On July 6, 2013, a Boeing 777 operated by Asiana Airlines was nearing its destination at San Francisco International Airport. What should have been a routine landing turned into a harrowing ordeal that claimed three lives and left dozens injured. This accident would raise serious questions regarding safety, training procedures, and the role of human factors within the aviation industry.
Let’s look at the details of the Asiana Flight 214, examining the key factors that led to this tragic event.
The aircraft involved in Flight 214
The Boeing 777-200ER, also known as Triple Seven, entered service in 1995 and swiftly earned a reputation for reliability and safety. It is basically a world’s first commercial plane completely designed by a computer.
A fresh new Boeing 777-200ER was delivered to Asiana Airlines on March 7, 2006. Prior to July 6th, 2013, it had logged 37,120 flight hours and undergone 5,388 takeoff and landing cycles.
As of 2013, in over 18 years of the Triple Seven’s operating history, Flight 214 was the first fatal accident, the second crash (following British Airways Flight 38) and the third hull loss (damaged aircraft without the possibility to repair it).
Crew and passengers involved
The cockpit of Asiana Flight 214 was manned by a skilled and experienced crew, three captains and one first officer.
Captain Lee Jeong-min, aged 49, occupied the right seat (first officer position) and served in the dual role of a check/instructor captain and pilot in command, bearing responsibility for the flight’s safe operation. With a total flying experience of 12,387 hours, including 3,220 hours on the 777, this marked his first flight in the role of an instructor.
Lee Kang-kook, aged 45, occupied the left seat (captain’s position) and was undergoing his initial operating experience. With a total flying experience of 9,793 hours, including 43 hours across nine flights (tenth during Flight 214) on a 777, he operated the controls under the guidance and supervision of the instructor in the right seat.
During the incident, Bong Dong-won, a 40-year-old relief first officer, observed from the cockpit jump seat. Lee Jong-joo, a 52-year-old relief captain, took a business-class seat with the passengers. There were twelve flight attendants on this flight.
Among the 291 passengers, 141 were Chinese, 77 were South Korean, 64 were from the United States. The remaining few hailed from Canada, France and various other countries across Asia.
Asiana Airlines Flight 214: what happened?
On July 6, 2013, Asiana Airlines Flight OZ214 departed from Incheon International Airport (ICN) at 17:04 Korean Standard Time (KST), 34 minutes later than expected (for reasons unknown). After crossing the Pacific Ocean, the aircraft was scheduled to land in San Francisco at 11:04 Pacific Daylight Time (PDT).
The weather conditions were very good, with only light winds, visibility extending to 10 miles, no precipitation, and no forecasts or reports of wind shear.
The pilot in the captain’s position received clearance from air traffic control to land and maintain a speed of 180 knots. Having deployed the landing gear and set the flaps at 30 degrees, the designated threshold speed was 137 knots. At 1,600 feet, the autopilot was disengaged, throttles set to idle, and the aircraft descended to 1,400 feet at a speed of 170 knots, reducing to 149 knots at 1,000 feet.
At 500 feet, the speed had fallen to 134 knots, three knots below the target of 137 knots. At 200 feet, the aircraft’s speed was a mere 118 knots. To put that in perspective, the takeoff or rotation speed for the Boeing 777-200ER typically ranges between 130 and 160 knots, depending on the aircraft’s weight.
It was a non-precision approach, due to the instrument landing system’s glide slope being inoperative at the runway at the time.
The instructor pilot reported observing four red PAPI lights. PAPI stands for precision approach path indicator. This is a set of visual aids installed beside a runway to assist pilots during the approach phase of landing. PAPI lights provide a visual indication of the aircraft’s position relative to the correct glide path for landing.
During this observation, it was noted that the autothrottle had failed to maintain the correct speed. Just eight seconds before impact, the throttles moved from idle forward, airspeed dropped to 112 knots, and a crew member called for an increase in speed. However, the unintended deactivation of automatic airspeed control by the pilot flying the plane made matters worse.
The stick shaker, a warning signal indicating an imminent stall, was heard on the cockpit voice recorder four seconds before impact. The airspeed then dropped to a minimum of 103 knots, falling 34 knots below the target speed. This occurred three seconds before impact.
A call for a go-around was made on the flight deck, but only 1.5 seconds were left until impact. During the accident, airspeed increased to 106 knots. The plane’s landing gear, followed by its tail, collided with a seawall. The tail and left engine were ripped off from the impact. The aircraft itself yawed left and spun 360 degrees before stopping 2,400 feet down the left side of the runway and bursting into flame.
Out of the 307 passengers and crew on board, three individuals lost their lives, 49 suffered serious injuries, and an additional 138 were injured.
Investigation and outcome of Flight 214
The U.S. National Transportation Safety Board investigation determined that the mishandling of the aircraft’s final approach by the flight crew was the primary cause of the accident. The plane’s approach airspeed had fallen well below its target and glide path. The crew failed to monitor and maintain the plane’s airspeed, or abort the landing when needed.
The pilots told NTSB that they were relying on the aircraft’s automated systems to control speed during the final descent. According to Asiana, the aircraft should have been designed in such a way that the autothrottle would maintain the appropriate speed once the pilot engaged it in ‘hold mode’. However, in the event the captain selected the wrong autopilot mode.
Also, the pilot flying the plane hesitated to abort the landing promptly when it became unstable, as he believed only the instructor pilot had the authority to make that decision.
This was attributed to a cockpit culture prevalent in South Korea where the senior captain held a supreme position. Following several airliner crashes, procedures and hierarchies were subsequently revamped in South Korea and other regions, including the United States.
Deficiencies in Boeing’s documentation of complex flight control systems and Asiana Airlines’ pilot training were also held to blame.
It was concluded that “the flight crew’s insufficient monitoring of airspeed indications during the approach 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.