Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation A-14-048
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: Once the minimum staffing level has been developed by the Aircraft Rescue and Firefighting (ARFF) Working Group, as requested in Safety Recommendation A-14-60, amend 14 Code of Federal Regulations 139.319(j) to require a minimum ARFF staffing level that would allow exterior firefighting and rapid entry into an airplane to perform interior firefighting and rescue of passengers and crewmembers.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable 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 - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 12/12/2014
Response: Although you regard your actions in response to this recommendation to be complete and you plan no further action, we point out that the recommended action is contingent on the ARFF Working Group’s first completing its response to Safety Recommendation A-14-60. The ARFF Working Group has informed us that they are beginning that work. We believe that it is premature to close this recommendation until after Safety Recommendation A-14-60 is closed. Accordingly, pending your taking the action recommended after the ARFF Working Group completes its action in response to Safety Recommendation A-14-60, Safety Recommendation A-14-48 is classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/9/2014
Response: -From Michael P. Huerta, Administrator: All major airports, such as San Francisco International (SFO), use the minimum staffing requirements of part 139. Each airport develops the staffing level that effectively meets its safety standards. We believe SFO is an excellent example of how the airport's fire department, working through mutual-aid agreements, has sufficient personnel to handle an aircraft incident of significant magnitude. Therefore, we believe that the current regulations, policies, and oversight are sufficient. In addition, independent organizations, such as the Airport Cooperative Research Program (ACRP) have previously evaluated the issue of minimum ARFF staffing. Researchers failed to reach consensus on staffing. The research found no conclusive evidence suggesting that enhanced ARFF staffing standards would make a difference in the survivability of the crashes studied. We do not believe that there is data available to support establishing ARFF staffing requirements. You can find a copy of the ACRP report, “How Proposed ARFF Standards Would Impact Airports,” at the following link: http://onlinepubs.trb.org/onlinepubs/acrp/acrp_webdoc_007.pdf