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Safety Recommendation Details

Safety Recommendation A-14-051
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: Conduct a special inspection of San Francisco International Airport’s emergency procedures manual and work closely with the airport to ensure that the airport meets its obligations under Part 139.325.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable 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 - Unacceptable Response)

Safety Recommendation History
From: NTSB
Date: 12/12/2014
Response: We are concerned that you do not fully understand the action we recommended. We issued Safety Recommendation A-14-51 because we had found during our investigation of the Asiana Airlines flight 214 accident that the FAA’s 2013 annual inspection of the San Francisco Airport’s Airport Emergency Plan (AEP) had not detected that the airport was operating with an out-of-date emergency plan from 2008 and was not using the plan that had been revised in December 2012. We also found that a post-accident third party review of the AEP found numerous areas in need of improvement that had not been identified by the FAA. In our investigation of the accident, we found problems with the airport’s emergency response regarding the medical response, disaster drills, and communications, and we concluded that the Alert 3 sections of the airport’s AEP manuals were not sufficiently robust to anticipate and prevent the problems that occurred. These findings call into question the thoroughness of the FAA’s annual inspections. In your letter you indicate that, in April 2014, you conducted a full inspection of the AEP, and found it to meet the requirements of Part 139.325. We believe that the April 2014 inspection was a normal FAA annual inspection performed by the same regional office that had performed the previous inspections, and not a special inspection, as recommended. Although your April 2014 inspection revealed that the AEP was in compliance with Part 139.325, it was not the special inspection we recommended and that we believe necessary to fully assess the adequacy of San Francisco Airport’s AEP. As a result, we ask that you reconsider your position that you have fully responded to this recommendation and your intention to take no further action. Pending your conducting the special inspection recommended, Safety Recommendation A-14-51 is classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
Date: 10/9/2014
Response: -From Michael P. Huerta, Administrator: When FAA approved the most recent Airport Emergency Plan (AEP) for SFO the plan met the requirements of§ 139.325. The FAA also conducted a full inspection of SFO to include its AEP and other emergency response requirements in April2014. We believe that SFO is effectively meeting its requirements.