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Safety Recommendation Details

Safety Recommendation A-14-058
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 AIRCRAFT RESCUE AND FIREFIGHTING WORKING GROUP: Work with the Federal Aviation Administration and equipment manufacturers to develop and distribute more specific policies and guidance about when, how, and where to use the high-reach extendable turret’s unique capabilities.
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: 10/22/2018
Addressee(s) and Addressee Status: Aircraft Rescue & Fire Fighting Working Group (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Aircraft Rescue & Fire Fighting Working Group
Date: 10/22/2018
Response: We note that you completed separate research projects for each recommendation, and these projects are described in detail, including recommended best practices based on the research results, in the reports that you included with your letter. We further note that each report was presented to the ARFF WG membership at your annual conference in September 2018. We were pleased to find that the reports support your thorough research and provide valuable information. Accordingly, Safety Recommendations A 14-58 through -61 are classified CLOSED--ACCEPTABLE ACTION.

From: Aircraft Rescue & Fire Fighting Working Group
To: NTSB
Date: 9/9/2018
Response: -From Jason Graber, Chairman, ARFF Working Group: The ARFFWG believes there is potential for improvement within the industry in each of the four recommendations, which would assist in the prevention of accidents and save lives. In order to thoroughly identify prospective enhancements, the ARFFWG conducted a collaborative applied research endeavor between the Federal Aviation Administration (FAA) and the ARFFWG. Each of the four NTSB recommendations were completed as separate and distinct research projects, supported by a specialized committee. Committee membership was supervised by joint chairs from the ARFFWG and the FAA and comprised of subject matter experts who contributed valuable knowledge and experience to each of the recommendations. A comprehensive ARFFWG response comprised of each committee’s final research reports is attached. We are confident this information is thorough, and the recommendations are solid solutions to address each of the concerns. Each report will be presented to the ARFFWG membership at our annual conference on September 17, 2018. Please let us know if you have any questions or concerns.

From: Aircraft Rescue & Fire Fighting Working Group
To: NTSB
Date: 11/21/2014
Response: -From Duane F. Kann, EFO, AFO, Fire Chief, Orlando International Airport: Thank you for your response. We will begin working with the FAA and establish task groups to address each specific recommendation. Updates to follow.

From: NTSB
To: Aircraft Rescue & Fire Fighting Working Group
Date: 11/20/2014
Response: We note that each recommendation will be the subject of a distinct research project, supported by an individual committee of the ARFF Working Group, and that you plan to submit all four committee final research reports to us once they are completed, as well as disseminate your findings to the aviation industry. We look forward to reviewing the results of your research once it is complete. In the meantime, Safety Recommendations A-14-58 through -61 are classified OPEN—ACCEPTABLE RESPONSE.

From: Aircraft Rescue & Fire Fighting Working Group
To: NTSB
Date: 10/13/2014
Response: -From Danny M. Pierce, A.F.O., BS: NFPA 402, 10.6.2, 11.4.2, A.11.4.5 NFPA 414, 4.19.6.11, 4.19.6.12 IFSTA ARFF 5th Edition, p.235

From: Aircraft Rescue & Fire Fighting Working Group
To: NTSB
Date: 10/13/2014
Response: -From Duane F. Kann, Chairman, ARFF Working Group: The ARFFWG believes there is potential for improvement within the industry in each of the four recommendations, which would assist in the prevention of accidents and save lives. In order to identify prospective enhancements, the ARFFWG proposes to address the four recommendations via a collaborative applied research endeavor between the Federal Aviation Administration (FAA) and the ARFFWG, with Embry-Riddle Aeronautical University serving in an academic research capacity. Each of the four NTSB recommendations will stand alone as distinct research projects, supported by an individual committee. The applied research teams would examine all four recommendations separately by utilizing systematic inquiry, which includes but is not limited to; accumulated theories, knowledge, methods and techniques. This type of research seeks to find applications within real specific settings using the scientific method. Committee membership will be comprised of subject matter experts who can contribute valuable knowledge and experience to the systematic inquiry and will be supervised by joint chairs from the ARFFWG and the FAA. The ARFFWG membership is worldwide and reaches approximately 30 countries with a wealth and variety of subject matter experts. The following is a sample of the arenas represented: ARFF vehicle, equipment and agent manufacturers; Aircraft manufacturers; Airlines; ARFF command professionals and combat firefighters from all size airports; ARFF training academies and instructors; Educational institutions; FAA and other government professionals; Military; National Fire Protection Association ARFF Technical Committee members; Professional and Private sector organizations; and a variety of stakeholder groups that can make meaningful contributions to advancing knowledge in each of the subject matter areas. A comprehensive ARFFWG response comprised of all four committee final research reports, and other documentation as necessary, will be submitted to the NTSB when the projects are completed. At present, the ARFFWG is prepared to begin assembling the collaborative applied research teams. One ARFFWG committee is already working on a project similar to the A-14-61, and is poised to begin the research on that recommendation very quickly. When each committee and their respective Co-Chairs are established by the end of 2014, the NTSB will be provided with the committee makeups. The committees will hold a meeting in early 2015, where they will determine the timelines, process and scope of their project. At that time we will be better able to provide the NTSB with a timetable for completion of research design target dates and research proposal target dates for each of the four projects. Upon completion of the research projects an effort will be made to get the findings out to the aviation industry. The information will be submitted to industry magazines and journals for publication, and will be placed on the ARFF Working Group website. Presentations will be submitted to ARFF Working Group, AAAE, ACI, NFPA and other industry conferences to share this information with all aviation professionals. Representatives with ARFF Working Group may also submit findings as recommended changes to industry standards to further vet this valuable information in formal written language. Please let us know if you have any questions or concerns.