Table Of ContentDescent 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 
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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 
iv
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 
v
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 
 
vi
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 
vii
Description:Seawall, Asiana Airlines Flight 214, Boeing 777-200ER, HL7742, San Francisco, California, July 6,. 2013. Aircraft Accident Report NTSB/AAR-14/01.