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General Aviation Safety
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.
TO THE BOEING COMPANY: Using the guidance developed by the low energy alerting system panel created in accordance with Safety Recommendation A-14-43, develop and evaluate a modification to Boeing wide-body automatic flight control systems to help ensure that the aircraft energy state remains at or above the minimum desired energy condition during any portion of the flight.
Original recommendation transmittal letter:
Open - Acceptable Response
San Francisco, CA, United States
Descent Below Visual Glidepath and Impact With Seawall, Asiana Airlines Flight 214
Addressee(s) and Addressee Status:
Boeing Company (Open - Acceptable Response)
Safety Recommendation History
We issued Safety Recommendatiion A-14-43 to the Federal Aviation Administration (FAA) as a result of our investigation of the Asiana Airlines flight 214 accident. In our investigation, we found that the Boeing 777 was equipped with a low airspeed alerting system that provided both an aural and a visual alert, which would have satisfied the recommendations we have issued about low airspeed alerting systems (Safety Recommendations A-03-53 and -54, which were superseded by Safety Recommendation A-10-12). However, the Asiana Airlines flight 214 accident demonstrated that existing low airspeed alert systems may not be adequately tailored to alert pilots to an impending hazard caused by a combination of conditions (such as a combination of low airspeed and low altitude). We issued Safety Recommendation A-14-43 because our investigation found that alerting systems based on a low energy state were needed in addition to, or instead of, a low-airspeed alerting system. Safety Recommendation A-14-43 asked the FAA to task a panel of human factors, aviation operations, and aircraft design specialists to develop design requirements for context-dependent low-energy alerting systems for airplanes. We note that you are not aware of the creation of a FAA low-energy alerting system panel nor any guidance issued as a result of Safety Recommendation A-14-43, but that you are ready to participate on such a panel and evaluate panel guidance, once it has been issued. In an October 7, 2014, letter, the FAA described the actions it is taking in response to Safety Recommendation A-14-43. The letter indicated that, since March 2013, the agency has been reviewing the findings and recommendations of its Avionics Systems Harmonization Working Group (ASHWG) related to low-airspeed alerting systems, and that, as a result, was considering rulemaking to require the systems we previously recommended. The letter further said that the FAA would evaluate the effectiveness of a change to the requirements based on the ASHWG recommendations to determine whether additional work is needed to address context dependent low-energy alerting systems for airplanes. We acknowledge that you are unable to act on Safety Recommendation A-14-57 until the FAA initiates action to satisfy Safety Recommendation A-14-43, and that the FAA is unlikely to start that action until after it has evaluated the regulatory changes for low-airspeed (not low energy) alerting systems based on the work of the ASHWG. We appreciate your commitment to participate in the panel that we asked the FAA to create, and to evaluate panel guidance once it has been issued. Pending completion of the recommended actions, Safety Recommendation A 14 57 is classified OPEN—ACCEPTABLE 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.
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