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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: Analyze, in conjunction with slide/raft manufacturers, the information obtained in this accident investigation and evaluate the adequacy of slide and slide/raft certification standards and test methods specified in Federal Aviation Administration regulations and guidance materials. If appropriate, modify certification standards and test methods for future slide and slide/raft design based on the results of this evaluation.
Original recommendation transmittal letter:
Closed - Acceptable Action
San Francisco, CA, United States
Descent Below Visual Glidepath and Impact With Seawall, Asiana Airlines Flight 214
Addressee(s) and Addressee Status:
FAA (Closed - Acceptable Action)
Safety Recommendation History
We note that you reviewed the information from our accident report and the results of the testing we conducted in our investigation of the escape slide detachment, and that you discussed the issues identified with slide/raft manufacturers, as we requested. We further note that you concluded it would not be appropriate to modify certification standards and test methods to include the crash loads experienced in the Asiana flight 214 accident because, in this event, the crash loads were many times higher than those specified in existing requirements. These combined actions satisfy Safety Recommendation A-14-46, which is classified CLOSED—ACCEPTABLE ACTION. Thank you for your careful analysis to address this recommendation.
-From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) reviewed the Board's accident report and the results of testing conducted during the investigation of the escape slide detachment. The investigation revealed that the escape slides experienced loads during the accident that exceeded the escape slide deployment mechanism design loads by an unknown amount. In addition, the escape slide packboard release mechanisms failed at tested loads between 2 and 4 times the required design loads for this equipment. We discussed these results with the slide/raft manufacturers and evaluated the adequacy of the slide and slide/raft certification standards. The slides and slide/rafts are only one component of the evacuation system on a transport category airplane. Specifically, we require emergency exits on both sides of an airplane because in many crash scenarios, conditions may prevent egress on one side of the airplane. In this case, the unusual side loading stressed the release mechanisms beyond their capability. The mechanisms on the other side of the airplane saw much lower loads and performed as designed. As a whole, the evacuation system on the accident airplane performed adequately. Design improvements might reduce the likelihood of slide deployment inside the cabin. However, requiring that slides remain operational under crash loads many times higher than existing requirements would not be supported by current rulemaking standards based on this single instance. We do not believe that modifying current requirements is warranted based on our evaluation of this issue. I believe that the FAA has effectively addressed this recommendation and consider our actions complete.
We note that you plan to investigate the detachment of escape slides during the accident sequence, as recommended. Pending completion of your investigation, and appropriate revisions being made to the certification standards as a result, Safety Recommendation A-14-46 is classified OPEN—ACCEPTABLE RESPONSE.
-From Michael P. Huerta, Administrator: The FAA agrees that the detachment of escape slides during the accident sequence warrants further investigation, which we will undertake.
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