NTSB · Safety Recommendation
Safety Recommendation A-14-048
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Once the minimum staffing level has been developed by the Aircraft Rescue and Firefighting (ARFF) Working Group, as requested in Safety Recommendation A-14-60, amend 14 Code of Federal Regulations 139.319(j) to require a minimum ARFF staffing level that would allow exterior firefighting and rapid entry into an airplane to perform interior firefighting and rescue of passengers and crewmembers.
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
You previously told us that you did not intend to establish minimum ARFF staffing levels because you believe existing regulations are sufficient. We asked you to explain how you made that determination, and you reported that ARFF services for airports can vary widely based on the airport size, type of aircraft, emergency activities, equipment, apparatus, and operating procedures. You also reported that, based on these factors and mutual-aid agreements, each airport develops its own staffing levels.
We note that you do not believe data are available to successfully pursue rulemaking to require minimum ARFF staffing levels and, therefore, you believe that the current regulations, policies, and oversight are sufficient, and the need to change current staffing regulations is not supported.
We are disappointed that you are basing your decision to not establish minimum ARFF staffing levels on research that was conducted in response to Safety Recommendation A-01-65, which we were aware of when we issued Safety Recommendation A-14-48. We also point out that, in response to Safety Recommendation A-14-60, the ARFF Working Group created a task group that conducted an applied research project to examine theories, knowledge, methods and techniques concerning the creation of a minimum staffing level.
The project consisted of a comprehensive literature review of all relevant documents and publications, as well as a research exercise that was conducted at Atlantic City International Airport. In addition, the task group, which you co-chaired, recommended establishing minimum ARFF staffing levels and performing a hazard risk analysis to determine any additional staffing needs based on each airport’s unique operations.
We continue to believe that minimum ARFF staffing levels should be established to ensure that ARFF crews arriving at the scene of an airplane have sufficient staff to begin rescue efforts for passengers and crew inside who may be unable to escape. However, because you have made it clear that you do not intend to revise section139.319 to address this concern, Safety Recommendation A-14-48 is classified CLOSED-- UNACCEPTABLE ACTION.
August 30, 2023 · Recipient Response · FAA
-From Kathryn B. Thomson, Deputy Administrator: In its June 30, 2022, letter, the Board asked the FAA how it determined that current regulations are sufficient and why the FAA will not require minimum ARFF staffing levels. In response, ARFF services for airports can vary widely based on the airport size, type of aircraft, emergency activities, equipment, apparatus, and operating procedures. Each airport develops the staffing level it feels will meet the standards for safety based on these factors and, with mutual-aid agreements, can have sufficient personnel to handle an aircraft incident or accident. We also continue to agree with what we stated in our October 7, 2014, letter to the Board: