Crash of a Boeing 777-28E in San Francisco: 3 killed

Date & Time: Jul 6, 2013 at 1128 LT
Type of aircraft:
Operator:
Registration:
HL7742
Survivors:
Yes
Schedule:
Seoul - San Francisco
MSN:
29171/553
YOM:
2005
Flight number:
OZ214
Crew on board:
16
Crew fatalities:
Pax on board:
291
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
9684
Captain / Total hours on type:
33.00
Copilot / Total flying hours:
12307
Copilot / Total hours on type:
3208
Aircraft flight hours:
37120
Aircraft flight cycles:
5388
Circumstances:
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, Seoul, Korea, operating under the provisions of 14 Code of Federal Regulations Part 129. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The flight was vectored for a visual approach to runway 28L and intercepted the final approach course about 14 nautical miles (nm) from the threshold at an altitude slightly above the desired 3° glidepath. This set the flight crew up for a straight-in visual approach; however, after the flight crew accepted an air traffic control instruction to maintain 180 knots to 5 nm from the runway, the flight crew mismanaged the airplane’s descent, which resulted in the airplane being well above the desired 3° glidepath when it reached the 5 nm point. The flight crew’s difficulty in managing the airplane’s descent continued as the approach continued. In an attempt to increase the airplane’s descent rate and capture the desired glidepath, the pilot flying (PF) selected an autopilot (A/P) mode (flight level change speed [FLCH SPD]) that instead resulted in the autoflight system initiating a climb because the airplane was below the selected altitude. The PF disconnected the A/P and moved the thrust levers to idle, which caused the autothrottle (A/T) to change to the HOLD mode, a mode in which the A/T does not control airspeed. The PF then pitched the airplane down and increased the descent rate. Neither the PF, the pilot monitoring (PM), nor the observer noted the change in A/T mode to HOLD. As the airplane reached 500 ft above airport elevation, the point at which Asiana’s procedures dictated that the approach must be stabilized, the precision approach path indicator (PAPI) would have shown the flight crew that the airplane was slightly above the desired glidepath. Also, the airspeed, which had been decreasing rapidly, had just reached the proper approach speed of 137 knots. However, the thrust levers were still at idle, and the descent rate was about 1,200 ft per minute, well above the descent rate of about 700 fpm needed to maintain the desired glidepath; these were two indications that the approach was not stabilized. Based on these two indications, the flight crew should have determined that the approach was unstabilized and initiated a go-around, but they did not do so. As the approach continued, it became increasingly unstabilized as the airplane descended below the desired glidepath; the PAPI displayed three and then four red lights, indicating the continuing descent below the glidepath. The decreasing trend in airspeed continued, and about 200 ft, the flight crew became aware of the low airspeed and low path conditions but did not initiate a go-around until the airplane was below 100 ft, at which point the airplane did not have the performance capability to accomplish a go-around. The flight crew’s insufficient monitoring of airspeed indications during the approach resulted from expectancy, increased workload, fatigue, and automation reliance. When the main landing gear and the aft fuselage struck the seawall, the tail of the airplane broke off at the aft pressure bulkhead. The airplane slid along the runway, lifted partially into the air, spun about 330°, and impacted the ground a final time. The impact forces, which exceeded certification limits, resulted in the inflation of two slide/rafts within the cabin, injuring and temporarily trapping two flight attendants. Six occupants were ejected from the airplane during the impact sequence: two of the three fatally injured passengers and four of the seriously injured flight attendants. The four flight attendants were wearing their restraints but were ejected due to the destruction of the aft galley where they were seated. The two ejected passengers (one of whom was later rolled over by two firefighting vehicles) were not wearing their seatbelts and would likely have remained in the cabin and survived if they had been wearing their seatbelts. After the airplane came to a stop, a fire initiated within the separated right engine, which came to rest adjacent to the right side of the fuselage. When one of the flight attendants became aware of the fire, he initiated an evacuation, and 98% of the passengers successfully self-evacuated. As the fire spread into the fuselage, firefighters entered the airplane and extricated five passengers (one of whom later died) who were injured and unable to evacuate. Overall, 99% of the airplane’s occupants survived.
Probable cause:
The National Transportation Safety Board determines that the probable cause of this accident was 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.
Final Report:

Ground fire of a Boeing 767-281SF in San Francisco

Date & Time: Jun 28, 2008 at 2218 LT
Type of aircraft:
Operator:
Registration:
N799AX
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
San Francisco – Wilmington
MSN:
23432/145
YOM:
1986
Flight number:
ABX1611
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On June 28, 2008, about 2215 Pacific daylight time, an ABX Air Boeing 767-200, N799AX, operating as flight 1611 from San Francisco International Airport, San Francisco, California, experienced a ground fire before engine startup. The captain and the first officer evacuated the airplane through the cockpit windows and were not injured, and the airplane was substantially damaged. The cargo flight was operating under the provisions of 14 Code of Federal Regulations Part 121. At the time of the fire, the airplane was parked near a loading facility, all of the cargo to be transported on the flight had been loaded, and the doors had been shut.
Probable cause:
The National Transportation Safety Board determines that the probable cause of this accident was the design of the supplemental oxygen system hoses and the lack of positive separation between electrical wiring and electrically conductive oxygen system components. The lack of positive separation allowed a short circuit to breach a combustible oxygen hose, release oxygen, and initiate a fire in the supernumerary compartment that rapidly spread to other areas. Contributing to this accident was the Federal Aviation Administration’s (FAA) failure to require the installation of nonconductive oxygen hoses after the safety issue concerning conductive hoses was initially identified by Boeing.
Final Report:

Crash of a Boeing 757-222 in Shanksville: 45 killed

Date & Time: Sep 11, 2001 at 1030 LT
Type of aircraft:
Operator:
Registration:
N591UA
Flight Phase:
Survivors:
No
Schedule:
Newark - San Francisco
MSN:
28142
YOM:
1996
Flight number:
UA093
Crew on board:
7
Crew fatalities:
Pax on board:
38
Pax fatalities:
Other fatalities:
Total fatalities:
45
Aircraft flight hours:
18435
Aircraft flight cycles:
6968
Circumstances:
The Boeing 757 departed Newark Airport at 0847LT on a regular schedule service to San Francisco, carrying 37 passengers and a crew of seven. Few minutes later, the aircraft was hijacked by terrorists who modified the flight path and apparently attempted to fly over Washington DC. At 1030LT, the aircraft crashed in an open field located about 4 km north of Shanksville. The aircraft disintegrated on impact and all 45 occupants were killed. The terrorist attacks of September 11, 2001 are under the jurisdiction of the Federal Bureau of Investigation. The Safety Board provided requested technical assistance to the FBI, and this material generated by the NTSB is under the control of the FBI. The Safety Board does not plan to issue a report or open a public docket.
Probable cause:
The Safety Board did not determine the probable cause and does not plan to issue a report or open a public docket. The terrorist attacks of September 11, 2001 are under the jurisdiction of the Federal Bureau of Investigation. The Safety Board provided requested technical assistance to the FBI, and any material generated by the NTSB is under the control of the FBI.

Crash of a McDonnell Douglas MD-83 off Anacapa Island: 88 killed

Date & Time: Jan 31, 2000 at 1620 LT
Type of aircraft:
Operator:
Registration:
N963AS
Flight Phase:
Survivors:
No
Schedule:
Puerto Vallarta - San Francisco - Seattle - Anchorage
MSN:
53077
YOM:
1992
Flight number:
AS261
Crew on board:
5
Crew fatalities:
Pax on board:
83
Pax fatalities:
Other fatalities:
Total fatalities:
88
Captain / Total flying hours:
10460
Captain / Total hours on type:
4150.00
Copilot / Total flying hours:
8140
Copilot / Total hours on type:
8060
Aircraft flight hours:
26584
Aircraft flight cycles:
14315
Circumstances:
On January 31, 2000, about 1621 Pacific standard time, Alaska Airlines, Inc., flight 261, a McDonnell Douglas MD-83, N963AS, crashed into the Pacific Ocean about 2.7 miles north of Anacapa Island, California. The 2 pilots, 3 cabin crewmembers, and 83 passengers on board were killed, and the airplane was destroyed by impact forces. Flight 261 was operating as a scheduled international passenger flight under the provisions of 14 Code of Federal Regulations Part 121 from Lic Gustavo Diaz Ordaz International Airport, Puerto Vallarta, Mexico, to Seattle-Tacoma International Airport, Seattle, Washington, with an intermediate stop planned at San Francisco International Airport, San Francisco, California. Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan.
Probable cause:
A loss of airplane pitch control resulting from the in-flight failure of the horizontal stabilizer trim system jackscrew assembly's acme nut threads. The thread failure was caused by excessive wear resulting from Alaska Airlines' insufficient lubrication of the jackscrew assembly. Contributing to the accident were Alaska Airlines' extended lubrication interval and the Federal Aviation Administration's (FAA) approval of that extension, which increased the likelihood that a missed or inadequate lubrication would result in excessive wear of the acme nut threads, and Alaska Airlines' extended end play check interval and the FAA's approval of that extension, which allowed the excessive wear of the acme nut threads to progress to failure without the opportunity for detection. Also contributing to the accident was the absence on the McDonnell Douglas MD-80 of a fail-safe mechanism to prevent the catastrophic effects of total acme nut thread loss.
Final Report:

Ground collision of an Ilyushin II-62M in Anchorage

Date & Time: Nov 11, 1998 at 0133 LT
Type of aircraft:
Operator:
Registration:
RA-86564
Flight Phase:
Survivors:
Yes
Schedule:
Anchorage - San Francisco
MSN:
4934734
YOM:
1979
Crew on board:
12
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The Ilyushin II-62M was parked at gate with its 12 crew members on board, awaiting the passengers for the next leg to San Francisco. An Asiana Boeing 747-400 (HL7414) was taxiing to gate N6 for a refueling stop on the flight Seoul - New York (flight 211). While trying to make a U-turn, the Boeing's n°1 engine struck the wing of the Ilyushin. Then the left winglet struck the base of the Ilyushin's tail. The Asiana crew added more power causing the wing to cut through nearly half of the tail of the Russian aircraft. The maximum ground speed recorded by the on-board recorders was 16 knots, while according to the company flight manual it should have been "10 knots or below (5 knots if wet or slippery)".
Probable cause:
The excessive taxi speed by the pilot of the other aircraft. A factor associated with the accident was the other pilot's inadequate maneuver to avoid the parked airplane.

Ground accident of a Boeing 727-51C in Denver

Date & Time: Oct 1, 1997 at 0436 LT
Type of aircraft:
Operator:
Registration:
N414EX
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Denver – San Francisco
MSN:
18899/256
YOM:
1966
Flight number:
RYN607
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15020
Captain / Total hours on type:
7305.00
Aircraft flight hours:
47098
Aircraft flight cycles:
45215
Circumstances:
As the cargo jet was taxiing for takeoff in a non movement area, it was struck by an airport employee shuttle bus. The airplane captain was seriously injured. Visual meteorological conditions prevailed, and the collision occurred during predawn hours. The bus driver said he stopped at the stop sign, turned on the 4-way flasher lights, and looked both ways. He saw one inbound aircraft to the right that had stopped. He did not see the airplane approaching from the left as he started across the cargo ramp. The airplane crew stated they did not see the bus until seconds before impact. Airplane skid marks, measuring 22 and 24 feet in length, were noted on the taxiway. No bus skid marks were noted on the roadway.
Probable cause:
Failure of the bus driver to yield the right of way to oncoming traffic due to his inadequate visual lookout. Factors were visibility restrictions, inadequate driver training by management, and the flight crew's inadequate visual lookout due to their attention being diverted by performing the pre takeoff checklist.
Final Report: