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Safety Recommendation Details

Safety Recommendation A-14-043
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: Task a panel of human factors, aviation operations, and aircraft design specialists, such as the Avionics Systems Harmonization Working Group, to develop design requirements for context-dependent low energy alerting systems for airplanes engaged in commercial operations.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Aviation
Location: San Francisco, CA, United States
Is Reiterated: No
Is Hazmat: 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)

Safety Recommendation History
From: NTSB
Date: 12/12/2014
Response: We note that, since March 2013, you have been reviewing the findings and recommendations of your Avionics Systems Harmonization Working Group (ASHWG) related to low-airspeed alerting systems, and that, as a result, you are considering rulemaking. The work of the ASHWG was done in response to Safety Recommendations A-03-53 and -54, which were superseded by Safety Recommendation A-10-12. In our investigation of the Asiana Airlines flight 214 accident, we found that the Boeing 777 was equipped with a low airspeed alerting system that provided both an aural and a visual alert, which would have satisfied our previous recommendations on low airspeed alerting systems. However, the Asiana Airlines flight 214 accident demonstrated that existing low airspeed alert systems may not be adequately tailored to alert pilots to an impending hazard caused by a combination of conditions such as low airspeed and low altitude. We issued Safety Recommendation A-14-43 because our investigation had found that alerting systems based on a low energy state were needed in addition to, or instead of, a low airspeed alerting system. We are encouraged that you will evaluate the effectiveness of the potential rule change to determine whether additional work is needed to address a context-dependent low energy alerting systems for airplanes engaged in commercial operations. Pending completion of the recommended action, Safety Recommendation A-14-43 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
Date: 10/9/2014
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.