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General Aviation Safety
This report discusses the July 6, 2013, accident involving a Boeing 777-200ER, Korean registration HL7742, operating as Asiana Airlines flight 214, which 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. Safety issues relate to the need for Asiana pilots to adhere to standard operating procedures regarding callouts; reduced design complexity and enhanced training on the airplane’s autoflight system; opportunity at Asiana for new instructors to supervise trainee pilots in operational service during instructor training; guidance for Asiana pilots on use of flight directors during a visual approach; more manual flight for Asiana pilots; a context-dependent low energy alert; research that examines the injury potential from significant lateral forces in airplane crashes and the mechanism that produces high thoracic spinal injuries; evaluation of the adequacy of slide/raft inertia load certification testing; aircraft rescue and firefighting (ARFF) training for officers in command of an aircraft accident response; guidance on when to use a skin-piercing nozzle on a burning airplane fuselage; integration of the medical supply buses at SFO into the airport’s preparation drills; guidance or protocols for ensuring the safety of passengers and crew at risk of a vehicle strike during ARFF operations; requirements for ARFF staffing; improvements in SFO emergency communications; and increased Federal Aviation Administration (FAA) oversight of SFO’s emergency procedures manual. Safety recommendations are addressed to the FAA, Asiana Airlines, Boeing, the ARFF Working Group, and the City of San Francisco.
TO THE FEDERAL AVIATION ADMINISTRATION: Require Boeing to develop enhanced 777 training that will improve flight crew understanding of autothrottle modes and automatic activation system logic through improved documentation, courseware, and instructor training.
Original recommendation transmittal letter:
Open - Unacceptable Response
San Francisco, CA, United States
Descent Below Visual Glidepath and Impact With Seawall, Asiana Airlines Flight 214
Addressee(s) and Addressee Status:
FAA (Open - Unacceptable Response)
Safety Recommendation History
We do not agree with you that it is less effective to redesign or reengineer the procedures for one aircraft type, such as the Boeing 777, when every aircraft has potential vulnerabilities associated with its design and operation. We agree that every aircraft has potential vulnerabilities, that you need to address these problems, and that the scope of your action in this area may be expanded to include other aircraft types, as you deem appropriate. We issued Safety Recommendation A-14-41, discussed below, based on these concerns with all aircraft. However, our investigation of the Asiana Airlines flight 214 accident revealed problems with the Boeing 777 that Safety Recommendations A-14-37 through -40 address. Your letter did not discuss any actions you have either taken or planned that would require Boeing to revise the training or FCTM for the Boeing 777. Rather, you plan for Boeing 777 operators to review the facts of the Asiana Airlines flight 214 accident and determine whether their data show that they may have the same risks we identified; if they identify any such risks, you expect the operators to develop mitigations. Our investigation found deficiencies in Boeing documentation and training that apply to all operators. These deficiencies involved unclear and potentially misleading explanations of autoflight system functionality. We do not agree that improving these materials should wait until an analysis of operational data has been completed, nor do we agree that having individual operators review their own data looking for problems will help all Boeing 777 operators, as would be achieved if Boeing were to revise the materials it provides to its customers. Accordingly, pending the FAA’s taking the actions recommended, Safety Recommendations A-14-37 and -39 are classified OPEN—UNACCEPTABLE RESPONSE. In consideration of these issues, we have concluded that your plan for operators to review their data to determine whether they have the same risks that we found in the Asiana Airlines flight 214 accident, and to revise their training, if necessary, does not constitute an acceptable alternate response to Safety Recommendations A-14-38 or -40. We are concerned that training improvements will be unnecessarily delayed and that the “lessons learned” will be limited to a single airline’s analysis, that neither the FAA nor other Boeing 777 operators will be aware of the problems found, and that no resultant training revisions will be made. Accordingly, pending your taking the recommended actions, Safety Recommendations A-14-38 and -40 are classified “Open—Unacceptable Response.” We invite you to share with us any information that you may have illustrating how lessons learned by one operator was shared with all Boeing 777 operators and was incorporated into all operators’ training materials. If you can supply us with one or more examples of such an occurrence, we may reconsider whether your proposal constitutes an acceptable alternate method of addressing the recommendations.
-From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) believes it would be less effective to simply redesign or reengineer the procedures for one aircraft type, such as the Boeing 777, when every aircraft has potential vulnerabilities associated with its design and operation. Where necessary, we will encourage carriers to amend their procedures and/or their training to mitigate the potential vulnerabilities to their operation of that aircraft. The FAA tasked a working group under the Performance-Based Aviation Rulemaking Committee and the Commercial Aviation Safety Team on Operational Use of Flight Path Management Systems to determine the human factors associated with the use of those systems. The working group produced a number of recommendations, which the FAA is reviewing. The FAA has also established the Air Carrier Training Aviation Rulemaking Committee (ACT ARC), which is developing additional guidance for air carriers based, in part, on the group's recommendations. The ACT ARC is currently developing additional recommendations for guidance on issues such as mode awareness and training for pilot monitoring. The FAA will ask Boeing 777 operators to review the facts of this accident and determine whether their data shows they may have the same risks identified by the Board. If risks are identified, the operators will be expected to develop mitigations, in accordance with their safety management systems, to address those risks.
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