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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: Convene a special certification design review of how the Boeing 777 automatic flight control system controls airspeed and use the results of that evaluation to develop guidance that will help manufacturers improve the intuitiveness of existing and future interfaces between flight crews and autoflight systems.
Original recommendation transmittal letter:
Open Acceptable Alternate 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 Acceptable Alternate Response)
Safety Recommendation History
We note that you do not believe that an SCR, as defined in FAA Order 8110.4C, “Type Certification,” is warranted; however, you are conducting a thorough review of the Boeing 777 AFCS design using normal investigative processes managed by the responsible FAA type certificate management office. We understand that this technical review will focus on the areas of airspeed control and associated flight crew interfaces and that, based on your results, you plan to evaluate your current certification requirements and guidance. We have previously said that we believed our investigation of the Asiana Airlines flight 214 accident provided sufficient justification for you to initiate an SCR of the Boeing 777 AFCS but that we would consider additional information that you submitted indicating that an alternative action not involving an SCR was more appropriate. We stated that such an alternate action might include examination of your aviation safety information analysis and sharing system (ASIAS) to determine whether (1) AFCS problems identified in our report (such as the potential for mode confusion and delayed flight crew recognition of decaying airspeed with the autothrottle on and in HOLD mode) are unique to the Asiana Airlines flight 214 accident or (2) similar hazardous low-energy situations have periodically occurred during other line flight operations. Your review may constitute an acceptable alternative that will result in guidance that will help manufacturers to improve the intuitiveness of existing and future interfaces between flight crews and auto flight systems. To aid us in evaluating whether the review is acceptable, we ask that you provide us your results after completing it. Specific issues we will consider when determining whether the review is an acceptable alternate include the following: 1. An analysis of information from ASIAS to address the question we posed 2. A comparison of significant functional and training similarities and differences between the Boeing 777 AFCS and AFCS designs installed on other Boeing airplanes (for example, auto throttles always recommended to be engaged, reversionary mode changes in response to manual throttle inputs, and gaps in low airspeed protection features) 3. A summary of the circumstances for each Boeing flight, certification flight, or operational line flight event with the Boeing 777 AFCS (or equivalent system, such as the AFCS on the Boeing 787) that resulted in mode confusion, delayed low airspeed recognition, and/or a low airplane energy state Pending completion of your review and appropriate revisions to guidance and certification standards regarding interfaces between flight crews and auto flight systems, Safety Recommendation A-14-42 is classified OPEN--ACCEPTABLE ALTERNATE RESPONSE.
-From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) evaluated the Board's accident report along with the Boeing 777 automatic flight control system (AFCS) design and service history and determined that a special certification review (SCR), as defined in FAA Order 811 0.4C, Type Certification, is not warranted. An SCR is appropriate for potential safety issues linked to complex or unique design features. The 777 AFCS, which is similar to the AFCS design installed on other Boeing airplanes, has been in service for more than 20 years. In addition, as cited in the Board's report, contributing factors to the accident were the operator's Jack of understanding and mismanagement of the AFCS coupled with a lack of crew resource management during a critical phase of flight. Although an SCR is not warranted in this case, the FAA is in the process of conducting a thorough review of the 777 AFCS design using normal investigative processes managed by the responsible FAA type certificate management office. This technical review, which will include evaluation of relevant service history, is focused on the areas of airspeed control and associated flightcrew interfaces. The outcome of this review will be used to evaluate the adequacy of our current certification requirements and guidance. I will keep the Board informed of the FAA's progress on this recommendation and provide an update by February 28, 2017.
It is unclear whether your plan to work with Boeing to review the design and examine the various means by which the Boeing 777 AFCS controls airspeed constitutes an SCR as described in FAA Order 8110.4; if not, such a plan does not constitute an acceptable response. We believe that our investigation of the Asiana Airlines flight 214 accident provides sufficient justification for you to initiate an SCR of the Boeing 777 AFCS, which (according to the order) would involve a thorough exploration of every significant aspect and ramification of the potential safety problem in question by a team of FAA personnel from multiple offices and possibly additional personnel from other governmental agencies, outside consultant firms, and/or industry representatives. We will consider additional information that you submit indicating that an alternative action not involving an SCR may be more appropriate. Such action might include, for example, an examination of information in your aviation safety information analysis and sharing system to determine whether (1) AFCS problems identified in our report (such as the potential for mode confusion and delayed flightcrew recognition of decaying airspeed with the autothrottle on and in HOLD mode) are unique to the Asiana Airlines flight 214 accident or (2) similar hazardous low-energy situations have periodically occurred during other line flight operations. Pending your convening an SCR of how the Boeing 777 AFCS controls airspeed or providing us an acceptable alternate solution, Safety Recommendation A-14-42 is classified OPEN—UNACCEPTABLE RESPONSE.
-From Michael P. Huerta, Administrator: In March 2013, the Avionics Systems Harmonization Working Group (ASHWG) submitted the Low Airspeed Alerting findings and recommendations to the FAA. To address the ASHWG recommendations, we are considering rulemaking for parts 121 and 129. We will evaluate the effectiveness of the potential rule change to determine whether additional work will be needed to address context-dependent low energy alerting systems for airplanes engaged in commercial operations. The FAA will also work with Boeing to review the design and examine the various means by which the Boeing 777 automatic flight control system controls airspeed. We will evaluate the results of our review and determine the appropriate course of action regarding flightcrew interfaces with autoflight systems.
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