aircraft near the fire. It pinned a second flight attendant until a co-pilot deflated it with a dinner knife.

Some passengers sitting at the rear of the aircraft escaped through the hole left by the missing tail section.

The cockpit crew and many passengers aboard United Airlines Flight 885, a Boeing 747-400 which was on taxiway F adjacent to the runway, witnessed the incident in close proximity. The moment of impact was also observed by eyewitnesses at the airport terminal and onlookers near the airport and was captured by an amateur video.

Immediately after the crash, the pilots of Flight 885 reported seeing several survivors near the "28L" lettering at the beginning of the runway, far from the final resting location of the fuselage. News reports quoted an email that the first officer of Flight 885, who described himself as a witness, allegedly sent to family and friends:

I then noticed at the apparent descent rate and closure to the runway environment the aircraft looked as though it was going to impact the approach lights mounted on piers in the SF Bay. The aircraft made a fairly drastic-looking pull up in the last few feet and it appeared and sounded as if they had applied maximum thrust. However the descent path they were on continued and the thrust applied didn't appear to come soon enough to prevent impact. The tail cone and empennage of the 777 impacted the bulkhead seawall and departed the airplane and the main landing gear sheared off instantly.

— United Flight 885 first officer, Inside United Flight 885: A pilot's gripping account, Chicago Business Journal

Passengers and others praised Flight 214's flight attendants. San Francisco fire chief Hayes-White called cabin manager Lee Yoon-hye, who was last off the plane after the fire erupted, "a hero". "She wanted to make sure that everyone was off", the chief said.

A firefighter who entered the cabin said that the back of the plane suffered structural damage, but the seats near the front "were almost pristine".

Investigation

Flight 214's data recorder (left) and cockpit voice recorder (right) were recovered from the aircraft

The National Transportation Safety Board (NTSB) began an investigation and sent a team to the scene. On July 7, 2013, NTSB investigators recovered the flight data recorder and cockpit voice recorder and transported them to Washington, D.C., for analysis. Additional parties to the investigation include the Federal Aviation Administration, Boeing, Pratt & Whitney, and the Korean Aviation and Railway Accident Investigation Board (ARAIB). ARAIB's technical adviser is Asiana Airlines.

According to the NTSB, the weather was fair and the aircraft was cleared for a visual approach. There is no indication yet of any problem, mechanical or otherwise, with no distress calls or other problem reports during the flight, although the agency is investigating whether a failure in the mechanics or in the crew's use of the aircraft's autothrottle system could have occurred.

Preliminary indications suggest the plane's approach was too slow and too low. Eighty-two seconds before impact, at an altitude of 1,600 feet (490 m), the autopilot was turned off, and the plane was operated manually during final descent. 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." "Three seconds before the crash, someone in the cockpit called for the plane to abort the landing, or 'go around.' Then, 1.5 seconds before impact, a different crew member again called for a 'go around.'" Flight 214 impacted short of the runway when the rear of the aircraft hit the seawall, just as the crew attempted to abort the landing and execute a go-around. Based on preliminary data from the flight data recorder (FDR), the NTSB said the plane's airspeed on final approach was as much as 34 knots below its target approach speed of 137 knots (254 km/h; 158 mph). 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 about 125 feet (38 m), 8 seconds before impact, the airspeed had dropped to 112 knots (207 km/h; 129 mph). 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 the autothrottle was failing to maintain that speed. The instructor pilot stated that the PAPI indicated a deviation from the glide path at approximately 500 feet above ground level, and he attempted to correct it at that time. Between 500 and 200 feet, the instructor pilot also reported a lateral deviation, which they attempted to correct as well.

Flight 214 final approach airspeed and glide path (July 6 flight shown in red).

About 7 seconds before impact, one of the pilots called for an increase in speed. The FDR showed that throttles were advanced at about this time as well. 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 he reached for the throttles. The sound of the stick shaker (warning of imminent stall) could be heard about 4 seconds before impact on the cockpit voice recorder. Airspeed reached a minimum speed of 103 knots (191 km/h; 119 mph) (34 knots below the target speed) 3 seconds before impact, with engines at 50% power and increasing. The crew called for a go-around 1.5 seconds before impact. At impact, the aircraft speed had increased to 106 knots (196 km/h; 122 mph).

NTSB Chairman Deborah Hersman said that the NTSB conducted about four hours of interviews with each pilot, adding that they were open and cooperative. She said both of the pilots at the controls had ample rest, both before they left South Korea and during the flight, when they were relieved by the backup crew.

Initial interviews with the three pilots who were present in the cockpit during the attempted landing revealed that the pilot at the controls was attempting his first landing at San Francisco Airport flying a 777, and the teaching pilot was on his first flight as an instructor. 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.

The pilot flying reported initially to Korean investigators that he was blinded by a bright light at about 500 ft (35 seconds prior to impact). The NTSB said the pilot flying did not believe the bright light affected his ability to fly the aircraft, and no reference to any light was made by the other pilots during interviews or on the cockpit voice recorder.

The NTSB clarified that the flying pilot, in the left seat, was in a training situation and that the instructor pilot, in the right seat at the time of the crash, was the "pilot in command".

The NTSB stated that there was no anomalous behavior of the engines, the autopilot, of the flight director and of the auto throttles based on the preliminary review of FDR data. 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. All three fire handles were extended; they operate machinery to put out fires on the aircraft (engines and auxiliary power unit). The speedbrake lever was down, showing it was not being used.

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 auto throttle 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 that 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.

In response to South Korean media reports that air traffic controllers had a shift change 30 seconds before the crash, Hersman said the flight crew "received their final landing clearance 90 seconds prior to impact." When the plane crash-landed, "the tower actually called for the emergency and the emergency vehicles prior to the flight crew calling the tower for an emergency."

In the U.S., drug and alcohol tests are standard after air accidents, but not a requirement for foreign pilots, and the Asiana pilots were not tested.

The San Mateo County coroner, Robert Foucrault, conducted autopsies on the first two dead, but has not released results. Officials have confirmed that one of the fatalities was hit by a fire truck, but have not said if that was the cause of death.

Aftermath

The airport was closed for about five hours after the crash. Flights headed for San Francisco were diverted to Oakland and San Jose as well as Sacramento, Los Angeles, and Seattle. By 3:30 p.m. PDT (22:30 UTC), runways 01L/19R and 01R/19L were reopened; the runway of the accident (10R/28L) and the one in parallel to it (10L/28R) remained closed. About 24 hours later, the parallel runway (10L/28R) reopened. The accident runway, 10R/28L, reopened on July 12.

Chinese citizens and West Valley Christian School mourned the loss of the two students, and Boeing offered its condolences to the families of the victims.

In the hours after the incident, Asiana Airlines CEO Yoon Young-doo said the airline had ruled out mechanical failure as the cause of the crash but also later defended the flight crew, indicating that they were "very experienced and competent pilots". On July 9, Yoon arrived in San Francisco on Flight 214, the same route as the crashed aircraft, to meet with the NTSB and directly apologized to the parents of the two victims prior to boarding the flight. Asiana is flying the families of the victims in to San Francisco for free and has continued to operate its Seoul–San Francisco route on schedule as Flight 214.

The Korean government has announced it will investigate whether the crew followed procedures and how they were trained, according to a Ministry of Land, Infrastructure and Transport statement.

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 will 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.

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 on the first day of trading after the crash.

South Korean transport ministry officials ordered Korean Air and Asiana to check engines and landing equipment on all 48 of their 777s and announced that the government would conduct special inspections on the nation’s eight carriers through August 25, 2013. "The measures could include [changing] 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.

Criticism of NTSB

The Air Line Pilots Association (ALPA) criticized the NTSB for releasing "incomplete, out-of-context information" that "fueled rampant speculation about the cause of the accident" and created an impression that pilot error was entirely to blame. NTSB Chair Deborah 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.

See also

• Asiana Airlines Flight 733 – crash in 1993
• Asiana Airlines Flight 991 – crash in 2011

External links

• Asiana Airlines
  • Information for Incident Involving Asiana Flight OZ 214
  • OZ214편(7월 7일) 인천발 샌프란시스코 사고 관련 안내 Template:Ko icon
  • 韩国仁川至美国旧金山OZ214失事航班相关信息 Template:Zh-cn icon
• Amateur video recording of the entire landing sequence (CNN exclusive). Retrieved July 7, 2013.
• Communication between Asiana 214 and SFO Tower
• New York Times photographs of the crash site and debris locations