NTSB · Safety Recommendation
Safety Recommendation A-14-040
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Once the revision to the Boeing 777 Flight Crew Training Manual has been completed, as requested in Safety Recommendation A-14-39, require operators and training providers to incorporate the revised stall protection demonstration in their training.
Safety Issue and Context
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.
Response History
November 4, 2024 · NTSB Correspondence · FAA
We previously pointed out that the following actions constituted an acceptable alternate solution to the training that we wanted Boeing to develop in response to Safety Recommendations A-14-37 and –39: • Boeing’s updated 777 Airplane Information Management System (AIMS) software, which includes, in the automatic autothrottle activation, additional autothrottle mode combinations that provide expanded minimum speed protection, and • Boeing’s revisions to the 777 Flight Crew Operations Manual (FCOM) and FCTM with information that will improve flight crew understanding of the new autothrottle modes and automatic activation system logic.
However, because 777 operators were not required to incorporate Boeing’s updated 777 AIMS software, we told you that a requirement was needed and would represent an acceptable alternate solution to Safety Recommendations A-14-38 and -40.
We are aware that, on March 19, 2024, you published Final Rule Airworthiness Directive (AD) 2024-04-09, “The Boeing Company Airplanes,” which requires 777 operators to incorporate Boeing’s updated AIMS software to include, in the automatic autothrottle activation, additional autothrottle mode combinations that provide expanded minimum speed protection. Consequently, Safety Recommendations A-14-38 and -40 are classified CLOSED--ACCEPTABLE ALTERNATE ACTION.
October 5, 2023 · Recipient Response · FAA
-From Kathryn B. Thomson, Deputy Administrator: The Federal Aviation Administration (FAA) published Advisory Circular (AC) 120-123, Flightpath Management (FPM), on November 21, 2022. This AC provides guidance and recommended practices for operators to implement operational procedures and training for the planning, execution, and assurance of the guidance and control of aircraft trajectory and energy under 14 CFR Parts 121 and 135