3 fatal · BOEING 777-200ER · 2013-07-06 · San Francisco, CA, USA
Event
NTSB number
DCA13MA120
Event ID
20130707X83745
Type
Accident
Date
2013-07-06
Location
San Francisco, CA, USA
Coordinates
37.613334, -122.363891
Injuries
Highest injury
FATL
Fatal
3
Serious
50
Minor
137
Uninjured
117
Total aboard
307
Aircraft
Make
BOEING
Model
777-200ER
Registration
HL7742
FAR Part
129
Engines
2
Damage
DEST
Conditions
Light
DAYL
Weather
VMC
Probable cause
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.