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Safety Recommendation Details

Safety Recommendation A-14-047
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: Work with the Aircraft Rescue and Firefighting Working Group and equipment manufacturers to develop and distribute more specific policies and guidance about when, how, and where to use the high-reach extendable turret’s unique capabilities.
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 issued this recommendation because we had found in our investigation of the Asiana Airlines flight 214 accident that better guidance was needed to resolve the concern among airport fire departments and individual firefighters that the potential risk of injuring airplane occupants while piercing aircraft structure with a skin-penetrating nozzle outweighed the potential benefit of an early and aggressive interior fire attack using the HRET. We are encouraged that you plan to work with the ARFF Working Group to publish and recommend additional techniques and training on the use of the HRET. We also issued Safety Recommendation A 14 58 to the ARFF Working Group asking them to work with you on these efforts. Pending completion of the recommended action, Safety Recommendation A-14-47 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/9/2014
Response: -From Michael P. Huerta, Administrator: The FAA has published guidance on the use and capabilities of High Reach Extendable Turrets (HRET), including a September 30, 20 l 0, update of Advisory Circular (AC) 150/5210-23, " Aircraft Rescue and Firefighting (ARFF) Vehicle and HRET Operation, Training and Qualifications." This AC referenced other FAA ACs and various National Fire Protection Association standards as it outlined HRET use and qualification. Information contained in AC 150/5210-23 was also complemented by the most recent edition of the FAA ARFF Digital Video Disc (DVD) training program, which is available through the FAA (a copy will be forwarded to the NTSB separate from tills letter). These DVD sets were provided to every applicable airport and are available free upon request. Although much work has been done developing HRET guidance, we concur that more could be done to publish and recommend additional techniques and training that ARFF organizations can choose to use to enhance proficiency in HRET. To that end, we will work with the ARFF Working Group and meet with them to develop a plan to address this recommendation.