Asiana Boeing 777-200, HL7742, Flight OZ-214: Accident occurred July 06, 2013 in San Francisco, California

NTSB Identification: DCA13MA120 
Scheduled 14 CFR Part 129: Foreign operation of Asiana Airlines
Accident occurred Saturday, July 06, 2013 in San Francisco, CA
Probable Cause Approval Date: 02/03/2015
Aircraft: BOEING 777-200ER, registration: HL7742
Injuries: 3 Fatal, 50 Serious, 137 Minor, 117 Uninjured.

NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.

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 National Transportation Safety Board determines the probable cause(s) of this accident as follows:
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.

NTSB Identification: DCA13MA120
 Scheduled 14 CFR Part 129: Foreign operation of Asiana Airlines
Accident occurred Saturday, July 06, 2013 in San Francisco, CA
Aircraft: BOEING 777-200ER, registration: HL7742
Injuries: 3 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.

On July 6, 2013, about 1128 pacific daylight time, Asiana Airlines flight 214, a Boeing 777-200ER, registration HL7742, impacted the sea wall and subsequently the runway during landing on runway 28L at San Francisco International Airport (SFO), San Francisco, California. Of the 4 flight crewmembers, 12 flight attendants, and 291 passengers, about 182 were transported to the hospital with injuries and 3 passengers were fatally injured. The airplane was destroyed by impact forces and postcrash fire. The regularly scheduled passenger flight was operating under the provisions of 14 Code of Federal Regulations Part 129 between Incheon International Airport, Seoul, South Korea, and SFO. Visual meteorological conditions prevailed at the time of the accident.
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 San Francisco's fire chief has explicitly banned firefighters from using helmet-mounted video cameras, after images from a battalion chief's Asiana Airlines crash recording became public and led to questions about first responders' actions leading up to a fire rig running over a survivor.

Chief Joanne Hayes-White said she issued the order after discovering that Battalion Chief Mark Johnson's helmet camera filmed the aftermath of the July 6 crash at San Francisco International Airport. Still images from the footage were published in The Chronicle.

Filming the scene may have violated both firefighters' and victims' privacy, Hayes-White said, trumping whatever benefit came from knowing what the footage shows.

"There comes a time that privacy of the individual is paramount, of greater importance than having a video," Hayes-White said.

Critics, including some within the department, questioned the chief's order and its timing - coming as Johnson's footage raised the possibility of Fire Department liability in the death of 16-year-old Ye Meng Yuan.

Unaware she was there

The footage shows a Fire Department rig running over the Chinese schoolgirl as she was covered with fire-retardant foam. It also makes clear that Johnson, who was in charge of the firefighting and rescue effort and was directing rig movements, had not been told that Ye was on the ground near the wreckage of the Boeing 777.

The San Francisco Police Department, which is investigating Ye's death, has a copy of the footage, as does the San Mateo County coroner, who concluded that Ye was alive when she was struck. The footage is also in the hands of the National Transportation Safety Board, which is reviewing the circumstances surrounding Ye's death.

Hayes-White banned video cameras in "any department facility" in 2009. She said Friday that she realized after Johnson's footage became public that she needed to spell out that the order covered helmet cameras.

"I think it is fairly clear," she said. "Without someone's permission, videos are not to be taken."

It is not clear how many San Francisco firefighters and paramedics have such cameras, but their use has spread in recent years. Paramedics, in particular, say having still and video images can be helpful if patients question how they were treated before arriving at a hospital.

Footage shot with helmet cameras has been used as a learning device to train new firefighters, said Battalion Chief Kevin Smith, president of the employee group that includes Johnson, the Black Firefighters Association.

Hayes-White said Johnson "has been interviewed" about possibly being in violation of the 2009 policy. Johnson has referred queries about the footage to Fire Department officials.

The footage raised several questions about the handling of the firefighting and rescue efforts after the Asiana plane slammed into a seawall short of the runway at SFO, spun to a stop and caught fire. Two passengers in addition to Ye died, and 180 were injured.

Girl left for dead

The helmet-camera video shows that although Johnson took command of the effort within minutes after the crash, firefighters never told him that Ye was on the ground near the plane's left wing. Johnson arrived just as other injured crash victims were being taken to an initial triage area away from the plane.

Sources have said two firefighters had concluded that Ye was already dead - a determination that the coroner's autopsy found was incorrect.

As the firefighter in charge of the scene, Johnson should have been told of the girl's presence, regardless of whether she was alive or dead, veteran firefighting experts say.

Unaware of Ye's presence, Johnson ordered a foam-spraying rig into the area where the girl lay obscured, the footage shows. The rig ran over Ye, killing her instantly.

Smith said banning helmet cameras now was "regressive" and ill-timed, given the publicity over the airport crash footage.

"The department seems more concerned with exposure and liability than training and improving efficiency," Smith said. "Helmet cams are the wave of the future - they can be used to improve communication at incidents between firefighters and commanders.

"The department should develop a progressive policy to use this tool in a way that is beneficial and not simply restrict its use," Smith said. "We are public servants, we serve the public - why be secretive?"

Lawyer critical

Anthony Tarricone, a lawyer for Ye's family, also questioned Hayes-White's timing and motives.

"Why would anybody not want to know the truth?" he said. "What's wrong with knowing what happened? What's wrong with keeping people honest?

"That's what the helmet cam did, in effect, in this case," Tarricone said.

He said video recordings increasingly are "critically important" in reconstructing first responders' actions at disaster scenes, "the same way that airplanes have cockpit voice recorders and data recorders. The idea that the Fire Department wants to prevent these cameras from being used, it's really disturbing."

Camera 'kind of scary'

Arin Pace, a lieutenant with the Jacksonville, Fla., Fire Department who also runs a company that sells helmet cameras to firefighters, said San Francisco is not the first fire department to ban the equipment. At least two other cities, Houston and Baltimore, have also done so, he said.

"Departments in general are careful about how information is handled, and for good reason," Pace said. "I think a lot of them would prefer we didn't have Facebook and YouTube. For so long, they were able to feed the media what they wanted to feed them. I think a lot of them view the helmet cam thing as kind of scary."

He said as long as patient privacy issues are respected and firefighters are careful not to record grisly accident scenes, helmet-camera footage can help a department.

"It's good to the watch the tape - like any pro football team, they watch the tape of how they did at the last game," Pace said. "It's better than a live fire exercise, because it's a real fire. It's invaluable. More departments are starting to embrace it - the trend is toward it as opposed to departments running away from it."

Pace said he understands fire officials' concerns about liability issues, but "liability doesn't mean you can just keep things quiet and brush them under the rug."

"The camera doesn't lie - it just shows what happened," he said. "In some cases, it shows something that isn't very flattering. In those cases, what are you going to do?"

Protecting sensitive details

Hayes-White said the city has no control over what firefighters might do with footage they shoot while on duty, and that the Fire Department could end up being liable for violating privacy law.

"There's a lot of concern related to privacy rights and the city taping without a person being aware of it while responding to medical calls," the chief said. "A lot of information is sensitive."

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