NTSB · Safety Recommendation
Safety Recommendation A-14-042
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Convene a special certification design review of how the Boeing 777 automatic flight control system controls airspeed and use the results of that evaluation to develop guidance that will help manufacturers improve the intuitiveness of existing and future interfaces between flight crews and autoflight systems.
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
June 10, 2026 · Recipient Response · FAA
-From Bryan Bedford, Administrator: The Federal Aviation Administration (FAA) previously stated it was waiting for Boeing to complete software updates to the Boeing 787 Flight Management Function and Displays Crew Alerting System, as well as the Boeing 747-8 Flight Management Computer and Integrated Display System, to address this recommendation and support issuance of corresponding Airworthiness Directives (ADs).
• On October 23, 2024, the FAA published final rule AD 2024-16-07 (89 FR 76413), requiring the installation of certain new software as well as a software configuration check for Boeing 787 airplanes.
• Boeing continues to develop and certify software updates for the Boeing 747-8/8F airplanes, which the FAA intends to mandate via AD. Boeing has requested a delay in the 2025 expected completion of the software until early 2027. The FAA is discussing options with Boeing to accelerate completion from this new scheduled date. The FAA will initiate the rulemaking process when the software is complete.
I will keep the Board informed of the FAA’s progress on Safety Recommendations A-14-42 and -43 and anticipate providing an update by January 31, 2027.
November 4, 2024 · NTSB Correspondence · FAA
We are aware that AD 2024-04-09 requires 777 operators to install new software and perform a software configuration check. We are also aware that, on September 18, 2024, you published AD 2024-16-07, which is effective October 23, 2024, and requires 787 operators to update their thrust management, displays, and crew-alerting operational program software. On August 2, 2024, your staff informed us that Boeing continues to develop and certify software updates for 747 8/8F airplanes, and that you intend to publish an AD for those airplanes after Boeing’s updates have been finalized, which you expect to occur by the end of 2024.
Although the FAA was previously reviewing data collected from its Continued Operational Safety (COS) evaluation to determine if changes to current certification guidance material and policy are needed to address this safety issue for new designs, your staff informed us that this issue will be addressed as part of the design requirements that you are working on in response to Safety Recommendation A-14-43, which is discussed below.