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Safety Recommendation Details

Safety Recommendation A-14-041
Details
Synopsis: 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.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Convene an expert panel (including members with expertise in human factors, training, and flight operations) to evaluate methods for training flight crews to understand the functionality of automated systems for flightpath management, identify the most effective training methods, and revise training guidance for operators in this area.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Aviation
Location: San Francisco, CA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA13MA120
Accident Reports: ​Descent Below Visual Glidepath and Impact With Seawall, Asiana Airlines Flight 214
Report #: AAR-14-01
Accident Date: 7/6/2013
Issue Date: 7/16/2014
Date Closed:
Addressee(s) and Addressee Status: FAA (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 12/12/2014
Response: We note that you are reviewing the recommendations of a working group that you tasked with addressing the issues in this recommendation, and that you established an aviation rulemaking committee for air carrier training (ACT ARC). The ACT ARC is currently developing additional recommendations for guidance on such issues as mode awareness and training for pilot monitoring. The activities that you described appear to be steps toward satisfying this recommendation, but we ask that you provide more information regarding the specific recommendations and guidance developed. In particular, we are interested in any research evidence you may have that identifies best practices for training pilots in understanding the functionality of autoflight systems and in applying that knowledge in operational contexts. Pending our review of the recommendations and guidance developed by the working groups and the ACT ARC, Safety Recommendation A-14-41 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/9/2014
Response: -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.