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Safety Recommendation Details

Safety Recommendation A-14-052
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 ASIANA AIRLINES, INC.: Reinforce, through your pilot training programs, flight crew adherence to standard operating procedures involving making inputs to the operation of autoflight system controls on the Boeing 777 mode control panel and the performance of related callouts.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
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: 4/1/2015
Addressee(s) and Addressee Status: Asiana Airlines (Closed - Acceptable Action)

Safety Recommendation History
From: NTSB
To: Asiana Airlines
Date: 4/1/2015
Response: We are pleased that you are monitoring flight crew performance and are training flight crews in standard operating procedures for autoflight system controls and related callouts, as recommended. Accordingly, Safety Recommendation A-14-52 is classified CLOSED—ACCEPTABLE ACTION.

From: Asiana Airlines
Date: 1/26/2015
Response: -From Soo Cheon Kim, President and CEO, Asiana Airlines: I would like to take this opportunity to express my sincere gratitude towards you and the esteemed members of National Transportation Safety Board, for the continuous endeavors and contributions to investigate the accident of Asiana Airlines Flight 214 occurred on July 6, 2013, at San Francisco International Airport, San Francisco, California. Through Korean Aviation and Railway Accident Investigation Board (ARAIB)'s new accredited representative (AR), Asiana Airlines would like to submit our additional actions taken to reinforce the implementation plans for Safety recommendations A-14-52. Asiana Airlines has strongly emphasized the importance of contents within the Safety Recommendation A-14-52, by monitoring and cross-checking the flight crew's operational performances. In order to comply with Safety Recommendation A-14-52 and take precise remedial actions, we are conducting training courses utilizing the documented standards of "Awareness of pilot inputs and AFDS status"(FOM) and "Standard Callout & Response Procedures"(B777 POM) as our training material, to sustain the shared alertness within our flight crew. Once again, we truly appreciate all the support that you and your investigation team have given us throughout the investigation process of the accident. Your valuable recommendations will encourage us to reinforce the fundamentals for our safety management system, and improve our measures for the development of company's safety policy.

From: NTSB
To: Asiana Airlines
Date: 12/12/2014
Response: We note that you have reorganized the former “Monitoring and Workload Management” courses to add, and emphasize, training on monitoring, and that you notified all of your flightcrew about the importance of standard callouts of changes to the flight mode annunciation. We appreciate your taking these actions, and ask whether the revised monitoring training emphasizes the use of standard callouts to maintain shared awareness of flight crew inputs and autoflight system status. Pending our receipt of this information, Safety Recommendation A 14 52 is classified OPEN—ACCEPTABLE RESPONSE.

From: Asiana Airlines
Date: 10/10/2014
Response: -From Megan Kim, English Affairs Coordinator, Aviation and Railway Accident Investigation Board (ARAIB), Minstry of Land, Infrastructure, and Transport, Republic of Korea: Asiana Airlines Actions A. Training team reorganized the former ‘Monitoring and Workload Management’ courses which used to be general classes for flight crew, by rearranging into 3 classes (Basic, Line Operation, CRM). 1) Basic Training course A) Added a ‘Monitoring Skill’ class in Basic Training course. - [Attachment 1. Flight Crew Training Regulation] B) The ‘Monitoring Skill’ class in new flight crew basic training course (started 2014.5.7). - [Attachment 2. Internally approved document of training plan] 2) Line Operation Course A) ‘Monitoring & crosscheck’ class in OEGS(Operating Experience Ground School) for each fleet. (started 2014.6.30) – [Attachment 3. Operating Experience Training Procedure] B) ‘Monitoring Skill’ class in recurrent training for each fleet. (started 2014.7.1) – [Attachment 4. Internally approved document of recurrent training plan] 3) CRM course - Replace ‘Monitoring and Workload Management’ class with ‘Monitoring & Crosscheck’ class. (started 2014.5.22) – [Attachment 5. Internally approved document of training plan] B. Notified all crew that the importance of standard callouts of FMA (Flight Mode Annunciation) change. – [Attachment 6. Flight Crew Notice on 2014.1.2]