Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation A-14-044
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 FEDERAL AVIATION ADMINISTRATION: Conduct research that examines the injury potential to occupants in accidents with significant lateral forces, and if the research deems it necessary, implement regulations to mitigate the hazards identified.
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: 2/27/2018
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 2/27/2018
Response: We note that you concluded your research regarding injury criteria for lateral and oblique loading conditions and that, based on the results of this research, you use special conditions when certifying side-facing and obliquely oriented seats. We further note that you reviewed data from accidents other than the Asiana accident and determined that it is not necessary to apply lateral impact criteria to cases other than side-facing and obliquely oriented seats because the existing certification requirements of section 25.562 include a lateral loading component, and although the impact sequence in the Asiana accident introduced relatively high lateral loading, that was only one element of a complex and unusual sequence of events. As a result, you do not believe that it is appropriate to revise the certification requirements to address the unique loading situation in the Asiana accident. These actions satisfy Safety Recommendation A-14-44, which is classified CLOSED--ACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 9/11/2017
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) concluded its research regarding injury criteria for lateral and oblique loading conditions. The FAA applied, and will continue to apply, the criteria developed from this research to certification of both side-facing and obliquely oriented seats (i.e., seats installed at an angle greater than 18 degrees, but substantially less than 90 degrees. to the centerline of the airplane) through special conditions. These special conditions are in addition to the existing applicable requirements of Title 14, Code of Federal Regulations 25.562. The FAA reviewed data from accidents other than the Asiana accident and determined that it is not necessary to apply lateral impact criteria to cases other than side facing and obliquely oriented seats, in effect, forward and aft facing seats. The existing certification requirements of § 25.562 include consideration of a lateral loading component that correlates well with this broader set of accident data. The impact sequence in the Asiana accident introduced relatively high lateral loading; however, that lateral loading was only one element of a complex and unusual sequence of events that also included high aft loads. The FAA does not consider it appropriate to revise our requirements to address the unique loading conditions present in the Asiana accident. when the current requirements sufficiently address the general case observed from the broader accident set. I believe that the FAA has effectively addressed this safety recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 5/19/2016
Response: We note that your existing aviation safety research program is continuing to perform the research specified in the first part of these recommendations and that, based on the initial results of this research, you recently issued Special Conditions No. 25-580-SC, “Boeing Model 787-9, Dynamic Test Requirements for Single-Occupant Oblique (Side-Facing) Seats with Airbag Devices.” We further note that, when the final results from these research programs become available, you will determine whether additional rulemaking is necessary. Pending completion of the research, and the development and issuance of any appropriate regulatory revisions based on its final results, Safety Recommendations A-14-44 and -45 remain classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 2/29/2016
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) determined that the existing aviation safety research portfolio contains requirements that are responsive to the first part of these recommendations. Research results obtained so far were used in the issuance of Special Conditions No. 25-580-SC, Boeing Model 787-9, Dynamic Test Requirements for Single-Occupant Oblique (Side-Facing) Seats with Airbag Devices (80 FR 23441 ). The applicable airworthiness regulations do not contain adequate or appropriate safety standards for occupants of seats installed at an angle of greater than 18 degrees, but substantially less than 90 degrees, to the centerline of the airplane, nor for airbag devices. These special conditions contain the additional safety standards necessary to establish a level of safety equivalent to that established by the existing airworthiness standards. Once complete research data are available, the FAA will follow its established process for determining whether general rulemaking would be appropriate. I will keep the Board informed of the FAA's progress on these recommendations and provide an update by July 31, 2016.

From: NTSB
To: FAA
Date: 12/12/2014
Response: We note that your existing aviation safety research program is performing the research specified in the first part of these recommendations and that, when the relevant results from these programs become available, you will determine whether rulemaking is appropriate. Pending completion of the research, and the development and issuance of any appropriate regulatory revisions based on your results, Safety Recommendations A-14-44 and -45 are classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/9/2014
Response: -From Michael P. Huerta, Administrator: The existing aviation safety research portfolio contains elements that are responsive to the first part of these recommendations. With respect to implementation of regulations, the research data are only one element of the considerations involved in rulemaking. Once the research data are available, the FAA will follow its established process for determining whether rulemaking would be appropriate.