On July 6, 2013, the flight crew of Asiana Airlines Flight 214 mismanaged the final landing approach to San Francisco International Airport, crashing into a seawall and causing the 777 to cartwheel across the edge of the runway. NTSB investigators were divided over the main cause of the crash – was it due to pilot error or the complexities of flight deck automation? In the end, the NTSB decided that both factors contributed to the accident, and the Board made several recommendations that ultimately improved pilot training and cockpit design and drew attention to the dangers of malfunctioning emergency chutes. The crash also led to further FAA actions related to the perils of too much automation in flying. 

Asian 214 Prepares for Landing at Busy San Francisco International Airport

It is July 6, 2013, and Asiana Airlines Flight 214 is about 30 minutes away from landing at San Francisco International Airport.  As many of us who have traveled before may know, San Francisco International (or SFO) operates flights 24 hours a day. As of 2018, SFO experienced an average of about 1,300 flights each day. And aviation experts say it is one of the more difficult airports to land planes. According to a news article from the Associated Press in 2019, longtime American Airlines pilot Chris Manno said the runways are close together, requiring extra attention when landing. Aviation consultant John Cox said the airport’s location along the San Francisco Bay as well as the air traffic and overall design adds additional complications. The airport has a recent history of near-misses when it comes to landings. The general consensus among pilots is that when it comes to landing at SFO, experience really counts. 

And on this day in July 2013, the situation is no less busy as Flight 214 begins to prepare for its landing. The flight took off nearly eleven hours ago from Seoul, South Korea, with 291 passengers onboard. 

Among the passengers are 141 Chinese nationals, 70 of which are teenagers and their teachers on their way to attend camp in the United States. Joining this group are also a collection of international business travelers. 

The aircraft is a Boeing Triple Seven (777), which is an American wide-body airliner developed and manufactured by Boeing Commercial Airplanes. It is the world's largest twinjet. It can accommodate a ten-seat wide seating layout and has a typical 3-class capacity of up to 368 passengers. It is recognizable for its large-diameter turbofan engines, six wheels on each main landing gear, fully circular fuselage cross-section, and a blade-shaped tail cone. It is the first Boeing aircraft with fly-by-wire controls.

Asiana Airlines Flight 214 Crew Featured a Flight Instructor and Captain in Training

The aircrew of Flight 214 consists of three captains and one first officer. Captain Lee Jeong-min is fulfilling the dual role of a check/instructor captain and pilot in command and has overall responsibility for the flight. He has over 12,000 hours of flying experience, of which 3,220 hours were in a Triple Seven. This is his first flight as an instructor.

Captain Lee Kang-kook is the pilot flying and was receiving his initial operating experience (IOE) training and was halfway through Asiana's IOE requirements. He had almost 10,000 hours of total flying experience, of which 43 were in the Triple Seven over nine flights and under the supervision of the instructor in the right seat. Relief first officer Bong Dong-won was observing from the cockpit jump seat. And the second relief captain, Lee Jong-joo, occupied a business-class seat in the passenger cabin. Twelve flight attendants are also on board. 

At quarter of 11 a.m. local time, the pilots are busy completing the descent checklist and make important inputs to prepare for a safe landing. As the flight proceeded towards SFO, it was cleared to descend to lower altitudes and vectored to intercept a straight-in approach to runway 28L. The Captain flying called for “gear down”, which is essentially like putting on the breaks in a car – the landing gear and the flaps start to slow the plane down. In the cabin, the flight attendants begin to prepare passengers for arrival. 

Flight 214 has been approved for a visual approach to runway 28L, which means that air traffic control (ATC) has authorized them to proceed visually to the airport. Basically, the pilot will need to hand fly the plane during the landing sequence. 

Now less than one minute away from the airport, passengers who have a window seat in the cabin notice something is wrong. Looking out their windows, many passengers later reported seeing the usual pier jutting out from the end of the runway – but this time, the pier was much closer than they would expect it to be, and the plane seemed to be flying much lower over the water than previous flights many passengers had experienced. 

Asiana Flight 214 Hits Seawall and Tumbles Across Runway

Suddenly, in the cockpit, the stick shaker sounded, warning the pilots that a collision with the ground was imminent. The Captain in command takes control from the trainee Captain and tries to ascend as quickly as possible by pulling the plane’s nose up. But it is too late.

The tail section of Flight 214 slams against the seawall just feet from the edge of the runway. The impact causes the entire tail section, complete with many rows of passengers, to snap off and spin away. The force of this break causes many passengers to be thrown from the plane, including four flight attendants seated at the back of the plane and three passengers. While the tail section breaks away, the remaining fuselage continues to skid, spinning across the runway in a terrifying pirouette. 

For a brief and terrifying moment, the fuselage rises 30 feet high above the ground, then cartwheels and careens across the asphalt.  The destroyed plane finally comes to a halt with the wings miraculously still attached but badly damaged.

In the cockpit, all the pilots have amazingly survived. The Captain in command radios in to the control tower that Flight 214 has declared an emergency and requires rescue personnel, which the tower confirms back that they are already on their way. The controllers have witnessed the crash.

Rescue vehicles race to the scene and see immediately that time is of the essence – there is a fire beginning to burn in the main fuselage and they must work to extinguish it before it engulfs the entire remaining plane. 

Most Evacuation Chutes on Asiana Airlines Flight 214 Failed to Deploy 

And even with the evacuation, challenges begin almost immediately. On the Tripe Seven there are 8 emergency chutes that should inflate in this type of crash landing. But only 2 slides have deployed and of the remaining six slides, 2 opened inside the plane. One of those slides trapped a flight attendant, crushing her beneath its weight. Passengers quickly grab onto the onboard crash axe and start hacking away at the chute, finally freeing the flight attendant and preventing her from suffocating to death. 

The following passenger accounts were shared in a CBS News article linked in our episode show notes. Passenger Ben Levy said that once the plane skidded to a halt, he stood up and opened the exit door. Looking outside the plane, he could not believe what he saw: a piece of the wing was gone and there was debris strewn across the runway. But there was one thing to be thankful for: they were on the ground and not in the middle of the bay. The emergency chute did not deploy, but luckily, the debris had crushed in such a way that passengers could climb down it to the safety of the ground. Levy started to help other passengers off the plane, trying to keep them calm and telling them not to worry about their bags. He reported that the scene in the cabin was chaotic, but not panicked. Levy helped who he could, then tried to return and help a few more people, but someone grabbed him and pushed him out.

Other passengers slid down the inflatable emergency chutes, some running when they touched the ground and others walking away. One man told a relative later that there was so much smoke it was hard to breathe.

Passenger Eugene Rah told the TODAY show that he looked out the window as the plane descended and “knew something was going wrong.” He said he was not sure how long the chaos of the crash itself lasted, but afterward all he heard was silence. Then the pilot asked people to evacuate the mangled plane, he said.

Fellow passenger Vedpal Singh, who was sitting in the middle of the aircraft with his family, told The Associated Press that there was no warning before the plane landed hard. Then he heard a loud sound.  "We knew something was horrible wrong," he said. "It's miraculous we survived." Singh, who suffered a fractured collarbone and had his arm was in a sling, told the AP the plane went silent just before people tried to get out any way they could. 

San Francisco Fire Chief Joanne Hayes-White said that firefighters arriving at the scene found people in the shallow water of the bay beside the tarmac, presumably dousing themselves after the fire on the plane.

Flight Attendants Hailed as true Heroes of Asiana Airlines Flight 214 Crash 

With most stories of crashes that have survivors, we also have heroes. Astonishing photos taken moments after Flight 214 smashed into the tarmac show flight attendant and cabin manager Yoon-hye Lee heroically carrying passengers to safety on her back. The images, taken by a passenger after they fled the smoldering wreckage, show the slight woman hauling victims away from the crash site. Passengers described seeing Lee carrying people twice her size and making sure no one was left behind. Lee had unknowingly broken her tail bone as she rushed to save others, but as she explained during a press conference on Monday, “I had to hurry, I couldn't think of danger to myself.” Lee said she was the last person off the aircraft and added that one other flight attendant, Kim Ji-yeon also put a scared and injured elementary schoolboy on her back and slid down a slide.

When Asiana 214 finally came to a stop, senior flight attendant, Tae Sik Yoo saw the fire outside the second door on the right side of the aircraft. He ordered an evacuation even before the cockpit crew and flight services manager realized the danger.

In his interview with investigators, Yoo said, “I thought to myself, the crew does not know what is happening in the rear of the aircraft.” According to his statement, he made two emergency announcements and started the evacuation. 

Three of the 291 passengers died. Forty passengers received serious injuries, including eight of the 12 flight attendants, and one of the four flight crewmembers. The other 248 passengers, four flight attendants, and three flight crewmembers received minor injuries or were not injured. Relief First Officer Bong Dong-won received medical treatment for a cracked rib; however, none of the other pilots needed hospital care. The four flight attendants seated at the rear who were ejected from the aircraft when the tail section broke off all survived. Six flight attendants received physical and emotional treatment. 

Asiana Airlines Flight 214 Fatalities were Teenagers on Their Way to Camp

Sadly, the three passengers that had been ejected from the plane died. They were teenage girls from China on their way to a summer camp in the United States, according to airline officials and Chinese news outlets. Asiana Airlines identified two of the girls as Ye Mengyuan and Wang Linjia, both 16. In a tragic twist of events, rescue vehicles had run over Ye Mengyuan two different times as she lay on the tarmac, and her body was heartbreakingly later discovered under the foam used to douse the fire. But an autopsy revealed that her death was caused by the impact force of the ejection and not from either of the fire trucks. A third teenager also died due to the ejection, but due to her age and at the request of her family, authorities did not release her name to the public. 

When all was said and done, the impact forces and a post-crash fire destroyed the airplane that was Flight 214. Shortly after the crash, the global news media descended upon the scene at the airport, and images of the charred wreckage of Flight 214 quickly spread around the world. 

It also caused a few would-be passengers to communicate that they were NOT onboard. Facebook executive Sheryl Sandberg was scheduled to be on the flight, but she changed her plans at the last minute. Her friend David Eun was on the Asiana flight, but he escaped the accident physically unharmed. And David Eun happened to snap one of the most iconic pictures of the crash – the image that shows the plane right after it crashed with passengers running away from the mangled fuselage. 

The NTSB Intern Who Mistakenly Verified the Asiana Pilots’ Names Got Fired 

Following the crash, in a bizarre story, local news station KTVU ran a story on the crash, and within it, supposedly named the pilots. But here is what was wrong: the names of the pilots were fake. The names mentioned by the newscasters were Wi Too Lo, Ho Lee Fuk, and Captain Sum Ting Wong. And in the news story, the reporters say the NTSB confirmed the names of the pilots. But we know that the NTSB never, ever confirms names of crew. And the NTSB employee who confirmed them was an intern. The names were obviously made up and offensive. The intern apologized but was later fired by the NTSB.  It's still not clear where the names came from, though the San Francisco Chronicle notes that they probably originated from someone at the station who was pulling a prank.

Investigation Immediately Rules Engine Failure, Weather as Cause of Asiana 214 Crash 

At the time, Flight 214 was the first fatal accident involving a Triple Seven. Since then, of course, we have had Malaysia Airlines Flight 370 (which vanished over the Indian Ocean) and Malaysia Airlines Flight 17 (which was shot down by a missile) both in 2017. For the NTSB, this is a high-profile investigation not only because of this fact, but also because images of the wrecked plane were all over the global news. 

It is immediately clear from the damage to the seawall that this is where the plane first struck the ground. Two things that investigators quickly rule out is engine failure (because both engines were operating at full power at the time of the crash) and the weather (because it had been a clear, calm day with great visibility). 

Asiana Airlines Flight 214 Crash Survivors Tell of Difficult Evacuation, Failed Emergency Chutes 

This time, the NTSB has the immense privilege of interviewing survivors who were passengers onboard at the time of the crash, and they tell investigators they could tell the plane was too close to the water and pier as it was descending. The passengers also describe the sudden and violent collision with the ground, the subsequent pirouetting of the airplane, and the difficult evacuation caused by malfunctioning emergency slides. And the NTSB knows the truth that the passengers on Flight 214 simply got lucky in their evacuation: had the fire burned more rapidly, more people would have died.

Investigators need to understand why the emergency chutes did not deploy the way they were designed to do. The NTSB used a test crash facility like the ones that are used for car crash testing to find out the deployment capacity of the chutes. What they find is remarkable and disturbing – in a high-speed impact like Flight 214, which had an airspeed of 191 kmh or 119 mph, the inflation mechanism can fail. The chutes opened more consistently when the impact was at a much lower speed. This revelation is very concerning considering that most plane crashes do not happen at a low rate of speed. 

And not having the chutes to help passengers escape a plane puts the passengers’ safety at risk as they exit a plane. In fact, passenger Ben Levy, who was helping people get out, told the BBC he saw “a family, a husband and wife, holding their kids ... and just falling off.” 

An investigation by NBC later that year in 2013 discovered that the NTSB had been raising concerns over evacuation slides’ reliability with the Federal Aviation Administration (or FAA) for years. A study the board conducted in 2000 found that at least one evacuation slide did not properly function 37 percent of the time. 

Former FAA investigator David Soucie told NBC that the agency’s recommendations for improvements were unfulfilled. The FAA responded by saying it felt it had enough recommendations in place to make it safe already. 

Just two months before the crash of Flight 214, the FAA issued an airworthiness directive for slides on the same model Triple Seven planes, saying the slides were not properly deploying. Airlines had three and half years to address problems raised in the directive. However, the FAA directive may not have made a difference to Flight 214 since the FAA has no jurisdiction over planes registered outside the U.S., and with Asiana Airlines being a South Korean airline, it is up to those air regulators to enforce safety on all Asiana flights.

The final NTSB report on Asiana Flight 214 includes recommendations regarding the slides, and specifically, to conduct additional evaluation of the adequacy of slide/raft inertia load certification testing. The Board said that the forces experienced by the slide/rafts during the impact sequence far exceeded their certification limits, leading to overload failures of the slide/raft release mechanisms. They went on to say, given the critical nature of these evacuation devices and their proximity to essential crewmembers, slides and slide/rafts must be certified to sufficient loads so that they will likely function in a survivable accident. Though the NTSB acknowledged this exact accident scenario that happened on Flight 214 is unlikely to occur again, they felt the data obtained during this accident investigation could prove useful for future slide/raft design.

Automated escape slides have evolved since this accident, becoming more efficient and effective, according to a representative from Boeing quoted in an article for Aircraft Interiors International. Still, the rep acknowledges there is more to be learned from actual escape situations, saying, “We’re not at the pinnacle of design.”

Asiana Airlines Flight 214 Crash Shows Strengths and Weaknesses of 777 Interior Design 

Because of Asiana 214, investigators were able to learn about the impact forces on the interior of the fuselage. And this accident was the latest example of how past air disasters have created safer cabin interiors that are helping to save lives now. During the impact, the rear fuselage separated, and the rest of the aircraft continued on – becoming airborne briefly as it rotated 330°. Then the belly of the aircraft slammed onto the ground. Cabin structures including seats, overhead bins, galleys, and lavatories experienced g-forces in excess of that for which they were designed. And in some cases the structures failed, but still offered protection to the occupants in the cabin and cockpit. Basically, experts said, the aircraft did exactly what designed wanted it to do – the fuselage and the seating systems worked together to absorb the impact energy.

The biggest advances in cabin safety – stronger seats and fire-retardant cabin materials – came about in the 1980s when seat manufacturers were required to work on the impact a seat could withstand and remain intact and increase it from nine times the force of gravity to 16 times. And when it comes to designing an airplane seat, protecting the head in a sudden stop is an important component to survivability. And this is what happened during the rough landing of Flight 214. 

Seats were most damaged in the C section of the passenger cabin. From row 36 and beyond, there were several instances in which supports were broken and seat rows were knocked down so that the backs were facing the ceiling. In one instance, a seatback was reclined onto another. When a seat or seat row falls onto another, it can cause serious injuries, obstruct evacuation or trap passengers. 

A flight attendant on the Asiana flight reported that a woman seated in 42E was stuck in her seat until a man “kicked and punched the seat, breaking it forward so the woman could get out”. Even then, the woman’s leg injury made her unable to move on her own, the attendant reported.

The 16g tests are designed to ensure that the seat stays attached to the aircraft structure, and in many cases that goal was successful. 

But after looking at the video of the Asiana accident and photos of the aircraft interior, one expert said he thought, “Wow, that’s a level of movement in an aircraft in a crash that must be in excess of what we actually test for.” 

With Asiana Airlines Flight 214, according to the NTSB report, there was a high number of serious injuries to passengers’ high thoracic spines, and the mechanism that produces these injuries is poorly understood. The Board recommended additional research be conducted that examines the injury potential from significant lateral forces in airplane crashes and how seat design can mitigate those injuries. 

Investigators Name Pilot Error as Probable Cause of Asiana 214 Crash

Getting back to the cause of the crash itself, investigators quickly focus on the pilots since so many other factors could be safely ruled out as causing the crash, including engine failure, weather, and air traffic control factors. None of those elements caused the crash. And because other flights successfully landed that day shortly before Flight 214, investigators must consider how a human performance error may have contributed to the accident. 

One element that comes to their attention early on is that the glide slope was out of service for the runway Flight 214 was landing on. As we have mentioned in other episodes, the glide slope sends signals to the plane’s autopilot and helps to guide the plane to the ground at a precise angle. But at the time Flight 214 was landing, this is switched off. But the pilots knew about that.

And then the investigative team align the two flight recorders to get a full picture of what was happening in the cockpit at the time of the landing – and what they find prompts even more questions.

As the plane is just one minute from the runway, the engines go to idle. This is odd since a plane needs more power upon landing to counter the drag created by the landing gear and the flaps. And the team knows there was nothing mechanically wrong with the engines. So why were the engines running at idle at this critical moment in the flight?

Here is what they find out. As the plane nears the runway, signs of trouble begin to unfold in the cockpit. The plane isn’t descending fast enough to make the landing. Remember, at SFO, planes are often coming in very fast and very steep and then must get to a specific altitude quickly to be able to make the landing. The Captain in command takes actions to fix the rate of descent problem, but he doesn’t tell the trainee Captain, who is the one actually flying the plane.

Then, the Captain in command switches the autopilot to an incorrect setting known as the flight level change mode, which disrupts the landing and tells the plane to climb to a pre-entered altitude that is known as the go around altitude. This switch of a setting makes the plane climb, which is not at all what it should be doing during a landing sequence. But the Captain in command notices the error he just made and starts to pull back the throttles to idle power to slow the plane down and bring it out of the climb. 

But here is the issue with all of these actions – the Captain in command does not make any callouts to the trainee Captain who is the one who ultimately must land the plane. What we have is a situation where one’s Captain’s actions have put the plane’s engines into idle during a landing when the engines should be at high power, and the Captain who is flying the plane has not been told about any of this. 

Asiana Pilot Nervous About Landing at SFO Before Crash

Investigators interview both pilots to understand from their perspectives what was happening. The trainee Captain admits to the team that he was very nervous about landing at SFO without the glide slope. But as so many pilots have said in news articles related to this crash, the glide slope was completely unnecessary. Landing a plane by hand on a clear day is one of the most basic and initial things that any pilot learns how to do. And when investigators tell the trainee Captain about the engines being at idle during the time of the crash, he says he has no idea why the plane’s engines would be at idle power. And both pilots thought that the plane’s auto throttle system, which regulates air speed automatically at the different phases of a flight, would kick in and regulate the speed and keep them safe. 

What investigators find is that the inputs made by the Captain in command leading up to the crash actually ended up causing the auto throttle system to switch off. The Captain in command chose an autopilot setting that was not supposed to be used during a descent and then he pulled back on the throttle levers when that same setting put the plane into a climb. These actions essentially made the plane a giant glider.

And when investigators ask the trainee Captain why he had not noticed the change in airspeed as the engines were at idle power, the Captain basically reveals that he was overwhelmed with learning to fly the Triple Seven and was hyper-focused on making the landing. 

But there was a physical sign that would have told the pilots that they were lining up correctly with the runway. As the plane got closer to the runway, the runway’s PAPI (precision approach path indicator) changed colors to show the pilots that the plane was coming in too low. But the Captain in command, who was serving as the flight instructor that day, did not intervene quickly enough. This is his first time as a flight instructor, and he essentially did not have the experience to know at what point do I step in and take over.

And when the team looks at the experience of the trainee Captain, who had been flying the plane, they found training records that revealed he was having trouble adjusting to the Triple Seven. Most of his career had been spent flying the A320, which is very different from the Triple Seven. And, Asiana Airlines had a policy at the time that pilots should use the autopilot for as much of the flight as possible, which meant that while the trainee Captain had almost 10,000 flight hours – barely any of those hours were spent hand flying the plane. And the landing at SFO was his first manual landing. He was basically a beginner when it came to landing the plane himself. 

The Captain in command on Flight 214 said the airline recommended using as much automation as possible. One of the airline’s simulator instructors told investigators that pilots avoided flying manually over concerns they might do something wrong, and the company might blame them for a less-than-perfect landing.

These findings spark a debate across the investigative team about which came first: the overreliance on automation or these specific pilots’ error which caused the crash of Asiana Flight 214? 

NTSB Says Pilot Error, Automation Led to Asiana Flight 214 Crash

The NTSB determined that the flight crew mismanaged the initial approach, and that the airplane was well above the desired glidepath as it neared the runway. In response to the excessive altitude, the captain in command selected an inappropriate autopilot mode and took other actions that, unbeknownst to him, resulted in the auto throttle no longer controlling airspeed. As the airplane descended below the desired glidepath, the crew did not notice the decreasing airspeed, nor did they respond to the unstable approach. The flight crew began a go-around maneuver when the airplane was below 100 feet, but it was too late, and the airplane struck the seawall.

As a result of this accident investigation, the NTSB made recommendations to the Federal Aviation Administration, Asiana Airlines, The Boeing Company, the Aircraft Rescue and Firefighting Working Group, and the City of San Francisco.

These recommendations address the safety issues identified in the investigation, including the need for reinforced adherence to Asiana flight crew standard operating procedures, more opportunities for manual flying for Asiana pilots, a context-dependent low energy alerting system, and both certification design review and enhanced training on the Boeing 777 auto flight system.

The recommendations also address the need for improved emergency communications, and staffing requirements and training for aircraft rescue and firefighting personnel. 

The crash is a telling example of the perils of too much of a good thing in the cockpit — automation. While flight experts credit automated systems with helping improve safety and making airline operations more efficient, they caution that an overreliance on automation leaves pilots unprepared for tricky situations that require their expertise. 

A 2016 government report by the Office of the Inspector General echoes the warnings on over relying on automation, and says the FAA needs to do more to make sure that airlines ensure their pilots effectively monitor automated systems and keep their manual flying skills sharp.

The report warns that as aviation technology advances, pilots will have fewer chances during flights to keep their manual skills sharp. These abilities will likely diminish, which could prove disastrous in a situation where a human pilot needs to take control.

Asiana Airlines Apologizes, Settles with Families Following Flight 214 Crash 

The leadership at Asiana Airlines publicly apologized for the deaths of the three teenagers just one day after the accident. The U.S. Department of Transportation fined Asiana Airlines $500,000 for failing to assist families following the crash of Asiana flight 214 in San Francisco in July.

According to a report by CNN, the Korean airline was slow to publicize a phone number for families, took two full days to successfully contact the families of three-quarters of the passengers and did not contact families of several passengers until five days following the crash, authorities said. The half-million-dollar penalty is the first time the DOT has issued a fine under a 1997 law that requires airlines to adopt and adhere to a “family assistance plan” for major accidents.

Following the crash, Asiana Airlines reached a settlement with many passengers for their personal injury claims that stemmed from the crash. The terms of the settlement are confidential.

When the final NTSB report came out in 2014, the airline said, "We believe the National Transportation Safety Board (NTSB) has properly recognized the multiple factors that contributed to the accident…” The airline went on to say that they implemented all four training recommendations made by the NTSB, and since the accident, has implemented its own enhanced flight crew training and evaluation, strengthened flight instructor training, enhanced crew resource management training, and revamped their safety management structure.

And THAT is the story of Asiana Airlines Flight 214.