Date:	Saturday 6 July 2013
Time:	11:28
Type:	Boeing 777-28EER
Owner/operator:	Asiana Airlines
Registration:	HL7742
MSN:	29171/553
Year of manufacture:	2006
Total airframe hrs:	37120 hours
Cycles:	5388 flights
Engine model:	Pratt & Whitney PW4090
Fatalities:	Fatalities: 3 / Occupants: 307
Aircraft damage:	Destroyed
Category:	Accident
Location:	San Francisco International Airport, CA (SFO) -   United States of America
Phase:	Landing
Nature:	Passenger - Scheduled
Departure airport:	Seoul-Incheon International Airport (ICN/RKSI)
Destination airport:	San Francisco International Airport, CA (SFO/KSFO)
Investigating agency:	NTSB
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
A Boeing 777-200 passenger jet, operated by Asiana Airlines, was destroyed in a landing accident at San Francisco International Airport, CA (SFO). There were 291 passengers and 16 crew members on board. Three passengers died and 48 were seriously injured.
Flight OZ-214 originated in Seoul-Incheon International Airport (ICN), South Korea were it departed at 16:35 local Korean time. Destination of the flight was San Francisco, CA.
The weather at San Francisco was fine with 6-7 knot winds and a visibility of 10+ miles. The pilot undergoing initial operating experience was in the left hand seat as Pilot Flying. An instructor pilot was sitting in the right hand seat. The relief first officer was in the jump seat at the time of the approach.
The pilot flying had logged about 9700 flying hours. Flight 214 was his tenth flight leg on a Boeing 777 while undergoing initial operating experience.
The flight was cleared for an approach to runway 28L, the ILS glidepath of which had been declared unserviceable in the current Notam.
The airplane was configured for landing with 30 degrees of flaps and gear down. Target threshold speed was 137 knots. According to preliminary information from the cockpit voice recorder, the crew did not state and anomalies or concerns during the approach. The throttles were at idle and autothrottle armed.
At 1600 feet the autopilot was disengaged. The aircaft descended through an altitude of 1400 ft at 170 kts and slowed down to 149 kts at 1000 feet.
At 500 feet altitude, 34 seconds prior to impact, the speed dropped to 134 kts, which was just below the target threshold speed. The airspeed then dropped significantly, reaching 118 knots at 200 feet altitude. The instructor pilot reported that he noticed four red PAPI lights and concluded that the autothrottle had not maintained speed.
Eight seconds prior to impact, the throttles were moved forward. Airspeed according to the FDR, was 112 knots at an altitude of 125 feet. Seven seconds prior to impact, one of the crew members made a call to increase speed.
The stick shaker sounded 4 seconds prior to impact. One second later the speed was 103 knots, the lowest recorded by the FDR. One of the crew members made a call for go a around at 1.5 seconds before impact. The throttles were advanced and the engines appeared to respond normally.
The main landing gear and rear fuselage then struck a sea wall, just short of runway 28L. Airspeed was 106 knots. The empennage separated at the rear bulkhead.
The airplane then ballooned, yawed left and spun 360 degrees before it came to rest to the left of runway 28L, 735 m (2400 ft) from the seawall.
A post impact fire occurred when a fuel tank ruptured inboard of the no. 2 engine, spilling fuel on the hot engine, causing it to ignite.

The ILS glidepath for runway 28L and 28R at SFO had been declared unserviceable from June 1 until August 22.

PROBABLE CAUSE:
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.

17:56 UTC / 10:56 local time:
KSFO 061756Z 21006KT 10SM FEW016 18/10 A2982 RMK AO2 SLP097 T01780100 10183 20128 51005
Wind 210 degrees at 6 knots; Visibility: 10 or more miles; few clouds at 1600 feet AGL; Temperature: 18°C, Dew point: 10°C; Pressure 1010 mb

18:56 UTC / 11:56 local time:
KSFO 061856Z 21007KT 170V240 10SM FEW016 18/10 A2982 RMK AO2 SLP098 T01830100
Wind 210 degrees at 7 knots, varying in direction between 170 and 240 degrees; Visibility: 10 or more miles; few clouds at 1600 feet AGL; Temperature: 18°C, Dew point: 10°C; Pressure 1010 mb

NTSB
SKYbrary 

photo (c) NTSB; San Francisco International Airport, CA (SFO/KSFO); 06 July 2013; (publicdomain)

photo (c) NTSB; San Francisco International Airport, CA (SFO/KSFO); July 2013; (publicdomain)

photo (c) NTSB; San Francisco International Airport, CA (SFO/KSFO); July 2013; (publicdomain)

photo (c) NTSB; San Francisco International Airport, CA (SFO/KSFO); July 2013; (publicdomain)

photo (c) NTSB; San Francisco International Airport, CA (SFO/KSFO); July 2013; (publicdomain)

photo (c) NTSB; San Francisco International Airport, CA (SFO/KSFO); July 2013; (publicdomain)

photo (c) NTSB; San Francisco International Airport, CA (SFO/KSFO); July 2013; (publicdomain)

photo (c) NTSB; San Francisco International Airport, CA (SFO/KSFO); July 2013; (publicdomain)

photo (c) NTSB; San Francisco International Airport, CA (SFO/KSFO); July 2013; (publicdomain)

photo (c) NTSB; San Francisco International Airport, CA (SFO/KSFO); July 2013; (publicdomain)

photo (c) NTSB; San Francisco International Airport, CA (SFO/KSFO); July 2013; (publicdomain)

photo (c) NTSB; San Francisco International Airport, CA (SFO/KSFO); 07 July 2013; (publicdomain)

photo (c) NTSB; San Francisco International Airport, CA (SFO/KSFO); July 2013; (publicdomain)

photo (c) NTSB; San Francisco International Airport, CA (SFO/KSFO); 08 July 2013; (publicdomain)

photo (c) NTSB; San Francisco International Airport, CA (SFO/KSFO); 08 July 2013; (publicdomain)

photo (c) NTSB; San Francisco International Airport, CA (SFO/KSFO); 08 July 2013; (publicdomain)

photo (c) NTSB; San Francisco International Airport, CA (SFO/KSFO); 08 July 2013; (publicdomain)

photo (c) NTSB; San Francisco International Airport, CA (SFO/KSFO); 08 July 2013; (publicdomain)

photo (c) NTSB; San Francisco International Airport, CA (SFO/KSFO); July 2013; (publicdomain)

photo (c) NTSB; San Francisco International Airport, CA (SFO/KSFO); July 2013; (publicdomain)

photo (c) Aviation Safety Network; San Francisco International Airport, CA (SFO/KSFO); 07 July 2013

photo (c) NTSB; San Francisco International Airport, CA (SFO/KSFO); 06 July 2013; (publicdomain)

photo (c) Leslie Snelleman; Seoul-Incheon International Airport (ICN/RKSI); 14 March 2013

photo (c) Pål Leiren; Frankfurt International Airport (FRA/EDDF); 12 September 2009

Date/time	Contributor	Updates
07-Feb-2024 20:19	ASN	Updated [Damage]