A Sunny Day in San Francisco: The story of Asiana Airlines flight 214

Admiral Cloudberg
46 min readJun 6, 2023
An NTSB investigators stands behind the burned-out hulk of Asiana Airlines flight 214. (Reuters)

On the 6th of July 2013, an Asiana Airlines Boeing 777 descended too low on approach, clipped a seawall short of the runway, and crashed to earth with a dramatic pirouette and a great cloud of dust. As hundreds looked on, the doors opened, the slides deployed, and the passengers and crew evacuated the burning airplane, carrying with them their remarkable stories of survival. Just three were not so lucky, all teenage girls from China, including two who were thrown from the plane as it spun around nearly 360 degrees. Nevertheless, the crash captivated a nation and ended the Boeing 777’s 18-year fatality-free record. So why did the pilots end up on a collision course with the seawall, flying too low and too slow in the seconds before the crash? In the end there was no simple answer, but rather a confluence of circumstances, rooted in the interactions between pilot and computer, as a trainee captain tried to salvage an approach that was going increasingly off the rails. The crash highlighted the ways in which airlines were neglecting key piloting skills, raised questions about the rising complexity of aircraft automation, and led to competing narratives and blame over potentially deadly errors during the emergency response. Only now, with the benefit of a decade of hindsight, are some of these questions — and the industry’s answers — beginning to find their place in the historical arc of aviation safety.

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HL7742, the aircraft involved in the accident. (Aero Icarus)

Founded in 1988, Asiana Airlines was the first independent airline in South Korea, and to this day it remains the largest private competitor to flag carrier Korean Air. Asiana’s passenger fleet features a substantial cohort of 45 wide body airliners, including 9 Boeing 777s, down from 14 a decade ago. The 777 (pronounced “triple seven,” never “seven seven seven”) is the world’s largest twin-engine jet, with a capacity for between 300 and 400 passengers depending on the configuration, and with over 1,700 built since 1994, it remains one of the most popular wide body airliners ever made. From its entry into service in 1995, it was also one of the safest, lasting 18 years with no fatal accidents — until Asiana Airlines received the unfortunate distinction of having ended that streak.

The flight in question was a regular overnight transpacific service from Seoul, South Korea to San Francisco, California. Designated flight 214, the route was normally served by a Boeing 777, of which the unlucky aircraft assigned to the flight on July 6th, 2013, was an unremarkable example. No major defects had been reported, and indeed the flight would end up being utterly normal until the final five minutes.

With an augmented crew of four pilots and 12 flight attendants, the flight departed Seoul that morning under the command of 49-year-old newly minted Instructor Captain Lee Jeong-Min, an experienced Boeing 777 pilot with over 12,000 flying hours, including over 3,000 in the 777. Lee had just finished instructor training and for the first time was now supervising a trainee of his own: 45-year-old Captain Lee Kang-kook, who had just upgraded to the 777 after six years as Captain on the Airbus A320. Although he had over 9,600 flying hours, only 43 of them were on the Boeing 777, and he was still completing the probationary period known as Initial Operating Experience, during which he flew from the left seat while an instructor occupied the right seat.

Note: Because Lee Jeong-min and Lee Kang-kook have the same family name, I will be referring to them either by their full names or by their positions (“trainee Captain” and “Instructor Captain”) rather than by their family names as I normally do.

The route of Asiana Airlines flight 214. (Own work, map by Globe Turner)

With 291 passengers in the back, the two Captains flew the takeoff and first part of the cruise phase of the 10-hour flight, before retiring to the business class cabin to catch some sleep and avoid exceeding duty time limits. Passengers might have seen them splayed out on the reclining seats, while the relief crew, consisting of 40-year-old Relief First Officer Bong Dong-won and 52-year-old Relief Captain Lee Jong-joo, took over command of the flight deck.

The cruise phase passed without incident, however, and after approximately five hours, the original crew awoke and made their way back to the cockpit. Trainee Captain Lee Kang-kook was the first to return, whereupon Relief Captain Lee Jong-joo informed him that they were expecting a localizer approach to runway 28 Left at San Francisco, and that he had already set up the approach in the plane’s flight management computer.

Ten minutes later, Instructor Captain Lee Jeong-min also emerged from the business class cabin, and at 9:55 US Pacific time, the two primary crewmembers relieved the relief crew. After settling in, Lee Kang-kook led the approach briefing, during which he noted — apparently not for the first time — that the glide slope equipment for runways 28 Left and 28 Right was out of service. Normally, an instrument landing system, or ILS, comes with both lateral and vertical guidance, in the form of a localizer, which helps the plane align with the runway, and a glideslope, which helps the plane maintain an optimal 3-degree descent path. At that time, however, construction was underway to expand the runway overrun areas on the parallel runways 28R and 28L, requiring the temporary removal of the ILS equipment, and only the localizer had been reinstalled. The Federal Aviation Administration had issued a Notice to Airmen, or NOTAM, informing pilots that the glideslope would be out of service until August, which had been included in the Asiana pilots’ briefing materials.

Differences between a full ILS approach and an approach with only a localizer. (Pilot Cafe and Tech Explore, captions mine)

The absence of the glideslope meant that while the crew would have help aligning with the runway, they would need to manage their descent profile themselves, achieving the proper descent rate, forward airspeed, and flight path angle without the benefit of ground-based aids. However, the weather was fine, with few clouds in the sky and near unlimited visibility, and the landing aids were hardly needed; in fact, the crew fully expected that air traffic control in San Francisco would clear them for a visual approach, in which the primary landing aid is the pilot’s eyes.

Although visual approaches have historically been a pilot’s bread and butter, trainee Captain Lee Kang-kook was nervous. He had never flown to San Francisco before, and even more importantly, he had never flown a real approach in the 777 without the benefit of a glideslope. This would be his first time attempting to do so outside a simulator, and he was far from confident in his energy management skills. But he never voiced his concerns — after all, he was the captain on a Boeing 777, and there was an expectation that he would know how to fly it. Besides, every other pilot landing in San Francisco that day was flying the same approach, and none of them were having any trouble, so to admit that he was unprepared would be a major embarrassment. In any case, he probably assumed that if he made a mistake, the instructor would point it out — after all, that was why the instructor was there, right?

Approaching the San Francisco Bay Area, the pilots now ran through the descent checklist, verifying various items, including their landing reference speed, or Vref, which Lee Kang-kook confirmed was 132 knots.

At this point, Relief First Officer Bong Dong-won returned to the cockpit, where his job was to act as an extra set of eyes during the descent and approach, compensating for the distraction imposed on Instructor Captain Lee Jeong-min by his instructional duties. At first, however, he had little to do, and as flight 214 received several progressive clearances to descend toward the airport, all appeared to be normal. In fact, the pilots took a moment to absorb the scenery on approach to the famed city: “Ah, I can see San Francisco well!” said Lee Jeong-min. “That bridge leads to Oakland,” he added, pointing out the San Francisco Bay Bridge.

“Is that the Golden Gate?” asked Lee Kang-kook.

“The Golden Gate is over there,” said Lee Jeong-min, pointed toward a white wall blanketing the west side of the city — San Francisco’s signature fog. “This is to Oakland, and it leads to Sacramento, which is the capital of California, and the location of University of Berkeley,” he continued, muddling his geography slightly.

“Yeah. Ah,” said Lee Kang-kook.

“Golden Gate is that side, but can’t see it because of clouds,” Lee Jeong-min concluded.

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Minutes later, descending through 6,300 feet, the pilots reported the airport in sight, and the controller cleared flight 214 for a visual approach to runway 28L, as expected. One minute later, the signal from the localizer was detected, and the autopilot automatically began aligning the plane with the runway. Now came the part that Lee Kang-kook was worried about: managing the steady descent to the runway, while simultaneously reducing their speed from 215 knots to the target approach speed of 137 knots, or Vref + 5. Every approach faces this basic contradiction — namely, that descending tends to cause airspeed to increase, while a plane descending for landing needs airspeed to decrease. Accomplishing both simultaneously, while also accounting for changes in lift and drag as the flaps and landing gear are extended, is without question the hardest part of any manually flown approach.

When the 777 is following the signals from a glideslope, the autopilot and autothrottle can automatically perform all the required changes in pitch angle and engine thrust that are needed to maintain the optimal 3-degree glide path. This is the way ILS approaches are normally flown. Without a glideslope, however, the pilot must perform these actions themselves. This sometimes means disconnecting all the automation and flying the approach by eye, but more often than not in the 777 it means making strategic inputs using the Mode Control Panel, or MCP, where pilots can select target airspeed, descent rate, and altitude values, which the autopilot and autothrottle will work together to achieve.

An overview of the Mode Control Panel. (NTSB)

The autopilot, which manipulates the control surfaces, and the autothrottle, which controls engine power, can be engaged in various modes that help them achieve the parameters selected by the crew. The crew should be aware of what mode these two systems are in at all times, and will often decide to change the active mode in order to better achieve their goals. Three modes may be engaged at a time: a lateral mode, a vertical mode, and an autothrottle mode.

Throughout the approach and accident sequence, the lateral mode was set to Localizer (LOC), where it tracked the localizer signal. The details of the lateral modes were not a factor in the accident and will not be discussed. However, several vertical modes and autothrottle modes will soon become important to the story, and are described below.

1. Vertical Speed (V/S) — in this vertical mode, the autopilot pitches the plane up or down in order to achieve a climb or descent rate selected by the crew in the MCP (e.g., “-1,000 feet per minute”). Additionally, when the vertical mode is V/S, the autothrottle normally switches automatically to Speed (SPD) mode. In SPD mode, the autothrottle increases or decreases engine thrust in order to achieve an airspeed selected by the crew in the MCP.

2. Flight Level Change Speed (FLCH SPD) — in this vertical mode, the autopilot pitches the plane up or down in order to achieve an airspeed selected by the crew in the MCP. Pitching up causes airspeed to decrease, and pitching down causes airspeed to increase. When the vertical mode is FLCH SPD, the autothrottle normally switches automatically to Thrust (THR) mode, in which it increases thrust to gain altitude or decreases thrust to lose altitude. The autopilot will automatically level the plane when the altitude reaches a value selected by the crew in the MCP, but the rate of altitude change is not directly controlled.

3. Hold (HOLD) — in this autothrottle mode, the autothrottle motor is disconnected from the thrust levers and it can make no inputs. The autothrottle can enter HOLD mode from either mode described above if the pilot overrides the autothrottle and moves the thrust levers manually, or, if the vertical mode is FLCH SPD, when the thrust levers reach the flight idle position (minimum thrust).

Lastly, it’s worth noting that when the autopilot is disengaged, target values set in the MCP are sent to the Flight Directors instead of the autopilot. The Flight Director (FD) is an overlay on the pilot’s attitude indicator that highlights the target pitch and roll angles that the pilot must achieve in order to reach and maintain the MCP airspeed, descent rate, or altitude, or a pre-programmed track. In essence, the FD helps the pilot more easily step into the role of the autopilot, and the autothrottle will continue to work in one of the modes described above (usually SPD) in order to assist the pilot, if desired.

All currently active modes appear here, on the Flight Mode Annunciator, located on each pilot’s primary display. (NTSB)

If we return now to the cockpit of Asiana Airlines flight 214 at approximately 11:23 local time, as the plane was descending through 5,300 feet, we can note the following. First of all, the active vertical mode was FLCH SPD. The pilots had selected a target MCP altitude of 3,100 feet, and the plane was in a descent toward this altitude with the thrust levers at flight idle, which meant that the autothrottle had entered HOLD mode. The target MCP airspeed was 212 knots, and the autopilot was modifying their pitch angle in order to maintain this speed. The lateral mode was set to LOC and the plane was turning to align with the localizer. So far, so good.

At that moment, Instructor Captain Lee Jeong-min said, “Let’s descend slowly to one thousand eight hundred feet,” which was the minimum altitude at waypoint DUYET, located about 5.4 nautical miles from the runway. DUYET was the final approach fix when flying an instrument approach to runway 28L, but since they were flying a visual approach, there was no requirement to cross DUYET at any particular altitude. However, an altitude of 1,800 feet at DUYET was consistent with the optimal 3-degree glideslope, so the pilots considered it to be a handy benchmark to ensure that they were on course. In response, trainee Captain Lee Kang-kook changed the target MCP altitude to 1,800 feet.

Seconds later, the San Francisco approach controller called flight 214 and said, “Asiana two one four heavy, reduce speed to one eight zero, maintain that till five mile final, there’s traffic behind and to the right that does have you in sight.”

In response to the controller’s request, trainee Captain Lee Kang-kook decreased the target MCP airspeed to 180 knots. Shortly after that, he called for flaps five, and after briefly waiting for the airspeed to drop below the maximum for this flap setting, Instructor Captain Lee Jeong-min extended the flaps to five degrees.

(Own work)

At this point the first signs of a problem were already beginning to develop. When Lee Kang-kook decreased the target MCP airspeed to 180 knots, the autopilot began pitching the nose up to reduce airspeed, according to the working logic of the FLCH SPD vertical mode, described above. However, because the thrust levers were already at flight idle, the autothrottle could not reduce thrust any further to compensate. Therefore, the plane’s descent rate became shallower, reducing from -900 feet per minute to only -300 feet per minute. On the pilots’ navigation displays, an arc depicting their projected descent path now clearly showed that they would cross the DUYET waypoint well above the desired 1,800 feet.

The pilots were now in a situation where their current configuration, including both physical controls and autoflight modes, was such that the desired descent path could not be achieved. One way to rectify the situation would be to deploy the speed brakes, which reduce the lift generated by the wings and increase the descent rate, but this was not done.

Instructor Captain Lee Jeong-min quickly noticed the problem, however, and he made an unintelligible comment about it, to which trainee Captain Lee Kang-kook replied, “Yeah, I am descending now.” To accomplish this, he pressed the V/S button on the Mode Control Panel, changing the active vertical autopilot mode from Flight Level Change Speed (FLCH SPD) to Vertical Speed (V/S). He then used the MCP to select a target vertical speed of -1,000 feet per minute. In V/S mode the autopilot can pitch down to achieve a higher descent rate, which it immediately did. This also caused the autothrottle to switch to SPD mode, in which it uses engine thrust to achieve the target MCP airspeed. However, because the thrust levers were already at idle, it was not possible for the autothrottle to reduce their airspeed any further, and since the autopilot was now pitching down to achieve the selected vertical speed of -1,000 feet per minute, their airspeed stopped decreasing at 185 knots, and the target MCP airspeed of 180 knots was never reached.

(Own work)

Noticing the discrepancy some 30 seconds later, observer pilot Bong Dong-won commented, “One eight zero to five miles,” reminding them of the controller’s order. Trainee Captain Lee Kang-kook sounded confused, and the statement had to be repeated to him three more times before he finally replied, “Okay, one eight zero, five miles.” For some 13 seconds, he apparently plotted a course of action, before announcing, “Gear down please.” Deploying the landing gear would increase drag and hopefully slow the plane to 180 knots. By this point it had actually begun to accelerate slightly, reaching 188 knots, and their projected descent path showed them overshooting the target altitude by even more than before. Unless they slowed down substantially, a descent rate of only -1,000 feet per minute wasn’t going to cut it.

At that moment, Instructor Captain Lee Jeong-min pointed out, “It seems a little high.”

“Yeah,” said Lee Kang-kook.

“This should be a bit high,” Lee Jeong-min repeated.

“Do you mean it’s too high?” Lee Kang-kook asked.

Lee Jeong-min issued an unintelligible reply, to which Lee Kang-kook responded, “I will descend more.” He then reached up to the MCP and increased the target vertical speed to -1,500 feet per minute. The autopilot pitched down even more, and the plane finally began to descend back toward the optimal 3-degree glide path. Furthermore, with the landing gear extended, the airspeed was able to decrease to the target of 180 knots. For a moment, it seemed like they might be back on track.

Twenty-seven seconds later, however, Instructor Captain Lee Jeong-min remarked, “One thousand,” and trainee Captain Lee Kang-kook changed the MCP vertical speed back to -1,000 feet per minute. He probably thought that the plane was approaching the glidepath and that such a steep descent rate would soon be unnecessary, but he was mistaken, and the plane soon began to diverge above the 3-degree glide path again.

(Own work)

At that moment they reached 3,000 feet, at which point the approach controller handed them over to the tower for landing clearance. At the same time, Lee Kang-kook called out, “Missed approach three thousand,” recalling from their approach briefing that 3,000 feet was the altitude that they would climb back to if the approach failed. He then changed the target MCP altitude to 3,000 feet, in accordance with Asiana Airlines procedures, so that the plane would automatically climb to that altitude if he selected the autopilot’s “Go-around” (TOGA) mode. Because the autopilot’s vertical mode was currently Vertical Speed (V/S), in which there is no target altitude, his selection would lie idle until or unless he selected a vertical mode which could use it.

Now, shortly before 11:26, flight 214 crossed the DUYET waypoint at 2,250 feet, which was 450 feet above the target altitude. Furthermore, their descent rate was nowhere near high enough to regain the optimal glide path before reaching the runway. In an effort to lose speed and altitude, trainee Captain Lee Kang-kook ordered that the flaps be extended to 20 degrees, then changed the target MCP speed to 152 knots in order to slow down enough to extend the flaps more. Within seconds, he ordered flaps 30, but Lee Jeong-min replied, “Speed check flaps thirty, sir,” pointing out that they were still traveling at 174 knots, while the maximum speed with flaps 30 was 170 knots. The problems were really starting to pile up now, and trainee Captain Lee Kang-kook was in a bind: what could he do to get back on course?

Realistically, there were few options available to him. The most obvious was probably to admit that the approach had failed, make a missed approach, and come in again at a slower speed and a lower altitude. Alternatively, he could have tried to salvage the approach by deploying the speed brakes and selecting a higher vertical speed in the MCP. But instead of taking either of these valid courses of action, Lee Kang-kook chose a truly puzzling third option: he reached up to the MCP and changed the autopilot’s vertical mode to Flight Level Change Speed (FLCH SPD). If you’re interested in a fun logic puzzle, then before reading any further, go back to the description of this mode and see if you can figure out why this was a terrible idea.

(Own work)

The problem, of course, was that in FLCH SPD mode, the autothrottle will increase or decrease thrust in order to achieve the target altitude set in the MCP. Recall also that about 40 seconds earlier, Lee Kang-kook had set the target altitude to 3,000 feet in case of a missed approach. Therefore, the sadly predictable outcome when he selected FLCH SPD mode was that the autothrottle immediately increased thrust in order to climb to 3,000 feet, while the autopilot pitched the nose up in order to decelerate to the target MCP airspeed of 152 knots. Consequently, the plane started to level off, and would have transitioned to a climb had the trainee Captain not intervened.

At first, trainee Captain Lee Kang-kook appeared not to notice, and he called again for “Flaps thirty.” But within seconds, Instructor Captain Lee Jeong-min spotted the plane’s unexpected behavior and said, “Sir,” drawing attention to the problem. Simultaneously, Lee Kang-kook realized what was happening and disconnected the autopilot in order to stop the plane from pitching up, and the autopilot status annunciation changed from Autopilot (A/P) to Flight Director (FLT DIR). He then reached down and pulled the thrust levers back to idle to stop the acceleration as well, which fulfilled the conditions for the autothrottle to enter HOLD mode, wherein it would not make any inputs until a new mode was selected. But nobody noticed or called out the mode change, and both pilots apparently thought that the autothrottle was still in SPD mode. Instead, Lee Kang-kook called out “Flight director,” noting the autopilot status annunciation, but not the autothrottle mode.

The problem now was that with the autothrottle in HOLD mode, it could not move the thrust levers, and therefore would not maintain the target MCP airspeed. When using FLCH SPD mode to descend, this normally is not a problem because the autothrottle will automatically exit HOLD mode when the target MCP altitude is reached. But with the autopilot disconnected and no vertical mode engaged, the only way to get the autothrottle out of HOLD mode was for the pilots to select a new mode in the MCP.

At this point, Instructor Captain Lee Jeong-min called out “Speed,” and trainee Captain Lee Kang-kook replied, “Target speed one three seven.” This corresponded to Vref + 5 knots, which was the speed they wanted to maintain during final approach, so he reached up and set the target MCP airspeed to 137 knots. But because the autothrottle was in HOLD mode, this target speed simply sat there in the little window, waiting for someone to engage a mode that would take the MCP speed as an input.

How to read the PAPI lights. (Unknown author)

The plane was now 2.9 nautical miles from the runway, descending through 1,300 feet at a rate of -1,000 feet per minute, with a forward airspeed of 165 knots and decreasing. At the moment they were still too high and too fast, and unless trainee Captain Lee Kang-kook took immediate action, they would be unable to land. In fact, by now they could have seen the Precision Approach Path Indicator, or PAPI, lights — a set of lights on the runway — telling them that they were too high. The PAPI system consists of four lights which appear all white when the observer is far above the optimal 3-degree glidepath, all red if the observer is far below the glidepath, or various combinations in between. In this case, they were showing all white.

Then, as the plane neared 1,000 feet above the ground, trainee Captain Lee Kang-kook ordered “Flight Director off,” in accordance with Asiana Airlines’ normal procedure for a visual approach flown manually. On such an approach, the Flight Director doesn’t have any input signals that will tell it where the pilot wants to fly, so its suggestions are not very useful. Therefore, Instructor Captain Lee Jeong-min replied, “Okay,” then reached up and turned off the captain’s side Flight Director, while keeping his own Flight Director engaged. This was common practice at Asiana Airlines, only he missed a step: the normal procedure was to disengage both Flight Directors, then turn the monitoring pilot’s Flight Director back on if desired. Coincidentally, had he done this, all current autoflight modes would have been cleared, and the autothrottle would have departed HOLD mode and then re-engaged in SPD mode automatically in order to maintain the target MCP airspeed. But because only one Flight Director was turned off, the system did not register any status change, and the autothrottle remained in HOLD mode.

A few seconds later, returning his attention to their descent path, Instructor Captain Lee Jeong-min remarked, “It’s high.” Shortly thereafter, the plane reached 1,000 feet, prompting him to call out, “One thousand.” By this point, trainee Captain Lee Kang-kook was pushing the descent manually, reaching a descent rate of -1,800 feet per minute. But Asiana Airlines procedures prohibited pilots from using descent rates greater than -1,000 feet per minute below 1,000 feet, so observer pilot Bong Dong-won called out, “Sink rate, sir.”

“Yes sir,” Lee Kang-kook replied.

On the radio, Lee Jeong-min transmitted, “Tower, Asiana two one four, short final.”

“Sink rate sir,” Bong Dong-won called out again.

“Cleared to land?” Lee Jeong-min asked.

“Sink rate!” someone repeated.

“Asiana two one four heavy, San Francisco tower, runway two eight left cleared to land,” the controller replied.

“Cleared to land two eight left, Asiana two one four,” Lee Jeong-min read back.

(Own work)

Thanks to Lee Kang-kook’s rapid descent, the plane was now approaching the proper 3-degree glide path, prompting him to begin reining in their sink rate. Just as the plane reached the optimal glide path, they arrived at a height of 500 feet, and an automated voice called out, “Five hundred.”

“Landing checklist,” Lee Kang-kook called out.

“Landing checklist complete, cleared to land,” said the Instructor Captain. “On glide path, sir.”

At this point, in his capacity as the non-flying pilot, Instructor Captain Lee Jeong-min was supposed to conduct the stabilized approach check, ensuring that the flight met the “stabilized approach” criteria: on glide path, within 5–10 knots of the target speed, in landing configuration, with an appropriate thrust setting, and on a trajectory that would require no further significant control inputs. At that moment the plane appeared to be on the 3-degree glidepath; the airspeed had decelerated to approximately 137 knots, right where it was supposed to be; and the flaps and gear were down, but the approach was far from stable. Their sink rate was still greater than -1,000 feet per minute, requiring major control inputs to prevent further premature descent, and the thrust levers were still at idle — even though at this phase of flight, with all the drag from the flaps and landing gear, a power setting around 50% was required to avoid decelerating below landing speed and descending below the glide path. Normally, the autothrottle would have kicked in to advance the thrust levers and maintain the target MCP airspeed of 137 knots, but it was still in HOLD mode, so it did not.

Considering all of the above, the approach was not stable and should have been discontinued. But neither pilot appeared to appreciate the nature of their situation, and they continued to descend, unaware that they were now on track to strike the ground short of the runway.

(Own work)

As trainee Captain Lee Kang-kook gradually pulled the nose up to slow their descent, their speed simply kept dropping, until it fell below the target speed of 137 knots. And without enough power to maintain the 3-degree glide path, the plane began to descend below it. The PAPI changed from two white and two red lights, indicating “on glide path,” to one white and three red lights, indicating “below glide path.” Lee Kang-kook responded by pitching up even more, but this only worsened their decaying airspeed. Internally, alarm bells were ringing: he knew that if the PAPI changed to four red lights, the incident would probably be reported to management, which would be embarrassing. But why were they too low? What was he doing wrong?

“Two hundred,” an automated voice called out. The plane was now wallowing along at an airspeed of 122 knots, 10 knots below landing reference speed, still descending at 900 feet per minute, with its nose pitched more than 7 degrees up, and there was still the better part of a mile to go until the runway threshold. At that point, the PAPI indication changed to four red lights, warning that they were dangerously low. In response, Lee Kang-kook pulled the nose up even more, but it wasn’t working, because they didn’t have enough speed.

Instructor Captain Lee Jeong-min now saw the four red PAPI lights, then glanced down at his airspeed indicator and realized that they were traveling at only 120 knots, which was way too slow. This discovery confused him: shouldn’t the autothrottle have automatically held the speed at 137 knots? Had it somehow malfunctioned? Deciding to warn the trainee Captain, he called out, “It’s low.”

“Yeah,” said Lee Kang-kook. But nobody advanced the thrust levers. Seconds later, a quadruple chime sounded, indicating a caution-level alert, in this case due to low airspeed. They had decelerated to 114 knots, their altitude was only 124 feet, they were descending at 600 feet per minute, and they still had half a mile to go.

“One hundred,” the automated voice called out.

“Speed!” Lee Jeong-min exclaimed. Suddenly realizing that the situation had become truly dire, he finally reached down and pushed both thrust levers to maximum power in a desperate attempt to prevent the plane from crashing into the waters of San Francisco Bay. In the passenger cabin, there were exclamations of alarm, as the approach lighting pier extending from runway 28L streaked past their windows, much closer than normal. The nose was high, the engines were accelerating hard, the water was rising up beneath them, and the inevitable had suddenly become obvious: they were going to crash!

Watch security camera footage of flight 214’s final seconds and impact sequence. (CBS News)

By now the pilots knew it too. An automated voice called out, “Fifty,” and the airspeed bottomed out at a terrifyingly slow 103 knots, causing the stick shaker stall warning to activate. The engines were accelerating, but they were only 39 feet above the ground and still dropping. The pitch angle reached an alarming 12 degrees nose up, on the brink of a stall, catching the attention of onlookers in the terminal and along the shoreline. Even to untrained bystanders over a mile from the runway, it was obvious that something was seriously wrong.

In the cockpit, the automated voice called out, “Forty, thirty.”

“Oh shit, go around!” Lee Jeong-min exclaimed.

“Twenty!”

“Go around!” Lee Kang-kook repeated, but it was far, far too late.

“Ten,” said the automated voice.

A split second later, traveling at 106 knots with its nose high in the air, the 777’s low-hanging tail started to hit the water. A huge splash enveloped the windows in the last few rows, and then, with a resounding boom, the tail section plowed directly into the 3-meter-high stone seawall at the threshold of runway 28L. The devastating impact ripped the tail off the plane and sent the nose crashing back down onto the runway, immediately collapsing the landing gear. The plane slid forward on its engines and belly, disgorging dust and debris behind it, until the left wing seemingly caught on some unseen obstruction. As onlookers watched in awe and horror, the entire airplane rotated counterclockwise about its left wingtip, its fuselage and right wing rising high into the air in a dramatic, violent pirouette, spinning around nearly 360 degrees before it slammed back to earth with a heavy, bone-shattering impact. Enveloped in a cloud of dust, the badly damaged plane slid a few dozen meters onward across the grass beside runway 28L, then came abruptly to a halt, upright and, somehow, almost intact.

◊◊◊

Watch an alternate view of the crash sequence as seen from the control tower, with an additional 11 minutes of footage of the evacuation and rescue. (KTVU 2 News)

On board the plane, a few seconds passed before the passengers and crew came to their senses, discovering that they had survived the terrifying rollercoaster ride with varying degrees of injury. The pilots, shaken and injured but alive, found that they still had emergency electrical power, and Lee Jeong-min used the radio to call the tower. “Asiana two one four…” he said, sounding disoriented. He never managed to finish the thought.

“Asiana two one four, emergency vehicles are responding,” the controller replied. In the tower, the controllers had witnessed the crash sequence from beginning to end, and someone had pressed the big red crash button before the plane had even come to a stop, triggering an “alert 3” emergency notification at the airport’s several fire stations. Fire crews were already launching toward the scene, but it would take them a couple of minutes to arrive, and until then the crew were on their own.

In the cabin, the lead flight attendant immediately went up to the cockpit to ask if they should evacuate, and was told to stand by — the pilots wanted to ask air traffic control about the condition of their plane before ordering an evacuation. The damage inside the cabin was, however, quite extensive: most notably, the emergency escape slides at doors R1 and R2 on the right side had inflated inside the plane, trapping the flight attendants seated at these positions. Flight attendant R1 was pinned against the wall, causing her to lose consciousness, while flight attendant R2A had her legs pinned to the adjacent galley structure and was screaming for help. Flight attendant L2A rushed to help her from across the aisle, but as he did so, he looked out the window and spotted fire and smoke. Realizing that they were in serious danger, he picked up the intercom and unilaterally broadcast an evacuation order.

A still from the control tower video shows the scene during the first moments of the evacuation, before the first emergency vehicles had arrived. (KTVU 2 News)

The source of the fire was apparently the №2 (right) engine, which had separated from the wing and become lodged against the right side of the fuselage. The engine oil tank had burst and caught fire, and if the flames spread to the cabin or the fuel tanks, catastrophe could ensue. Following the order, however, the flight attendants responded quickly, opening the L1 and L2 doors on the left front side of the plane about 90 seconds after it came to a stop. The slides deployed and passengers immediately began to escape down them.

Farther back, however, the damage was more severe. The L4 door near the tail was entirely missing, along with the four aft flight attendants and their seats, all of which were no longer attached to the plane. The L3 flight attendant attempted to open her door, but found that it was jammed. The R3 flight attendant was severely injured and was unable to assist, but a passenger managed to open the R3 door, and an evacuation commenced from that exit as well. A few passengers also escaped through the hole at the rear of the plane where the tail section had been, dodging hanging debris and wires.

Outside the plane, the first fire trucks began to arrive, negotiating their way around crowds of escaping passengers before taking up positions to fight the fire. At the same time, several crewmembers and passengers were attempting to free the two trapped flight attendants, and a party was sent out to ask the firefighters for a sharp object that could be used to deflate the malfunctioning slides. Before they could return, however, the lead flight attendant managed to deflate the R2 slide by stabbing it with a knife from the galley, freeing the R2A flight attendant. Farther forward, meanwhile, others were trying to free the R1 flight attendant, including her husband, who had been riding as a passenger. It took several minutes, but they eventually managed to move the slide out of the way, and the unconscious R1 flight attendant was carried from the plane by passengers.

The interior of the aft cabin, where passengers were trapped between collapsed seat rows. (NTSB)

By now, almost everyone was off the plane, and smoke was beginning to pour into the cabin, creeping down the shattered and empty aisles. Toward the back, however, the L3 flight attendant was still on board. As passengers carried the badly injured R3 flight attendant out through the exit, L3 spotted four to six more passengers who were still in their seats, apparently unable to move. Amid gathering smoke, she tried to free them, but the conditions were becoming increasingly hostile. How relieved she must have been, then, when a group of firefighters and police officers entered through the hole in the back of the plane and came to her aid! Using their tools and expertise, they managed to free all those who remained on board in the nick of time. In fact, parts of the cabin were already ablaze by the time the firefighters managed to pull the last trapped passenger from the wreckage, a full 19 minutes after the crash.

By this point, however, first responders had already realized a grim truth: not everyone had made it out alive. A group of Chinese high school students, en route to the United States to attend summer camp, had been seated together in the last few rows, and two of their number were unaccounted for. Three girls, all aged 16, had been seated in the last middle row, in seats 41D, 41E, and 41G, but when the plane came to a stop, only the girl in 41G was still in her seat — the other two girls, Wang Linjia and Ye Mengyuan, were nowhere to be found. It was obvious enough to passenger 41G that they had been thrown from the plane: unfortunately, she recalled, Ye Mengyuan in seat 41E had not been wearing her seatbelt, and Wang Linjia in seat 41D was curled up under a blanket, possibly asleep, likely without having fastened her seat belt either. Although the flight attendants had come around the cabin during the approach to make sure that all seat belts were fastened, the two girls might have been missed, or may have undone their seatbelts after the check — the exact reason why they were not strapped in is uncertain. However, none of the schoolchildren were experienced flyers, and the missing girls probably did not appreciate the importance of fastening their seat belts for landing.

An aerial view shows the long debris trail where the flight attendants were found. (NTSB)

The crew, meanwhile, were deeply concerned for several of their own. Four flight attendants had been seated in the aft galley in jump seats R4, L4, M4A, and M4B, all of which were missing — there was nothing more than a gaping hole in the fuselage where that part of the cabin used to be. Some of the crewmembers managed to get word of the missing flight attendants to the fire crews, but by this point responding mutual aid units from the San Francisco Fire Department had taken over the scene, and the on-scene commander had appointed a lead firefighter who was not trained in airport operations. This lack of knowledge became apparent when the lead firefighter, apparently taking “cabin crew” to mean “pilots,” ordered his subordinates to search the cockpit for the missing crewmembers, when in fact they should have been checking the runway behind the plane.

The whereabouts of the missing flight attendants were not discovered until 20 minutes after the crash, when, by some miracle, the R4 flight attendant was spotted alive and on their feet, limping across the runway toward the airplane through the vast debris field. Several passengers spotted them and ran to their aid, at which point the flight attendant collapsed to the ground at the edge of the grass, and was provided with urgent first aid. This discovery prompted a more thorough search of the debris field, which included large pieces of airplane structure, the left engine, passenger baggage, and other unidentifiable wreckage. Amid the destruction, firefighters managed to find the other three missing flight attendants, all miraculously alive, albeit severely injured. Two of them were still in their seats, while the other two had been thrown loose onto the asphalt, but nevertheless survived. Unfortunately, however, they were not the only victims found in this area: nearby, first responders discovered the body of 16-year-old Wang Linjia, who had been ejected out of the back of the plane as it pirouetted through the air, killing her instantly.

As it turned out, the other missing girl, Ye Mengyuan, had already been found. Arriving firefighters spotted her on the ground in front of the left wing, lying in a fetal position, not moving and with no outward signs of life. Two firefighters spotted her body and wrote her off as “obviously deceased,” taking the time only to direct a fire truck around her, without rendering aid. Unfortunately, their efforts to make her position known eventually broke down as firefighting foam gathered in the area, partially obscuring her body. About 22 minutes after the crash, Ye Mengyuan was run over at slow speed by an airport fire truck, Rescue 10, as it approached the fuselage with a specialized penetration device. No one appeared to notice, and to add insult to injury, she was run over again several minutes later by another truck, Rescue 37. The question of whether she died in the crash or was killed by the fire truck would later spark considerable controversy and will be discussed later.

Another, closer view of the chaotic debris field. (NTSB)

Wang Linjia and Ye Mengyuan were initially the only fatalities, but they were tragically joined 6 days later by Liu Yipeng, a 15-year-old girl from the same school group, who had been sitting in seat 42A when she was mortally wounded by the flying L4 emergency exit door, which came loose during the crash sequence. She was initially discovered unresponsive inside the cabin and was taken to hospital in a coma with a severe traumatic brain injury. Unfortunately, she never awoke, and she died in her hospital bed with her parents at her side.

The tragic deaths of three teenagers severely darkened what would otherwise have been a remarkable story of survival. Despite the violence of the crash, 304 out of the 307 passengers and crew lived to tell the tale, of whom 117 walked away with no injuries whatsoever. The crew was hard hit, with 8 of the 16 crewmembers suffering serious injuries, along with 41 passengers, but all eventually recovered. In the end, some credit for this outcome has to go to the Boeing 777 itself, which stayed in one piece despite being thrown through the air with considerable force. Even more impressive, the crash did not breach either fuel tank, and even though parts of the cabin burned over, the fuel never became involved in the fire, ensuring that all the occupants had plenty of time to escape. Luck certainly played a role, but it’s also worth pointing to advancements that were made in airliner crashworthiness during the 1980s and 1990s that directly contributed to this outcome, especially improvements in passenger seat design. Investigators were pleased to note that almost every seat stayed attached to the floor, rather than being thrown about the cabin as has occurred in many historical crashes.

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The front page of the San Francisco Chronicle on July 7th, 2013.

The investigation into the accident by the National Transportation Safety Board began with a flood of phone calls to the NTSB offices from witnesses who had seen the crash, many of them utterly hysterical, and at first investigators were unsure what, if anything, had happened. A call to San Francisco International Airport, which came back busy, cleared up their doubts, and the first television images followed soon after. Before long, the NTSB had pulled out all the stops, launching a massive investigative team to find the cause of what had turned out to be the first ever fatal crash of the vaunted Boeing 777.

Although the NTSB arrived to a chaotic scene, with the smoldering plane at one end and a trail of wreckage at the other, one thing was quite clear: the plane must have come in too low. Witnesses agreed that it was low and slow, as did security camera footage. Interviews with the pilots and examinations of the black box recordings slowly added detail, until at last, the NTSB was able to reconstruct the sequence of events described earlier in this article.

To recap, the proximate cause of the crash was insufficient airspeed on final approach. If they had been flying at the correct speed, it would have been possible for trainee Captain Lee Kang-kook to keep the plane on the 3-degree glidepath and bring it down for a normal landing. And as it turned out, the main reason for this low airspeed was that the autothrottle did not increase thrust to maintain the target MCP speed, and neither did the pilots, until it was much too late.

A review of the critical mode changes during the flight. (NTSB)

The sequence of events began when trainee Captain Lee Kang-kook first allowed the plane to drift above the glide path after aligning with the runway. Essentially, he left the vertical mode in FLCH SPD for too long, and switched to V/S mode, which is better for steep descents, slightly too late. Now he was in a position that required him to catch up with the glide path from above, which can be notoriously tricky. But instead of making use of features like the speed brakes, he seemed barely aware of the situation and unsure what to do. He seemed caught between their high speed and high altitude, able to deal with only one at a time, at the expense of the other. And finally, once he figured out that he needed to descend much faster, he switched back to FLCH SPD mode, which was probably the worst possible mode under the circumstances. Lee Kang-kook told investigators that he considered using FLCH SPD at that point because he thought it would cause the autothrottle to move the thrust levers to idle, allowing him to achieve a higher descent rate. This made little sense because the thrust levers were already at idle, and besides, he had already set the MCP altitude to 3,000 feet in case of a go-around, so he should have known that selecting FLCH SPD mode would cause them to climb.

When he realized that he had made an error, Lee Kang-kook did what he probably should have done earlier and disconnected the autopilot to fly the approach fully manually. But he also overrode the autothrottle, causing it to switch into HOLD mode, a fact which he apparently never noticed. Flying manually with more high-drag devices extended, he was then able to descend back to the glide path, but he did so too aggressively, and they began to drop below it. He pitched up steeply in an attempt to halt their descent, but as a result their airspeed plummeted, and the plane did not begin to level off as he was expecting. Instead, the speed and altitude both kept dropping until the plane hit the ground.

Firefighters examine the burned out hulk of the 777. A pale yellow sheet covering the body of Ye Mengyuan can be seen at the edge of the asphalt path. (KRON 4 News)

Trainee Captain Lee Kang-kook told the NTSB that this behavior caught him by surprise because he expected the autothrottle to maintain the target MCP airspeed, regardless of what mode it was in. Furthermore, he thought that even if it failed to do so, the plane still should not have decelerated so far below the landing reference speed, because he had been told that if the airspeed dropped into the amber “low speed caution” zone on his airspeed indicator, the autothrottle would wake up and add thrust even if it was disconnected. In essence, he thought that the autothrottle had a low speed protection system that functioned similarly to the “alpha floor” concept on the Airbus A320, which is always active and makes it impossible under normal circumstances to decelerate to dangerous speeds.

In reality, however this simply wasn’t the case. The Boeing 777 had a low speed protection system that was usually active, but it had several notable exceptions. The system was designed to wake up the autothrottle and automatically increase thrust if the airspeed drops at least 8 knots below Vref for one second, but the protection was inhibited if the plane was below 400 feet on takeoff or below 100 feet on landing, if the vertical autopilot mode was set to Takeoff/Go-around, or — and this is the kicker — if the autothrottle was in HOLD mode, because this mode physically disconnects the autothrottle’s drive motor from the thrust levers, which are the only means of controlling thrust on the 777.

These exceptions were described in the Boeing 777 Flight Crew Operations Manual, but it would have taken a number of inferences to realize that they applied to the situation flight 214 was actually in, even if the pilots knew about them. But as it turned out, neither Lee Kang-kook nor his instructor Lee Jeong-min was aware that the low speed protection system would not kick in when the autothrottle was in HOLD mode. The NTSB then asked five Asiana instructor captains to name the circumstances under which the autothrottle would not provide low speed protection; four answered correctly that this would happen in HOLD mode, but one said he only learned this after the accident, and the fifth was unaware of the exception.

The spotty knowledge of this exception and its potential effects had bled into pilot training at Asiana Airlines. During the Boeing 777 training course attended by Lee Kang-kook not long before the accident, the low speed protection feature was demonstrated to trainee pilots by disconnecting both the autopilot and autothrottle and letting the airspeed drop below Vref, at which point the autothrottle would wake up and advance the thrust levers. Lee Kang-kook told the NTSB that he was “astonished” by this capability, which he probably thought was exclusive to Airbus aircraft, and it clearly left quite an impression upon him. Notably, however, the training course did not mention that this protection would not work if the autothrottle was in HOLD mode. Had he been aware that there were several common exceptions, Lee Kang-kook might have monitored the airspeed and autothrottle modes more closely.

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A United 747 is towed back to the terminal past the wreckage of flight 214. Many passengers and the pilots aboard the 747 witnessed the crash from close range. (Los Angeles Times)

Many of these errors pointed the NTSB to a common culprit — fatigue. Missed callouts, difficulty comprehending repeated warnings, forgetting that the MCP go-around altitude had already been set — all these were symptomatic of fatigue, which is inevitable on any transpacific flight, but clearly negatively affected Lee Kang-kook’s performance. With only a few scattered hours of sleep on the plane, he was not operating at 100%, and it’s worth remembering that before rushing to judgment.

Taken together, however the above analysis of trainee Captain Lee Kang-kook’s actions still painted a picture of a pilot who was in over his head, lacked manual flying experience, and did not fully understand his aircraft. Of course, he was very new to the Boeing 777, and some of his shortcomings were not unexpected for a pilot with only 43 hours on the type. Surveys of pilots show that most don’t become comfortable with the automation on a new airplane until they’ve been flying it for at least 3 months, which was a lot longer than Lee Kang-kook had been flying the 777. However, there were a number of counterpoints as well. Most importantly, this simply should not have been a difficult approach: although they were routed to the start of the approach a little bit high and fast, this was common at San Francisco and no other flights that day had any trouble coping. Furthermore, the weather was perfect, there was minimal wind, the localizer had already helped the plane align with the runway, the controller imposed only one minor speed restriction, and a specialized vertical path indicator on each pilot’s navigation display physically depicted the optimal 3-degree glide path. All Lee Kang-kook had to do was fly it — but he couldn’t.

Although flying a visual approach is something every pilot should be able to do, effective “energy management” — the careful balancing of forward and vertical speed — requires certain skills that can only be imparted through rigorous practice. Nobody is born knowing how best to use autopilot modes, MCP selections, and manual inputs to achieve a 3-degree glide path. And yet studies conducted in the years leading up to the Asiana Airlines crash suggested that airline pilots around the world were beginning to lose these hard-won skills. At Asiana Airlines, pilots were explicitly encouraged to use as much automation as possible, and Lee Kang-kook had never flown an approach without the benefit of glideslope equipment in the real Boeing 777. At some airlines, when the weather is good and the skies are clear, pilots have great leeway to disconnect the autopilot and fly manually, but many other airlines, including Asiana, were actively discouraging this kind of behavior, at the expense of basic piloting skills. As a result, when the pilots of flight 214 found themselves in a situation where they had no choice but to manually control their descent profile, they were woefully underprepared.

A labeled aerial view of the entire impact zone. (Washington Post)

Although much attention necessarily was paid to trainee Captain Lee Kang-kook, the NTSB also analyzed the actions of Instructor Captain Lee Jeong-min, and found several unfortunate decisions and missteps that hold lessons for any instructor pilot. Before discussing them, it’s worth noting that Lee Jeong-min was also fatigued, and that this was his first time instructing a trainee captain during a real line flight, and he had not yet gotten a feel for how much supervision is necessary. In the end, however, his supervision was clearly insufficient for a number of reasons.

According to Lee Jeong-min’s own testimony, he found Lee Kang-kook’s performance during climb and cruise to be entirely satisfactory, which caused him to let his guard down as they neared San Francisco. In hindsight, this judgment was premature. He did not make many substantive suggestions to help Lee Kang-kook deal with the difficult task of energy management on approach, and when the trainee started to make major mistakes, he was unprepared. He never realized that Lee Kang-kook had selected FLCH SPD mode, nor did he notice that the autothrottle had entered HOLD mode, which the trainee was supposed to have called out, but did not. In the NTSB’s view, Lee Jeong-min was probably distracted by Lee Kang-kook’s sudden disconnection of the autopilot, and by their worsening position on the glide path, but the consequence was that he began to fall behind his trainee’s actions.

Consequently, as the plane descended below 500 feet and the approach became increasingly unstable, Lee Jeong-min was slow to catch on, and amid his increasing workload he failed to conduct the formal stabilized approach check, in the process missing some items which should have required a go-around. In fact, he didn’t notice the seriousness of the problem until about 200 feet, when he simultaneously saw four red lights on the PAPI and an airspeed of only 120 knots. At that point, the prudent thing to do would have been to call for an immediate go-around and take over control if Lee Kang-kook did not comply. But instead, it seemed as though he still had faith in the trainee Captain’s ability to recover the situation or make the correct call, and that belief persisted much longer than it should have. By the time he intervened, the situation was clearly unsafe and had been for about 15 to 20 seconds. Although he ultimately did advance the thrust levers 7 seconds before impact, NTSB simulations proved that due to the limited available energy, he would have had to take action no later than 11 seconds before impact — about the time of the low speed alert — to have averted the crash.

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NTSB investigators examine the damage to the airplane. (AP)

As the NTSB investigators and their Korean counterparts sifted through mountains of evidence and analyzed the sequence of events, it became clear to members of both investigation teams that while the pilots made serious mistakes, the design of the Boeing 777’s automation was also potentially problematic. The issue was one of human factors design: namely, the wisdom of including rare exceptions to a protection system that is otherwise almost always active.

The problem with such a design is that it greatly increases the likelihood of an “automation surprise”: an adverse crew reaction to unexpected behavior from an automatic system. In general, such unexpected behavior should be avoided, because it may not be noticed by the crew, could cause a startle reaction, or could lead to incorrect decision-making. In this case, the fact that the autothrottle did not provide low speed protection in HOLD mode was not widely known, in part because such a situation was rather rare, given that there was normally no reason to enter an unbounded descent with the autothrottle in HOLD mode. The likeliest way to end up in such a configuration was accidentally, which only compounded the problem.

This design deficiency apparently passed unnoticed when the 777 was certificated in 1994, probably because the low airspeed protection system was not a mandatory item, but it drew more scrutiny in 2010 during the certification of the Boeing 787, which has a virtually identical autothrottle. During a flight test, an FAA test pilot was descending in FLCH SPD mode when he received a traffic alert, which prompted him to take manual control and level off to avoid a collision. He subsequently noticed that the airspeed was falling, and as he watched it continued to fall well below the amber low speed caution bar on his airspeed indicator. He decided to increase thrust manually, after which he realized that the autothrottle had been in HOLD mode, and that this had deactivated the low speed protection system. In his view, this behavior was clearly undesirable, because an unexpected loss of airspeed protection during an unanticipated event, such as the one he experienced, had the potential to catch crews off guard. At his insistence, Boeing added a passage to the 787 Airplane Flight Manual which stated that, “When in HOLD mode, the A/T will not wake up even during large deviations from target speed and does not support stall protection.” However, no similar passage was added to the same document for the 777.

A closer view of the aft end of the plane shows how the fuselage was crushed or torn away almost up to the floor level. (Reuters)

Although the FAA raised this issue, as did the European Aviation Safety Agency, it was only a small piece of a much larger puzzle. Among NTSB investigators, there was some disagreement over the question of whether the Boeing 777’s automation was too complicated, with too many overlapping modes, exceptions, and if-statements. On the one hand, it was certainly possible to understand it, as some people did, and with more detailed training, general understanding among pilots could have been substantially improved. On the other hand, however, there will always be some pilots who develop an incorrect mental model of any sufficiently complicated system, and it’s incumbent upon manufacturers to avoid unnecessary complexity. In the end, the NTSB endorsed both viewpoints, because safety isn’t a zero sum game. The most obvious solution is for training and systems engineering to meet in the middle, creating a system that is comprehensible to pilots, while putting in the effort to ensure that pilots do, in fact, comprehend it.

To this end, the NTSB issued a total of 27 safety recommendations, including that the FAA research better training methods for flight path management, review the certification basis of the Boeing 777’s autothrottle, and develop standards for comprehensive “low energy” warning systems; that Asiana Airlines improve practical training for instructors and encourage more manual flight; and that Boeing improve the wording in its manual to clearly highlight exceptions to the speed protection logic and consider developing a “low energy” warning system.

Recommendations aside, the crash and others that preceded it made significant waves in the industry, and looking back now, the crash of Asiana Airlines flight 214 appears to have been a turning point in the industry-wide effort to halt the decline of basic piloting skills. Asiana’s automation use policy at the time of the accident increasingly appears anachronistic, and the tendency of such policies to encourage an unhealthy reliance on automation is now widely recognized. NTSB Acting Chairman Christopher Hart summed it up in a statement appended to the official report: “Although automation has a long history of improving safety and efficiency, too much reliance on automation can have unintended consequences,” he wrote. “One unintended consequence is that it caused this highly experienced pilot with an unblemished record to be uncomfortable about manually accomplishing a very basic task — landing on an 11,000 ft runway on a clear day with very little wind.” Member Robert Sumwalt, however, chose to focus on the system design, highlighting in his statement a seemingly obvious recommendation that the NTSB did not adopt: that Boeing redesign the autothrottle’s speed protection system.

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A seating map shows the assigned seats of the survivors and victims. Note that passenger 41B, Wang Linjia, was actually seated in seat 41D, next to Ye Mengyuan in 41E, during the crash. (NTSB)

Having analyzed the operation of the autothrottle, weighed the actions of the crew, and contemplated the significance of the findings, it nevertheless remains true that when the crash of Asiana Airlines flight 214 is mentioned to a lay audience, the first response is often something like, “Wasn’t that the crash where the girl was run over by a fire truck?” Consequently, it would be inappropriate to end this article without addressing the question.

In the immediate aftermath of the crash, autopsies of the victims were conducted by the San Mateo County Coroner. The autopsy reports for both victims who died at the scene stated that the cause of death was “multiple blunt injuries,” and that the manner of death was “accident,” with no differentiation between them. However, concurrent with the publication of the autopsy, the coroner stated that per his analysis, Ye Mengyuan was likely alive before she was fatally crushed by Rescue 10. Contemporary reports do not appear to provide the details of his justification of this conclusion, which remains widely cited today. On the other hand, the City of San Francisco, which is responsible for the San Francisco Fire Department, including the airport fire vehicle that ran over Ye Mengyuan, released a rebuttal claiming that she was already dead. The coroner pointed out that there was a conflict of interest — namely, that the City of San Francisco was likely to be sued, and indeed was sued, over the incident, and that the rebuttal was merely “the drama of litigation.”

A taxiway was used as a makeshift parking lot as large numbers of officials arrived at the scene. (ABC News)

In its final report, the NTSB avoided directly addressing the issue, but the investigators heavily implied that they backed San Francisco’s version of events. In their view, a number of items of evidence pointed toward a conclusion that Ye Mengyuan was already dead when she was run over. Foremost among them was the coroner’s finding that she suffered a lacerated aorta, which is usually a fatal injury, without any crushing of the ribcage. This combination of findings is normally indicative of death due to extreme deceleration, as one might expect if she were thrown from the aircraft at high speed. Furthermore, examinations of her trachea found no indication that she had inhaled any dust, dirt, or firefighting foam, despite being buried in all three before she was run over. Had she been breathing as she lay on the ground, inhalation of these materials would be expected.

Additionally, the NTSB noted that Ye Mengyuan was not wearing her seat belt, and that her seatmate Wang Linjia had been ejected from the plane. Both girls suffered a number of similar external injuries consistent with having slid across the ground, and no one recalled seeing Ye exit the plane under her own power or with assistance. Passenger 41G simply recalled that when she came to her senses after the crash, Ye was already gone. Although the four flight attendants survived being ejected, they were thrown from the plane before the midair pirouette and remained strapped into their seats, increasing their chances of survival. In contrast, Wang Linjia and Ye Mengyuan faced much longer odds, and any hope of surviving such an ejection has to have been rather dim. Ye Mengyuan’s parents did file suit against San Francisco, citing the coroner’s conclusions, but here too, no particular evidence in favor of those conclusions has emerged. In fact, the parents eventually decided to drop the lawsuit without any kind of monetary settlement, for reasons that remain unclear.

The fuselage of flight 214, as seen from the shoreline bike path across from the airport. (ABC News)

All of this having been said, as long as a contradiction remains between the coroner’s findings and the evidence in the NTSB report, it can’t be said with certainty which version is correct. After researching for this article, I believe that Ye Mengyuan was most likely already dead when she was run over, but I would not bet my life savings on it.

It’s also worth noting that the firefighters’ behavior during the incident did not make them many friends. Personnel were caught on tape making insensitive comments about Ye Mengyuan’s body after discovering it had been run over, in the way that first responders accustomed to death often do in private, but will avoid doing in public. The initial assessment that she was “obviously deceased” was also criticized in the NTSB report, which pointed out that video of the scene does not show any obvious external injuries on Ye Mengyuan’s body that would support such a conclusion. Additionally, no proper triage was conducted, no firefighters ever checked her vital signs, and no one ever covered her body with a yellow blanket, as is normally done during mass casualty events. None of these factors worked in the fire department’s favor, and it goes without saying that running over a victim’s body, even if she was already dead, was insulting to the victim, her family, and her memory, and should have been avoided.

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Survivors walk away from the plane, grateful to be alive. (Reuters)

In conclusion, then, the crash of Asiana Airlines flight 214 was an exercise in contradictions: survival versus tragedy, life versus death, humans versus automation — these dichotomies defined it. Although few people died, it was an important accident that changed the ways in which countless pilots and industry experts approach the problem of automation. Some might joke at the expense of a pilot who messed up a landing that was all but handed to him on a silver platter, and yet the safety rabbit hole is unfathomably deep, and extends far beyond one man and his moment-by-moment decisions. Even this article, as lengthy as it is, barely manages to scratch the surface of the deeper philosophical debates that the NTSB investigators no doubt spent many long hours discussing amongst one another. After all they learned, even their 189-page final report probably seemed unbearably short! But even in a condensed, dispassionate form, the tale of Asiana Airlines flight 214 holds important lessons for modern pilots, and is hopefully of interest to the public as well, shedding light on an accident which is too often reduced to a few tabloid-worthy moments that had little or nothing to do with what actually made the crash important. As the events of that day make the awkward transition from news into history, they deserve to be remembered for what they were, with all the uncertainties, nuance, and discomfort that may imply. It’s my hope that this retelling of the story might ultimately play some small part in keeping those truths in the light.

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Note: this accident was previously featured in episode 48 of the plane crash series on August 4th, 2018, prior to the series’ arrival on Medium. This article is written without reference to and supersedes the original.

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Admiral Cloudberg

Kyra Dempsey, analyzer of plane crashes. @Admiral_Cloudberg on Reddit, @KyraCloudy on Twitter and Bluesky. Email inquires -> kyracloudy97@gmail.com.