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DCA13MA120

2013-07-06 · San Francisco, California, United States · Fatal · 1 aircraft · Status: Completed

Airport SFO

Aircraft involved

Probable cause & findings

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.

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-14/01. On July 6, 2013, about 1128 Pacific daylight time, a Boeing 777-200ER, Korean registration HL7742, operating as Asiana Airlines flight 214, 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 by impact forces and a postcrash fire. Flight 214 was a regularly scheduled international passenger flight from Incheon International Airport (ICN), Seoul, Korea, operating under the provisions of 14 Code of Federal Regulations (CFR) Part 129. Visual meteorological conditions (VMC) prevailed, and an instrument flight rules (IFR) flight plan was filed. The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-14/01. On  July  6,  2013,  about  1128  Pacific  daylight  time, a Boeing 777-200ER, Korean registration HL7742, operating as Asiana Airlines flight 214, 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 by impact forces and a postcrash fire. Flight 214 was a regularly scheduled international passenger flight from Incheon International Airport (ICN), Seoul, Korea, operating under the provisions of 14 Code of Federal Regulations (CFR) Part 129. Visual meteorological conditions (VMC) prevailed, and an instrument flight rules (IFR) flight plan was filed. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12

NTSB Findings

FAA avdata. C = Cause, F = Factor.

  • C Personnel issues-Action/decision-Action-Incorrect action performance-Flight crew
  • C Personnel issues-Action/decision-Action-Delayed action-Flight crew
  • C Personnel issues-Psychological-Attention/monitoring-Monitoring equip/instruments-Flight crew
  • F Aircraft-Aircraft systems-Auto flight system-Auto throttle system-Related operating info
  • F Personnel issues-Action/decision-Info processing/decision-Understanding/comprehension-Flight crew
  • F Personnel issues-Experience/knowledge-Training-Training with equipment-Pilot
  • F Personnel issues-Physical-Alertness/Fatigue-Circadian rhythms or jetlag-Flight crew
  • — Not determined-Not determined-(general)-(general)-Unknown/Not determined
  • — Aircraft-Aircraft systems-Equipment/furnishings-Escape slide-Capability exceeded
  • — Organizational issues-Management-Policy/procedure-Adequacy of policy/proc-Emergency services
  • — Organizational issues-Management-Policy/procedure-Availability of policy/proc-Emergency services
  • — Aircraft-Aircraft systems-Equipment/furnishings-Passenger compartment equip-Not used/operated
  • — Organizational issues-Management-Resources-Availability of personnel-Emergency services
  • — Organizational issues-Support/oversight/monitoring-Training-(general)-Emergency services
  • — Environmental issues-Operating environment-Communication system-(general)-Not specified

Verbatim from NTSB's published report. Source file NTSB_2013_DCA13MA120.txt. Findings + structured fields enriched from FAA avall.mdb. Full investigation docket on data.ntsb.gov ↗.

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Related research

Matched on aircraft type or causal vocabulary (go-around, autopilot, flight director). All research papers