I recently wrote about emergency exercises and their role in improving your airport’s emergency plan. Exercises are not the only way to learn and to identify opportunities for improvement. Unfortunately, from time to time, the aviation industry suffers an accident and emergency response agencies kick into action. Even though these emergencies might occur at an airport far, far away, they can still provide worthwhile lessons.
In some cases you might learn about plan deficiencies, equipment malfunctions and human errors through informal channels and industry connections. And in a few cases, there might be a formal investigation covering the emergency response to a major accident. The NSTB report into the Asiana Flight 214 crash is one such investigation.
The NTSB obviously investigated the causes of the crash, which involved Boeing 777-200ER coming in low and crashing into the seawall short of the runway, and then they went further, looking at both the good and the bad aspects of the emergency response. I’d like to quickly distill some of these findings for you right here.
In July 2013, Asiana Flight 214 was on approach to San Francisco airport, runway 28L, after making its long-haul flight from Seoul, Korea. For a variety of reasons the aircraft drifted below the glide path for the runway and impacted the ground. Its momentum caused the aircraft to roll and slide on to the aerodrome movement area, break apart, pivot and come to rest approximately 500 metres down the runway.
My short words can’t do justice to the impact but a video can get you just a little closer. The survival rate is miraculous but sadly, three young women died in the accident.
There is a longer raw video provided at the bottom of this post and if you have a spare hour, check it out.
Lessons for the Taking
As mentioned above, the NTSB took some time to review and analyse the emergency response and identified eight issues. I’ve summarised six of them and their associated recommendations below.
Clear HRET Tactics
The Aerodrome Rescue & Fire Fighting Service (ARFFS) at the airport, provided by the local fire department (SFFD), were equipped with two vehicles with High Reach Extendable Turrets (HRETs). These are the turrets that operate on the end of a long arm that can, with the appropriate attachment, pierce the skin of an aircraft and deliver extinguishing agent to the inside of the cabin and other interior parts of an aircraft.
The NTSB found that these vehicles, the “SFFD’s most sophisticated”, were not deployed in the most effective manner - either in positioning or the timeliness of the decision to pierce the aircraft’s skin. In the case of the decision to pierce, the NTSB identified a lack of guidance on when to use the HRET in this manner as leading to the spread of the interior fire.
The NTSB recommended the development of further guidance on HRET use where there is the potential for people to be in the cabin and while the FAA hasn’t yet acted on this recommendation, airport operators could at least ensure that their tactics are clear and well communicated.
Check & Use Your All of Your Emergency Equipment
The airport operator had two medical supply buses that were intended for the response to an emergency such as this. There were to be delivered to the scene by airport staff “early in the response sequence” but they were not. When they were eventually sought for secondary triage, staff found that only one vehicle was operational. This failure led to a shortage of back boards at the scene.
The NTSB looked into this and found contradictions in the procedures and understanding of when these buses would be deployed. They also found that these buses were not deployed during monthly drills and had not be integrated into the airport’s response. This integration was the subject of a recommendation to the SFFD to ensure that it “use of all San Francisco Fire Department medical and firefighting vehicles in future disaster drills and preparatory exercises”.
Minimum ARFFS Staffing Levels
This issue was not a deficiency in this accident. Rather, the NTSB appears to want to highlight the value of having enough ARFFS and response personnel to “allow exterior firefighting and rapid entry into an airplane to perform interior firefighting and rescue of passengers and crewmembers”. In this case, it saved lives.
The report mentions in a number of sections that staffing levels allowed for some brave fire fighters and police officers to enter the aircraft early. They saved five passengers, who were unable to evacuate on their own, from a situation that was about to turn deadly.
This staffing issue was raised in an earlier NTSB accident investigation report and was closed with unacceptable action. Not many jurisdictions specify minimum personnel numbers and for the NTSB this newer recommendation remains open.
It is a question every airport operator (or ARFFS service provider) should ask themselves, can we carry out simultaneous exterior fire fighting and interior rescue/fire fighting? If not, have we formally accepted and documented this decision?
Incident Command Experience
The NTSB analysed quite a few decisions made by the fire attack supervisor. They noted a few deficiencies that they attribute to his lack of aircraft fire and aviation knowledge and experience. While it was found that these deficiencies did not lead to any additional injuries or fatalities, it raised concerns for the investigators.
Similarly, the NTSB noted that the ARFFS shift captain who served as incident commander for a time had not undertaken live fire training.
Overall, the NTSB recommended development of guidance and training material on minimum ARFF training for all airport and mutual aid organisations. This recommendation remains open.
I don’t think this issue would surprise anyone who has been involved in an emergency or emergency exercise. Inter-agency radio communication is notorious for being below what we need in these scenarios.
In the NTSB report, the investigators acknowledge work that had already been carried out by the City of San Francisco to address the issue. The report mentions a common frequency and while this might not be easy to implement everywhere, technological improvement are allowing more systems to talk to each other. Investment in these areas is often hard to secure given the rarity with which they may be used but perhaps a report like this could strengthen your case.
The Airport Emergency Plan
To bring these matters full circle, the NTSB identifies that for these issues to exist, the Airport Emergency Plan (AEP) must have been inadequate. The AEP used at the time of the incident was a document published in 2008. An newer AEP had been drafted and approved by the FAA but no yet distributed.
I think it is fair to say that, had the AEP been functioning effectively, the issues above could have been identified through reviews, exercises or drills and rectified earlier. It’s not a guarantee but a truly live document should see regular updates and improvements.
A mature safety management system can draw safety information and data from a broad range of sources. Accident investigations such as this can be used by any airport operator to learn these lessons and avoid some of these problems in the future.