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Safety Recommendation Details

Safety Recommendation A-14-045
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 to identify the mechanism that produces high thoracic spinal injuries in commercial aviation accidents, 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: 11/27/2018
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 11/27/2018
Response: We note that you sponsored a research study that evaluated spinal tension injuries in aircraft seat occupants; the study identified the mechanism that produces high thoracic spinal injuries and generated a spinal tension injury criterion. This research was reported in “Responses and Injuries to PMHS in Side-Facing and Oblique Seats in Horizontal Longitudinal Sled Tests per FAA Emergency Landing Conditions,” which appeared in the November 2016 Stapp Car Crash Journal. The research identified high thoracic spinal injuries in a seat test condition with the seat installed at an oblique angle of 45 degrees relative to the centerline of the airplane, but not in forward-facing seat test conditions. The difference in injuries for these two seat test conditions indicates that the spinal injuries observed in the Asiana accident in forward-facing seats may have resulted from the unique loading seen in that accident, particularly the high lateral loading onto armrests. We note that you consider oblique seat installations to be seats with installation angles greater than 18 degrees but less than 45 degrees from the centerline of the airplane. When certifying oblique seats, you now apply the spinal tension injury criterion developed as a result of your sponsored research study by issuing special conditions in accordance with Title 14 Code of Federal Regulations (CFR) Part 21, section 21.16. These special conditions applied to oblique seats are in addition to the existing applicable requirements of 14 CFR 25.562. Thank you for the work that you have completed as a result of this recommendation. Based on the research that you sponsored examining high thoracic spinal injuries in oblique seat installations, your development of a spinal tension injury criterion, and issuance of special conditions implementing that criterion for approving oblique seats, you have satisfied Safety Recommendation A-14-45, which is classified CLOSED—ACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 9/24/2018
Response: -From Daniel K. Elwell, Acting Administrator: The Federal Aviation Administration (FAA) sponsored a research study that evaluated spinal tension injuries through the Aviation Research Grant process. The Medical College of Wisconsin identified the mechanism that produces high thoracic spinal injuries and generated a spinal tension criteria that is below the threshold of injury. This research was reported in the Stapp Car Crash Journal and is available at the following website: https://www.ncbi.nlm.nih.gov/pubmed/27871096. This research identified high thoracic spinal injuries in a seat test condition with the seat installed at an oblique angle of 45-degrees relative to the centerline of the airplane but not in forward-facing seat test conditions. The difference in injuries for these two seat test conditions indicates that the spinal injuries observed in the Asiana accident in forward-facing seats may have resulted from the unique loading seen in that accident. particularly the high lateral loading onto armrests. Oblique seat installations are those seats with installation angles greater than 18 degrees but less than 45 degrees as measured from the centerline of the airplane from the forward direction. When certifying oblique seats, we now apply this spinal tension criteria by issuing special conditions in accordance with Title 14. Code of Federal Regulations (14 CFR) Part 2 1, Section 2 1.1 6. The injury criteria applied through special conditions to oblique seats are in addition to the existing applicable requirements of 14 CFR 25.562. We do not consider the unique and extreme loading observed in the Asiana accident an appropriate reason to revise our requirements for forward-facing seats to address that load case. The current requirements for forward-facing seats address the general load case observed from the vast majority of severe accidents. Based on the research that identified high thoracic spinal injuries in oblique seat installations, our development of a spinal tension criteria, and issuance of special conditions implementing that criteria for approving oblique seats, I believe the FAA has effectively addressed this safety recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 2/27/2018
Response: We note that your research program addressing spinal injuries, including thoracic injuries, is continuing, and that you have not yet determined whether new or additional injury criteria are necessary. Pending completion of your research and development and issuance of appropriate regulatory revisions based on your findings, Safety Recommendation A-14-45 remains classified OPEN--ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/11/2017
Response: -From Michael P. Huerta, Administrator: Our research into spinal injuries, including thoracic injuries, is ongoing. This work will continue into 2020, and possibly beyond. We have not yet determined whether new or additional criteria are necessary. I will keep the Board informed of the FAA's progress on this recommendation and provide an update by July 2018.

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.