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Asiana Flight 214 Accident Map - Coggle Diagram
Asiana Flight 214 Accident Map
Physical events, Processes and Conditions
Flight Crew was fatigued- contributing to degrading performance
Expectancy, automation reliance, workload during approach
Delayed choice to go-around
PM poor awareness and monitoring of airspeed and altitude
Lack of recency of hand flying
Degraded Crew Resource Managment
Non-standard communication between PF and PM
Flight crew did not consistently adhere to to Asiana's SOPs in regards to MCP selections and call outs
Lack of recency with visual approaches without ILS outside the simulator
PF had not flown to SFO in 10 years (reported being stressed about the approach)
Captain/PM was worried about failing- particular with approach and PAPI???
Organisation
Inadequacies in related training and documentation
Asiana 777 POM did not mention use of F/D switch position for visual approaches
PF/Captains first time flying a visual approach without ILS in 777 outside a simulator
Captains previous training on 777 did not allow time for high-energy approaches
Captain/PM not given opportunity during training to supervise and instruct
No opportunity to supervise unpredictable challenges as OE instructor
FLCH and A/T was discussed during training, but no reference was made regarding it in the training manual from Boeing
Little opportunity to practice manual hand flying during training
Consequences after failing a check ride????
EXTERNAL
Instrument Landing System (glideslope) being unserviceable
Design complexity of AFCS
Observability- FMA changes may go unnoticed in high workload situations
May coincide with F/D switch position and annunciation?
FAA only authorised inspection was ramp inspection
Crew training programs not overseen by FAA
Principal Operations Inspector (POI) only conducted checkrides for upgrades
Does not conduct type rating checks
Medical buses not effective intergrated into SFO monthly preparation drills
(Post accident issue) 2008 and 2012 SFO emergency procedures manuals were not sufficiently robust
SFO emergency procedures had not been distributed
SFO emergency personnel had not been trained on updated manual
Fire attack supervisor compromising attitudes
"Anybody's in there right now is dead" - response to suggestion to limited search of back of airplane
Closed to recommendations from rescue squad
Required 'convincing' to search and rescue actions that did not match his opinions
SFFD city assistant division chief/incident commander and SFFD city battalion chief/fire attack supervisor did not have any experience working at an airport?
Nature and timing of low airspeed alert
Outcomes
Descent below visual glide path
Impact with seawall
3 pax fatally injured
40 pax, 8 flight attendants and 1 flight crewmember seriously injured
The aircraft was destroyed