NTSB · Safety Recommendation
Safety Recommendation A-14-043
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Task a panel of human factors, aviation operations, and aircraft design specialists, such as the Avionics Systems Harmonization Working Group, to develop design requirements for context-dependent low energy alerting systems for airplanes engaged in commercial operations.
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 FAA previously indicated that we tasked RTCA Special Committee 231 (SC-231), Terrain Awareness Warning System (TAWS), to develop design standards for associated controlled flight into terrain/loss of control mitigations, with the intent to incorporate context-dependent low-energy alerting systems (CDLEAS) as a uniquely defined enhanced ground proximity warning system alert mode. Subsequently, RTCA SC-231 has indicated that developing CDLEAS functionality within TAWS poses significant technical difficulties due to many complex airplane performance and configuration interdependencies associated with providing timely low-energy alerting.
While SC-231 continues to work on product performance standards to prevent controlled flight into terrain accidents, including standards for Automatic Ground Collision Avoidance System for general aviation and commercial aircraft, the committee has recommended that CDLEAS be incorporated as part of each airplane’s basic type design.
The FAA is now considering alternative options for implementing industry recommendations for CDLEAS provided by the Avionics Systems Harmonization Working Group and Flight Test Harmonization Working Group. These options could emphasize revisions to existing certification guidance to enable voluntary implementation, or possible future rulemaking, if determined to be appropriate and cost-beneficial. In the interim, the FAA is actively working with type design approval holders to ensure airplane systems provide adequate alerting and/or envelope protection in new airplane designs.
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 note that, based on the Low Energy Alerting Recommendations Report from the Aviation Rulemaking Advisory Committee’s ASHWG, you determined that Context-Dependent Low Energy Alerting System (CDLEAS) standards are needed. On August 2, 2024, your staff informed us that RTCA Special Committee (SC) 231, Terrain Awareness Warning System (TAWS), is working to incorporate a low-energy alerting mode in the TAWS Minimum Operational Performance Standards (MOPS) and that the updated TAWS MOPS are expected by June 2025. We also note that, in February 2023, you completed FAA-sponsored research that assessed the performance of various technologies to prevent and manage low energy.