Asiana Airlines Flight 214

207 Pages·2014·4.63 MB·English

Descent Below Visual Glidepath and Impact With Seawall
Asiana Airlines Flight 214
Boeing 777-200ER, HL7742
San Francisco, California
July 6, 2013

Accident Report
NTSB/AAR-14/01
PB2014-105984
National

Transportation

Safety Board
NTSB/AAR-14/01
PB2014-105984
Notation 8518
Adopted June 24, 2014

Aircraft Accident Report
Descent Below Visual Glidepath and Impact With Seawall
Asiana Airlines Flight 214
Boeing 777-200ER, HL7742
San Francisco, California
July 6, 2013

National
Transportation
Safety Board

490 L’Enfant Plaza, SW
Washington, D.C. 20594
National Transportation Safety Board. 2014. Descent Below Visual Glidepath and Impact With
Seawall, Asiana Airlines Flight 214, Boeing 777-200ER, HL7742, San Francisco, California, July 6,
2013. Aircraft Accident Report NTSB/AAR-14/01. Washington, DC.
Abstract: This report discusses the July 6, 2013, accident involving a Boeing 777-200ER, Korean
registration HL7742, operating as Asiana Airlines flight 214, which was on approach to runway 28L
when it struck a seawall at San Francisco International Airport (SFO), San Francisco, California. Three of
the 291 passengers were fatally injured; 40 passengers, 8 of the 12 flight attendants, and 1 of the 4 flight
crewmembers received serious injuries. The other 248 passengers, 4 flight attendants, and 3 flight
crewmembers received minor injuries or were not injured. The airplane was destroyed.
Safety issues relate to the need for Asiana pilots to adhere to standard operating procedures regarding
callouts; reduced design complexity and enhanced training on the airplane’s autoflight system;
opportunity at Asiana for new instructors to supervise trainee pilots in operational service during
instructor training; guidance for Asiana pilots on use of flight directors during a visual approach; more
manual flight for Asiana pilots; a context-dependent low energy alert; research that examines the injury
potential from significant lateral forces in airplane crashes and the mechanism that produces high thoracic
spinal injuries; evaluation of the adequacy of slide/raft inertia load certification testing; aircraft rescue and
firefighting (ARFF) training for officers in command of an aircraft accident response; guidance on when
to use a skin-piercing nozzle on a burning airplane fuselage; integration of the medical supply buses at
SFO into the airport’s preparation drills; guidance or protocols for ensuring the safety of passengers and
crew at risk of a vehicle strike during ARFF operations; requirements for ARFF staffing; improvements
in SFO emergency communications; and increased Federal Aviation Administration (FAA) oversight of
SFO’s emergency procedures manual. Safety recommendations are addressed to the FAA, Asiana
Airlines, Boeing, the ARFF Working Group, and the City of San Francisco.

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through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable
causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety
effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions
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matter mentioned in the report.
NTSB Aircraft Accident Report
Contents
Figures .............................................................................................................................................v
Tables ............................................................................................................................................ vi
Abbreviations .............................................................................................................................. vii
Executive Summary ..................................................................................................................... xi
1. Factual Information ...................................................................................................................1
1.1 History of Flight .........................................................................................................................1
1.2 Injuries to Persons ....................................................................................................................13
1.3 Damage to Airplane .................................................................................................................13
1.4 Other Damage ..........................................................................................................................14
1.5 Personnel Information ..............................................................................................................14
1.5.1 The Pilot Flying .............................................................................................................14
1.5.1.1 The Pilot Flying’s Preaccident Activities ........................................................15
1.5.2 The Pilot Monitoring .....................................................................................................16
1.5.2.1 The Pilot Monitoring’s Preaccident Activities ................................................18
1.5.3 The Observer .................................................................................................................18
1.5.3.1 The Observer’s Preaccident Activities.............................................................19
1.5.4 The Flight Attendants ....................................................................................................19
1.6 Airplane Information ...............................................................................................................19
1.6.1 General ...........................................................................................................................19
1.6.2 Instrument Panel Displays .............................................................................................20
1.6.3 Automatic Flight Control System ..................................................................................22
1.6.3.1 Autopilot Flight Director System.....................................................................23
1.6.3.2 Autothrottle ......................................................................................................25
1.6.3.3 Flight Mode Annunciator .................................................................................25
1.6.3.4 Autopilot and Autothrottle Pairing ..................................................................26
1.6.3.5 Autothrottle Automatic Engagement ...............................................................27
1.6.4 Airspeed Awareness and Low Airspeed Alerting Features ...........................................28
1.6.4.1 Airspeed Awareness.........................................................................................28
1.6.4.2 Low Airspeed Alerting Systems ......................................................................29
1.7 Meteorological Information .....................................................................................................30
1.8 Aids to Navigation ...................................................................................................................30
1.9 Communications ......................................................................................................................30
1.10 Airport Information ................................................................................................................30
1.10.1 Emergency Plan and Drills ..........................................................................................32
1.10.2 Minimum Safe Altitude Warning System ...................................................................32
1.11 Flight Recorders .....................................................................................................................33
1.11.1 Cockpit Voice Recorder ..............................................................................................33
1.11.2 Flight Data Recorder....................................................................................................33
1.11.3 Quick Access Recorder ................................................................................................34
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NTSB Aircraft Accident Report
1.12 Wreckage and Impact Information ........................................................................................34
1.13 Medical and Pathological Information...................................................................................35
1.13.1 Fatalities .......................................................................................................................35
1.13.2 Survivors ......................................................................................................................35
1.13.3 Flight Crew Toxicological Testing ..............................................................................36
1.14 Fire .........................................................................................................................................36
1.15 Survival Aspects ....................................................................................................................37
1.15.1 General .........................................................................................................................37
1.15.2 Seatbelt Compliance ....................................................................................................39
1.15.3 Evacuation of Passengers and Crewmembers .............................................................40
1.15.4 Emergency Response ...................................................................................................42
1.15.4.1 Incident Command .........................................................................................44
1.15.4.2 Firefighting Tactics ........................................................................................45
1.15.4.3 Communication Problems ..............................................................................47
1.15.4.4 Aircraft Rescue and Firefighting Training .....................................................49
1.15.4.5 Triage .............................................................................................................49
1.15.5 Injury Severity .............................................................................................................51
1.15.6 Doors and Slide/Rafts ..................................................................................................52
1.15.6.1 Slide/Raft Information ...................................................................................52
1.15.6.2 Door and Slide/Raft Performance ..................................................................53
1.15.6.3 Slide/Raft Maintenance Information ..............................................................54
1.15.7 Cabin Damage .............................................................................................................55
1.16 Tests and Research .................................................................................................................56
1.16.1 Airplane Performance Study and Simulator Evaluations ............................................56
1.16.1.1 Workstation Simulation .................................................................................57
1.16.1.2 Pilot-in-the-Loop Simulation .........................................................................58
1.16.2 Mode Control Panel Examination ...............................................................................58
1.16.3 Autothrottle Component Examination .........................................................................59
1.16.4 Enhanced Ground Proximity Warning System ............................................................59
1.16.5 Slide/Raft Examination and Testing ............................................................................60
1.16.5.1 Slide/Raft Release Mechanism Examination .................................................60
1.16.5.2 Slide/Raft Certification Information ..............................................................60
1.16.5.3 Slide/Raft Tests ..............................................................................................60
1.17 Organizational and Management Information .......................................................................61
1.17.1 Pilot Standard Operating Procedures ...........................................................................61
1.17.1.1 Use of Automation .........................................................................................62
1.17.1.2 Descent Procedures ........................................................................................63
1.17.1.3 Visual Approach ............................................................................................63
1.17.1.4 Stabilized Approach and Go-Around .............................................................64
1.17.1.5 Flight Crew Duties During Approach ............................................................65
1.17.1.6 Expected Pitch and Power on Final Approach ..............................................66
1.17.1.7 Evacuation......................................................................................................66
1.17.2 Flight Crew Training ...................................................................................................67
1.17.2.1 Autothrottle Function Training ......................................................................67
1.17.2.2 Asiana Pilots’ Statements about A/T Function ..............................................68
1.17.2.3 Stall Protection Demonstration ......................................................................69
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NTSB Aircraft Accident Report
1.17.2.4 Flight Director Use During Visual and Circling Approaches ........................69
1.17.2.5 Instructor Pilot Training .................................................................................70
1.17.3 Regulatory Oversight ...................................................................................................70
1.18 Additional Information ..........................................................................................................71
1.18.1 Postaccident Safety Action ..........................................................................................71
1.18.1.1 Asiana Airlines...............................................................................................71
1.18.1.2 City and County of San Francisco .................................................................72
1.18.2 Boeing Certification Issue Involving A/T Automatic Engagement Logic ..................73
1.18.3 Federal Aviation Administration Actions About Manual Flight Operations ..............74
1.18.4 Federal Aviation Administration Guidance on Use of HRET .....................................75
1.18.5 Postaccident Flight Crew Toxicological Testing Requirements .................................75
2. Analysis .....................................................................................................................................77
2.1 General .....................................................................................................................................77
2.2 Accident Sequence ...................................................................................................................78
2.2.1 Approach from 14 to 5 nm from the Runway................................................................78
2.2.2 Approach from 5 nm to the Runway .............................................................................79
2.3 Flight Crew Performance .........................................................................................................85
2.3.1 Fatigue ...........................................................................................................................85
2.3.2 Flight Crew Communication .........................................................................................87
2.3.3 Flight Crew Monitoring .................................................................................................88
2.3.4 Go-Around Decision-Making ........................................................................................90
2.4 Autoflight System Training and Design ..................................................................................93
2.4.1 Autoflight System Training ...........................................................................................93
2.4.2 Autoflight System Design ..............................................................................................96
2.5 Pilot Training ...........................................................................................................................98
2.5.1 Visual Approach Training .............................................................................................98
2.5.2 Instructor Pilot Training ..............................................................................................100
2.6 Operations Issues ...................................................................................................................101
2.6.1 Cycling of Flight Director Switches ............................................................................101
2.6.2 Manual Flight ...............................................................................................................102
2.7 Low Energy Alert ..................................................................................................................104
2.8 Survival Aspects ....................................................................................................................107
2.8.1 Accident Survivability .................................................................................................107
2.8.1.1 Evacuation......................................................................................................107
2.8.1.2 Fatalities .........................................................................................................108
2.8.1.3 Injuries ...........................................................................................................111
2.8.1.4 Accident Survivability Summary ...................................................................113
2.8.2 Slide/Raft Performance ................................................................................................114
2.8.2.1 Slide/Rafts 1R and 2R ....................................................................................114
2.8.2.2 Slide/Rafts 3L and 3R ....................................................................................115
2.8.2.3 Slide/Rafts 4L and 4R ....................................................................................115
2.8.3 Emergency Response ...................................................................................................116
2.8.3.1 Firefighting Tactics and Use of High-Reach Extendable Turrets ..................116
2.8.3.2 Medical Response Issues ...............................................................................117
2.8.3.3 Staffing ...........................................................................................................120
2.8.3.4 Incident Command .........................................................................................121
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NTSB Aircraft Accident Report
2.8.3.5 Communication…………………………………………………………………123
2.8.3.6 Airport Emergency Procedures Manual………………………………………...125

3. Conclusions……………………………………………………………………….…………126
3.1. Findings……………………………………………………………………………………126
3.2 Probable Cause……………………………………………………………………………...129

4. Recommendations………………………………………………………………………..…130

Board Member Statements…………………………………………………………………...134

References…………………………………………………………………………...…………146

5. Appendixes……………………………………………………………………………...…..148
Appendix A: Investigation and Hearing………………………………………………………..148
Appendix B: Cockpit Voice Recorder Transcript………………………………………..……..149
Appendix C: The Republic of Korea Aviation and Railway Accident Investigation Board
Comments…………………………………………………………………………………...….182
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NTSB Aircraft Accident Report
Figures
Figure 1. Map of the accident location........................................................................................... 1
Figure 2. Diagram of cockpit showing flight crew roles. .............................................................. 2
Figure 3. Instrument approach chart for the SFO runway 28L ILS or LOC Z procedure. ............ 4
Figure 4. Profile view of the last 40 seconds of flight 214. ..........................................................11
Figure 5. Aerial view of the flight 214 wreckage. ....................................................................... 13
Figure 6. 777 instrument panel. ................................................................................................... 21
Figure 7. 777 navigation display depicting information for the approach to SFO. ..................... 22
Figure 8. 777 mode control panel. ............................................................................................... 23
Figure 9. 777 flight mode annunciator. ........................................................................................ 26
Figure 10. 777 indicated airspeed display. ................................................................................... 29
Figure 11. Fire damage to the fuselage of flight 214. .................................................................. 37
Figure 12. Diagram of flight 214’s cabin configuration. ............................................................. 38
Figure 13. Slide/raft components. ................................................................................................ 52
Figure 14. Automation sequence from 1,850 to 1,330 ft msl. ..................................................... 80
Figure 15. Location where ejected occupants were found. ........................................................ 109
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NTSB Aircraft Accident Report
Tables

Table 1. Timeline of selected events during last 1,000 ft of approach. .......................................... 9
Table 2. Injury chart. .................................................................................................................... 13
Table 3. Selected AFDS pitch modes. .......................................................................................... 24
Table 4. Selected AFDS roll modes. ............................................................................................. 24
Table 5. A/T mode summary. ....................................................................................................... 25

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NTSB Aircraft Accident Report
Abbreviations
AC advisory circular
ACARS aircraft communications addressing and reporting system
ACRP Airport Cooperative Research Program
AD airworthiness directive
AFCS automatic flight control system
AFDS autopilot flight director system
AFE above field elevation
AFFF aqueous film forming foam
AFM airplane flight manual
agl above ground level
A/P autopilot
ARAC Aviation Rulemaking Advisory Committee
ARFF aircraft rescue and firefighting
ASHWG Avionics Systems Harmonization Working Group
ASO airfield security officer
A/T autothrottle
ATC air traffic control
ATCT air traffic control tower
ATIS automatic terminal information service
BS body station
CFR Code of Federal Regulations
CG center of gravity
CRM crew resource management
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