“"The mode annunciator showed HOLD. Four pilots saw nothing. The seawall saw everything."”
Asiana Airlines Flight 214 from Seoul struck the seawall short of Runway 28L during a visual approach. The pilot flying selected FLCH SPD mode to increase the descent rate, but because the aircraft was below the selected altitude, the autoflight system initiated a climb instead. The pilot disconnected the autopilot, moved the thrust levers to idle, and pitched down—unintentionally placing the autothrottle in HOLD mode, where it no longer controlled airspeed. None of the four flight crewmembers noticed the mode change. The airspeed decayed, the approach became increasingly unstabilized, and the crew's go-around initiation below 100 feet was too late. Three passengers died; 187 were injured. The airplane was destroyed by impact forces and a post-crash fire.
Study Hook: The Asiana 214 crew had four pilots in the cockpit and still missed the autothrottle mode change to HOLD. How does automation complexity increase monitoring workload, and what CRM failures allowed a mode change to go unnoticed by four trained aviators?
Visual Prompt: A Boeing 777 fuselage lying broken on the San Francisco International Airport runway threshold, tail section separated and burning, with the seawall visible in the background and emergency slides deployed on the tarmac.
Tags: [Asiana 214, Boeing 777, SFO, automation, mode awareness, CRM, visual approach, 2013]
The Asiana 214 crew had four pilots in the cockpit and still missed the autothrottle mode change to HOLD. How does automation complexity increase monitoring workload, and what CRM failures allowed a mode change to go unnoticed by four trained aviators?