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Safety Recommendation Details

Safety Recommendation A-14-056
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 BOEING COMPANY: Revise the Boeing 777 Flight Crew Operating Manual to include a specific statement that when the autopilot is off and both flight director switches are turned off, the autothrottle mode goes to speed (SPD) mode and maintains the mode control panel-selected speed.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
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: 8/18/2015
Addressee(s) and Addressee Status: Boeing Company (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Boeing Company
Date: 8/18/2015
Response: We note that the June 2015 version of the Boeing 777 FCOM includes revisions to the Autothrottle System description in Chapter 4 that satisfy Safety Recommendation A-14-56. Accordingly, the recommendation is classified CLOSED—ACCEPTABLE ACTION.

From: Boeing Company
To: NTSB
Date: 5/8/2015
Response: -From Paul R. Richter, Director, Aviation Safety: Boeing is revising the Autothrottle System description in Chapter 4 of the 777 Flight Crew Operations Manual (FCOM) to include the following statement: When the autopilot is not engaged, but one or both flight directors are ON and the autothrottle is active, turning off both flight directors transitions the autothrottle to SPD. The autothrottle maintains the IAS/MACH window speed. This statement will be published in the June 2015 version of the 777 FCOM. In response to safety recommendation, A-14-57, Boeing is not aware of the creation of a FAA low energy alerting system panel or any guidance issued in accordance with Safety Recommendations A-14-57 or A-14-43, but stands ready to participate in such a panel, if invited, and evaluate panel guidance, when issued. In addition to being responsive to industry guidance, Boeing is continually monitoring the in-service performance of our airplanes and considering potential product safety enhancements. Our evaluation of the 777 Low Airspeed alert continues to find this alert to be effective, appropriate, and consistent with industry standards. Please feel free to contact us if you have any questions.