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Safety Recommendation Details

Safety Recommendation A-14-062
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 CITY OF SAN FRANCISCO: Routinely integrate the use of all San Francisco Fire Department medical and firefighting vehicles in future disaster drills and preparatory exercises.
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: 4/1/2015
Addressee(s) and Addressee Status: State of California, City of San Francisco (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: State of California, City of San Francisco
Date: 4/1/2015
Response: We are pleased to learn that, although SFO Airport currently operates the medical supply buses, the SFFD will operate and maintain the two new mass casualty response vehicles once they have been delivered. SFO Airport’s newly implemented procedures, which include integrating all SFFD medical and firefighting vehicles into monthly and annual disaster drills, satisfy Safety Recommendation A-14-62, which is classified CLOSED—ACCEPTABLE ACTION.

From: State of California, City of San Francisco
To: NTSB
Date: 1/12/2015
Response: -From John L. Martin, Airport Director and Joanne Hayes-White, Fire Chief, The City and County of San Francisco: As described in our letter dated August 14, 20 14, San Francisco, SFO, and the San Francisco Fire Department (SFFD) took immediate and substantive steps toward meeting the NTSB Recommendations. We are pleased to report that many of the initiatives of the last several months have become part of the regular protocols and procedures for SFO and its first responders, all enhancing our culture of safety. You have requested additional information concerning (1) operation of the medical supply buses and (2) the Airport Emergency Plan (AEP). Operation of the medical supply buses. You requested that we confirm whether the medical supply buses are now being operated by SFFD or continue to be operated by SFO staff. • Currently, SFO staff continues to operate the medical supply buses. SFO has implemented new procedures (a) to continuously connect the buses to charging stations when not in use; (b) start-test the buses on a weekly basis; and (c) activate the buses for Red Cap Drills on a monthly or more frequent basis. • In 2015-16, SFFD expects to take delivery of two new mass casualty response vehicles. Each vehicle will carry basic life support equipment and supplies, including backboards, for 250 patients. SFFD will operate and maintain the vehicles. Airport Emergency Plan (AEP). You have requested a copy of the AEP. We will transmit to the NTSB the most recent AEP, effective 14 April2014, under separate cover through a secure channel, as the AEP contains sensitive security information (SSI). In response to your listed concerns, however, kindly note that SFO/SFFD have addressed such items through improved operations and emergency preparation, not in the AEP document. We respond to the specific items as follows: • Training for SFO personnel on initiating Alert 3 communications to avoid confusion: SFO Communications Center personnel are now trained on the new SFO Alert mass notification system (supplied by Everbridge). The new system uses multiple media to alert required responders and the general public. SFO has tested the system and employed it in the September 24 full-scale exercise. Effective January 2015, Communications Center personnel will run system exercises on a monthly basis. • The addition of a new. specific communication plan: SFFD has adopted a specific SFO communication plan under SFFD General Order 14 A-41 and Memorandum CD2-14-04, enclosed. • The modification of SFO response plans to facilitate better communication among the SFO fire department, the police department and airport operations personnel: SFO has obtained a Raytheon ACU-1000m Multi-Agency Interoperability Communications system which can interface different responding agencies into one radio net, using their individual frequencies by connecting their portable (hand pack) radios into the system "blackbox". This allows separate agencies to communicate directly. SFO has successfully conducted operational testing with Customs and Border Protection, Federal Bureau of Investigation, Federal Air Marshal, Transportation Security Administration, San Mateo County Sheriff, SFFD-AB, and the San Francisco Police Department-Airport Bureau. During the tests, all units scattered throughout SFO were able to communicate with each other and the SFO Communications Center Dispatch. SFFD interoperability was tested using the patch technology incorporated into the main dispatch consoles. SFFD, SFFD-AB, and San Mateo County responders now have common channels. Additionally, regional authorities are establishing three Bay Area common use channels. SFO and SFFD have the common use channels active and San Mateo County is in the process of doing so. The three common use channels may be used for both fire/rescue or law enforcement response. In the September 24 full-scale exercise (see description of exercise below), interoperability was successfully implemented. • The modification of SFO response plans to better include mutual aid personnel within the incident command system: Mutual aid personnel are now better included in SFO's response plans through implementation of the Blue Card Incident Command system, regular Red Cap Drills, and the annual full-scale training exercise, as follows: o All SFFD-AB officers (Lieutenants and those firefighters who function occasionally as Like Work, Like Pay Lieutenants, Captains, Rescue Captains, and Chief Officers) are certified in the Blue Card program. The Blue Card Program is a training and certification system that teaches Company and Command Officers how to standardize local incident operations across their organization and incorporate mutual aid partners. The program uses a combination of online and in-class simulation training which results in an Incident Commander solution that addresses local Hazard Zone operations. o Regular monthly SFO Redcap Drills include San Francisco Fire Department-Airport Bureau (SFFD-AB) medical and firefighting vehicles. In 2015, SFFD-AB will include mutual aid companies in the RedCap Drills on a quarterly basis. A RedCap Drill is a multi-company ARFF exercise and time trial. These drills are scenario-based and normally carried out three times each month at a different time or the day (early morning. mid-day. and nighttime) for each evolution. The drills are used to evaluate response times to ARFF incidents and to exercise use of the Incident Command System (ICS) and basic strategy and tactics for aircraft-related incidents. o On September 24. 2014. SFO, its first responders and its mutual aid community participated in a full-scale Disaster Readiness Exercise. The exercise simulated the crash of a domestic aircraft on the airfield. The exercise used SFO's 8767 Training Aircraft. The exercise engaged SFO staff; the SFFD-A8 and SFFD Companies based in San Francisco: the San Francisco Police Department: San Mateo County Fire Departments, Health Department, and Public Safety Dispatch: AMR Ambulance Services: American Airlines: the American Red Cross: the Federal Aviation Administration; San Francisco Department of Emergency Management: and local hospitals. Over 200 individual volunteers also participated to simulate passengers in various levels of medical need and to simulate family members of passengers. Enclosed please find a more detailed description of the exercise entitled “2014 SFO Full Scale Exercise Overview” • The review and modification or the SFO emergency procedures manual to address the deficiencies noted and to ensure it is fully integrated with other local and regional disaster plans: The primary deficiency noted in the ICF Report regarding full integration with other local and regional disaster plans was to fully adopt and implement WebEOC [the communications technology for the Emergency Operations Center] as SFO's crisis management tool. interconnect it with other regional agencies and develop common practices for information sharing and resource management. We have implemented the WebEOC tool in the SFO EOC, trained personnel and aligned with San Mateo County Emergency Management System and the San Francisco Department of' Emergency Management. We fully exercised the tool during our September 24, 2014 Air Crash Exercise with the noted partners. We believe that these actions together with those described in our previous commentaries fully address the NTSB recommendations, but if there is any additional information needed to classify the file closed. Please advise.

From: NTSB
To: State of California, City of San Francisco
Date: 11/12/2014
Response: We are encouraged by your efforts thus far to (1) integrate all San Francisco Fire Department medical and firefighting vehicles into your monthly and annual disaster drills and (2) address the communication deficiencies identified in ICF International’s after action report. However, we request additional information so that we may better assess the extent of these efforts. Please confirm whether the medical supply buses are now being operated by the fire department or continue to be operated by the airport. We would also like to review the new SFO Airport Emergency Plan to determine whether the following changes have been included in the revision: • training for SFO personnel on initiating Alert 3 communications to avoid confusion • the addition of a new, specific communication plan • the modification of SFO response plans to facilitate better communication among the SFO fire department, the police department, and airport operations personnel • the modification of SFO response plans to better include mutual aid personnel within the incident command system • the review and modification of the SFO emergency procedures manual to address the deficiencies noted and to ensure it is fully integrated with other local and regional disaster plans Please send us a copy of the new SFO Airport Emergency Plan for our review. Pending our receipt and review of this material, Safety Recommendations A-14-62 and -63 are classified OPEN—ACCEPTABLE RESPONSE.

From: State of California, City of San Francisco
To: NTSB
Date: 8/14/2014
Response: -From John L. Martin, Airport Director and JoAnne Hayes-White, Fire Chief: San Francisco is committed to routinely integrating the use of all San Francisco Fire Department(SFFD) medical and firefighting vehicles in future disaster drills and preparatory exercises and has already started implementing this recommendation. SFO's efforts to fully adopt this recommendation include the following: San Francisco recently completed a new SFO Airport Emergency Plan (AEP), which includes Preferred Standard Emergency Response Plan (PSERP). Regular monthly SFO Redcap Drills now include San Francisco Fire Department-Airport Bureau (SFFD-AB) medical and firefighting vehicles. SFO has purchased a new Incident Command vehicle (anticipated delivery November 20 14), which will be activated by the Airport Operations Divisions in the event of a major airfield incident. The annual Disaster Readiness Drill scheduled for September 24, 2014 will incorporate SFFDAB response vehicles as well as SFFD support companies and San Mateo County mutual aid vehicles. SFO has budgeted the purchase of two Mass Casualty Unit vehicles, one in Fiscal Year 2014/15 and one in Fiscal Year 2015/16.