Asiana Airlines Flight 214

Aircraft

The Boeing 777-200ER, registration HL7742, was powered by two Pratt and Whitney PW4090 engines. It was delivered new to Asiana Airlines on 7 March 2006 and at the time of the crash had accumulated 36,000 flight hours and 5,000 (takeoff-and-landing) cycles.

The Boeing 777 has a good reputation for safety. This was its first fatal accident, second crash (after British Airways Flight 38), and third hull loss since the 777 began operating commercially in 1995.

Crash

On July 6, 2013, Flight OZ214 took off from Incheon International Airport (ICN) 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 told to maintain a speed of 180 knots (330 km/h; 210 mph) until the aircraft was 5 miles (8.0 km) from the runway. At 11:26 a.m., Northern California TRACON ("NorCal Approach") passed air traffic control to the San Francisco tower. A tower controller acknowledged the second call from the crew at 11:27 a.m. when the plane was 1.5 miles (2.4 km) away, and gave clearance to land.

The weather was very good; the latest METAR reported light wind, 10 miles (16 km) visibility (the maximum it can report), no precipitation, and no forecast or reports of wind shear. The pilots performed a visual approach assisted by the runway's precision approach path indicator (PAPI).

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 that the main landing gear, the first part of the aircraft to hit the seawall, "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 rotated counter-clockwise approximately 330 degrees, as it 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, 2,400 feet (730 m) 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.

Two evacuation slides 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, pinning the flight attendants seated nearby.

According to NBC reports in September 2013, the US 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, so as to detect and correct corrosion that might interfere with slide deployment.

This was the third fatal crash in Asiana's 25-year history.

Crew

The aircrew consisted of three captains and one first officer. Captain Lee Jung-min (Hangul: 이정민; Hanja: 李鄭閔), aged 49, in the right seat (co-pilot position) filled the dual role of a check/instructor captain and pilot in command, responsible for the safe operation of the flight. He had 12,387 hours of flying experience of which 3,220 were in a 777. This was his first flight as an instructor.

Captain Lee Kang-kuk (이강국; 李江鞠; variant Lee Gang-guk), aged 45, in the left seat (captain's position) was the pilot 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 9 flights, and was operating the controls under the supervision of the instructor in the right seat. This was Lee Kang-kuk's first landing at SFO in this aircraft type, although he had previously landed there in a Boeing 747 and other aircraft. This was his first flight with Lee Jung Min.

At the time of the crash, relief first officer Bong Dong-won, 41, was observing from the cockpit jump seat. Relief captain Lee Jong-ju, 52, occupied a business-class seat in the passenger cabin.

The first officer, who had been in the cockpit, received medical treatment for a cracked rib; none of the other pilots needed hospital care.

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

Two 16-year-old girls with Chinese passports were found dead outside the aircraft soon after the crash, having been thrown out of the aircraft during the accident. One was accidentally run over by an airport crash tender after being covered in fire-fighting foam. On July 19, 2013, the San Mateo County Coroner's office confirmed that the girl was still alive prior to being run over by a rescue vehicle, and was killed due to blunt force trauma. On January 28, 2014, the San Francisco city attorney's office announced their conclusion that the girl was already dead when she was run over.

Four flight attendants seated at the rear were ejected from the aircraft when the tail section broke off, and they survived.

Ten people in critical condition were admitted to San Francisco General Hospital and a few to Stanford Medical Center. Nine hospitals in the area admitted 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.

A third passenger, a 15-year-old Chinese girl, died of her injuries at San Francisco General Hospital six days after the accident.

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, 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 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; 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, 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.

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 moments 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, at which point the evacuation order was given some 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.

During the evacuation, a pilot used an extinguisher on a fire that had penetrated from the exterior to the inside of the cabin.

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 fire axe from the cockpit. The second chute expanded toward the center of the aircraft near the fire. It trapped 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.

Eyewitnesses to the crash included the cockpit crew and many passengers on board United Airlines Flight 885 (UA 885), a Boeing 747-400 that was holding on taxiway F, next to use 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:

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.

Passengers and others praised the flight attendants' conduct after the crash. Cabin manager Lee Yoon-hye was last off 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 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 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.

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 its 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. 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. The final report was released in June 2014.

On July 19, San Mateo County coroner confirmed that one passenger died of injuries received from a responding fire truck, not from the crash itself. The District Attorney ruled that her death was accidental and that the driver of the fire truck involved would not face any criminal proceedings.

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 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, which, without the captain's awareness, resulted in the autothrottle no longer controlling airspeed. The aircraft then descended below the desired glide path 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 pilot monitoring's awareness of the pilot flying'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 procedures and crew resource management were cited as additional factors.

The NTSB reached the following final conclusion:

The National Transportation Safety Board determines that the probable cause of this accident was the flight crew's mismanagement of the airplane's descent during the visual approach, the pilot flying'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 pilot flying's inadequate training on the planning and executing of visual approaches; (4) the pilot monitoring/instructor pilot's inadequate supervision of the pilot flying; and (5) flight crew fatigue, which likely degraded their performance.

Timeline of the accident

According to the NTSB, the weather was fair and the aircraft was cleared for a visual approach.

The instrument landing system's vertical guidance (glide slope) on runway 28L was out of service, as scheduled, beginning on June 1 (and a Notice To Airmen (NOTAM) to that effect had been issued); therefore, a Precision ILS approach to this runway was not possible.

Preliminary analysis indicated that the plane's approach was too slow and too low. Eighty-two seconds before impact, at an altitude of about 1,600 feet (490 m), 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." "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'". Both were spoken in the cockpit but not over the radio.

The main landing gear of the aircraft hit the seawall short of the runway 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 fell to 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 38 metres (125 ft), eight 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 below 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.

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 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 four seconds before impact on the cockpit voice recorder. Airspeed reached a minimum of 103 knots (191 km/h; 119 mph) (34 knots below the target speed) three seconds before impact, with engines at 50% power and increasing. The crew called for a go-around 1.5 seconds before impact. At impact, airspeed had increased to 106 knots (196 km/h; 122 mph).

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.

The pilot flying reported to Korean investigators that he was blinded by a bright light at 500 feet (35 seconds prior to impact). The NTSB, calling the bright light's effect 'temporary', said the pilot flying did not believe it affected his ability to fly the aircraft, and no reference to any light was made by the other pilots during interviews or at the time, according to the cockpit voice recorder.

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 (Primary Flight Display) was deactivated whereas the instructor pilot's was activated (this may prove to be significant, as deactivating neither or both Flight Directors enables and forces an autothrottle "wake-up" whereas deactivating only one Flight Director inhibits an autothrottle "wake-up"). All three fire handles were extended; these operate safety equipment intended to put out fires on the aircraft (a handle for each engine and the 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 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.

In response to media reports in South Korea that air traffic controllers had a shift change 30 seconds before the crash, Hersman said that the plane had been cleared to land over 30 seconds before crashing and, "the tower actually called for the emergency and the emergency vehicles prior to the flight crew calling the tower for an emergency."

The NTSB published a three-page preliminary report on August 7, 2013.

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 (ALPA) criticized the NTSB for releasing "incomplete, out-of-context information" that gave the impression that pilot error 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 is investigating whether the crew followed procedures and how they were trained, according to a Ministry of Land, Infrastructure and Transport statement.

Aftermath

The airport was closed for five hours after the crash. Flights destined for San Francisco were diverted to Oakland, San Jose, Sacramento, Los Angeles, Portland(OR), and Seattle–Tacoma. By 3:30 p.m. PDT, runway 1L/19R and runway 1R/19L (both 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. Asiana changed the flight number to 212 following the incident and still flies the Seoul-San Francisco route.

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 stated that she will 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 on the first day of trading after the crash, by 5.8%. Any insurance payment will not cover the loss of aircraft, litigation and other charges and erosion in passenger numbers following the accident, Cho Byoung Hee, an analyst at Kiwoom Securities Co., said in July 2013. As of August 2013, shares of the airline fell 2 percent to 4,530 won, the lowest price since April 5, 2010, in Seoul trading.

Response from Asiana Airlines

In the hours after the accident, Asiana Airlines CEO Yoon Young-doo (윤영두; 尹永斗) 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 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.

On August 12, 2013, Asiana Airlines announced initial payouts to crash survivors of US$10,000, 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 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 [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.

Response from the San Francisco Fire Department

Chief of the San Francisco Fire Department Joanne Hayes-White stated that the department's 2009 ban on video recording devices has now been extended to include any devices mounted on helmets that record emergencies. Helmet-recorded images were taken at the crash scene and resulted in inquiries regarding the death of one victim struck by an emergency vehicle. There will be no charges filed for the accidental death involving the firetruck.

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, the law firm Ribbeck Law Chartered filed a petition for discovery in Chicago on behalf of 83 passengers, alleging a possible failure of the autothrottle system and malfunctioning evacuation slides and seat belts. On July 25, 2013, the law firm Kreindler and Kreindler LLP announced that they represent each of the three passengers who died as a result of the crash. The law firm Cotchett, Pitre & McCarthy LLP filed an additional lawsuit against Asiana Airlines and Boeing Aircraft Company 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 3 Mar 2015, of which ten passengers were clients of Cotchett, Pitre & McCarthy LLP. 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 to file a defamation lawsuit against KTVU 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 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 (DOT) fined Asiana Airlines US$500,000 for failing to keep victims and family of victims updated on the crash.

In popular culture

Mayday: Air Crash Investigation included Asiana Airlines Flight 214 in Episode 11, "Getting Out Alive" of Season 13. Another episode, Episode 2, "Terror in San Francisco" of Season 15 aired on 13 January 2016 and focused solely on the accident, as the previous episode studied a series of accidents and how passengers were able to escape.

San Francisco television station KTVU fell victim to a prank in which it reported a quartet of racially offensive phonetic double entendres as the actual names of the flight crew; comedian Stephen Colbert parodied the mistaken reporting on his show, The Colbert Report.