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Asiana 214 Accident - NTSB
Findings & Recommendations for
SFO ARFF
http://www.youtube.com/watch?v=eXCwI6a1D
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Aircraft rescue and firefighting (ARFF) training
for officers placed in command of an aircraft
accident. The arriving incident commander
placed an officer in charge of the fire attack
who had not received ARFF training, and this
individual made decisions that reflected his
lack of ARFF training. Although no additional
injuries or loss of life could be attributed to
the fire attack supervisor’s lack of ARFF
training, it demonstrates the potential
strategic and tactical challenges associated
with having non-ARFF trained personnel in
positions of command at an airplane accident.
Guidance on when to pierce the fuselage of a
burning airplane with a skin-piercing nozzle.
The airport’s fire department had two vehicles
equipped with high-reach extendable turrets
(HRETs) that were not used to the best of their
capabilities in the initial attack. This was
partially the result of departmental guidance
that discouraged penetration of the fuselage
using the skin-piercing nozzles on the HRETs
until all of the occupants were known to have
evacuated the airplane. Current FAA guidance
provides information on how to pierce but
does not include any guidance on when to
pierce.
Integration of the medical supply buses at SFO
into the airport’s preparation drills. Although the
airport’s emergency procedures manual called for
airport operations personnel to deliver the
airport’s two emergency medical buses to the
accident site, neither of the medical buses
arrived. Further, the monthly emergency drills
conducted by the airport did not include
deployment of the buses either as a matter of
routine or as part of the unique scenario being
evaluated. This lack of integration of the medical
buses into the airport’s preparation drills likely
played a part in their lack of use in the initial
response to the accident.
Guidance or protocols for ensuring the safety of
passengers and crew at risk of being struck or
rolled over by a vehicle during ARFF operations.
In this case, only one passenger was at
significant risk for a vehicle strike due to her
close proximity to the burning airplane; however,
there are other accident scenarios in which many
injured or deceased persons could be located
near an accident airplane. There is currently no
guidance or any recommended protocols for
ensuring the safety of passengers and crew at
risk of being struck or rolled over by a vehicle
during ARFF operations.
Requirements for ARFF staffing. Seven ARFF vehicles
and 23 ARFF personnel from SFO’s fire department
were involved in the initial response to the accident.
This equipment level exceeded the FAA-required
minimum of three vehicles, and there is currently no
FAA-required minimum staffing level. Because of the
amount of available ARFF vehicles and personnel, the
airport firefighters were able to perform exterior
firefighting and send firefighters into the airplane who
rescued five passengers who were unable to selfevacuate amid rapidly deteriorating cabin conditions.
Due to the lack of an FAA-required minimum staffing
level, passengers involved in an aviation accident at a
smaller airport may not be afforded the same level of
protection that the passengers of flight 214 had.
23) Clearer guidance is needed to resolve the
concern among airport fire departments and
individual firefighters that the potential risk of
injuring airplane occupants while piercing
aircraft structure with a skin-penetrating
nozzle outweighs the potential benefit of an
early and aggressive interior attack using this
tool.
- NFPA 402, 11.4.2, Figure A.11.4.5
- NFPA 414, 4.19.6.11, 4.19.6.12 (Amend?)
24) Medical buses were not effectively
integrated into San Francisco
International Airport’s monthly
preparation drills, which played a part in
their lack of use in the initial response
to the accident and delayed the arrival
of backboards to treat seriously injured
passengers.
- NFPA 424, 13.3.3
25) Guidance on task prioritization for
responding ARFF personnel, that
addresses the presence of seriously
injured or deceased persons in the
immediate vicinity of an accident
airplane, is needed to minimize the risk
of these persons being struck or rolled
over by vehicles during emergency
response operations.
- NFPA 402, 7.3.4
- NFPA 424, 14.1, 14.2.3, 14.2.4
26) The overall triage process in this
mass casualty incident was effective
with the exception of the failure of
responders to verify their visual
assessments of the condition of
passenger 41E.
- NFPA 424, 13.6.3
27) The San Francisco Fire Department’s
aircraft rescue and firefighting staffing
level was instrumental in the department’s
ability to conduct a successful interior fire
attack and successfully rescue five
passengers who were unable to selfevacuate amid rapidly deteriorating cabin
conditions.
-NFPA 403, 8.1.2.1
28) Although no additional injuries or loss
of life were attributed to the fire attack
supervisor’s lack of aircraft rescue and
firefighting (ARFF) knowledge and training,
the decisions and assumptions he made
demonstrate the potential strategic and
tactical challenges associated with having
non-ARFF trained personnel in positions of
command at an airplane accident.
- NFPA 403, 8.1.4, (Ref. to NFPA 1003)
- NFPA 403, 8.1.4.1 (Ref. to NFPA 405)
29) Although some of the communications
difficulties encountered during the
emergency response, including the lack of
radio interoperability, have been remedied,
others, such as the breakdown in
communications between the airport and city
dispatch centers, should be addressed.
-NFPA 403, 7.1,
-NFPA 424, 11.1
30) The Alert 3 section of the San
Francisco International Airport’s
emergency procedures manual was not
sufficiently robust to anticipate and
prevent the problems that occurred in
the accident response.
- NFPA 424, 12.2
Work with the Aircraft Rescue and
Firefighting Working Group and
equipment manufacturers to develop
and distribute more specific policies and
guidance about when, how, and where to
use the high-reach extendable turret’s
unique capabilities.
Once the minimum staffing level has
been developed by the Aircraft Fire and
Rescue (ARFF) Working Group, as
requested in Safety Recommendation
[25], 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.
Work with the Aircraft Rescue and
Firefighting (ARFF) Working Group to
develop policy guidance and training
materials to ensure that all airport and
mutual aid firefighting officers placed in
command at the scene of an aircraft
accident have at least a minimum level
of ARFF training.
Issue a CertAlert to all Part 139 airports
to distribute the information contained
in the Federal Aviation Administration’s
(FAA) legal interpretation of 14 CFR
139.319 that requires all personnel
assigned to aircraft rescue and
firefighting duties to meet the initial and
recurrent training and live-fire drill
requirements and clarify how the FAA
will enforce this regulation.
Conduct a special inspection of San
Francisco International Airport’s
emergency procedures manual and
work closely with the airport to
ensure that the airport meets its
obligations under Part 139.325.
No references to any NFPA
documents!
11:28:00
11:31:11
11:32:10
11:37:00
11:38.37
11:42:00
11:47:00
11:48:34
11:49:41
Alert III (10s after impact)
First ARFF unit on scene (3:11s)
Full self-evacuation completed
Passenger 41E body sighted
Interior attack with handline
(10:37s)
Mutual-aid resources on scene
(24m)
Last passenger rescued (5 total)
Passenger 41E struck by first
ARFF vehicle
HRET deployed (21:41s)
11:51:30
11:52:42
11:55:00
12:01:11
12:06:29
12:18:30
13:01:00
17:58:00
Incident Commander on scene (23m)
Pierced aircraft above 2L door (3:01s)
Piercing tip withdrawn
(50s -broken)
Passenger 41E struck again by
second ARFF vehicle
Passenger 41E body covered
Fire brought under control (50:30s)
Last non-ambulatory transported
(1:33:00)
Last ambulatory transported
Thank-you!