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Safety Recommendation Details

Safety Recommendation A-14-054
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.: Issue guidance in the Boeing 777 Pilot Operating Manual that after disconnecting the autopilot on a visual approach, if flight director guidance is not being followed, both flight director switches should be turned off.
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: 12/12/2014
Addressee(s) and Addressee Status: Asiana Airlines (Closed - Acceptable Action)

Safety Recommendation History
From: NTSB
To: Asiana Airlines
Date: 12/12/2014
Response: The guidance in Asiana Airlines’s Boeing 777 Pilot Operating Manual, 12th revision, satisfies Safety Recommendation A-14-54, which is classified CLOSED—ACCEPTABLE ACTION.

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 ? Completion of the revision of B777 Pilot Operation Manual (2014.6.23) – [Attachment 8. B777 POM 12th revision] - Auto pilot & FD Use – “Both FD off then ON (PM SIDE)” was revised to “Both FD off”. - Typical Visual Approach with traffic pattern – 2 steps added on section “e. Base Leg & Final turn” A) Maintain visual profile. Disengage autopilot. B) At this time both FD to OFF. (“Both FD off”) This eliminates unwanted commands for PF/PM.