NTSB issues safety recommendations following B737 tailwind landing accident

December 11, 2011

The NTSB has issued four safety recommendations and reiterated one older recommendation to prevent runway excursion accidents following tailwind landings.

On December 22, 2009, American Airlines flight 331, a  Boeing 737-800, N977AN, ran off the departure end of runway 12 after landing at Kingston-Norman Manley International Airport (KIN), Jamaica. The aircraft landed approximately 4,000 feet down the 8,911-foot-long, wet runway with a 14-knot tailwind component and was unable to stop on the remaining runway length. After running off the runway end, it went through a fence, across a road, and came to a stop on the sand dunes and rocks above the waterline of the Caribbean Sea adjacent to the road. No fatalities or postcrash fire occurred.

The investigation, being conducted by the Jamaica CAA, is still ongoing. The NTSB, being part of the investigation, decided to issue the following recommendations to the Federal Aviation Administration (FAA):


Require principal operations inspectors to review flight crew training programs and manuals to ensure training in tailwind landings is (1) provided during initial and recurrent simulator training; (2) to the extent possible, conducted at the maximum tailwind component certified for the aircraft on which pilots are being trained; and (3) conducted with an emphasis on the importance of landing within the touchdown zone, being prepared to execute a go-around, with either pilot calling for it if at any point landing within the touchdown zone becomes unfeasible, and the related benefits of using maximum flap extension in tailwind conditions. (A-11-92)

Revise Advisory Circular 91-79, “Runway Overrun Prevention,” to include a discussion of the risks associated with tailwind landings, including tailwind landings on wet or contaminated runways as related to runway overrun prevention. (A-11-93)

Once Advisory Circular 91-79, “Runway Overrun Prevention,” has been revised, require principal operations inspectors to review airline training programs and manuals to ensure they incorporate the revised guidelines concerning tailwind landings. (A-11-94)

Require principal operations inspectors to ensure that the information contained in Safety Alert for Operators 06012 is disseminated to 14 Code of Federal Regulations Part 121, 135, and 91 subpart K instructors, check airmen, and aircrew program designees and they make pilots aware of this guidance during recurrent training. (A-11-95)

The National Transportation Safety Board also reiterates the following recommendation to the Federal Aviation Administration and reclassifies it “Open—Unacceptable Response”:
Require all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to accomplish arrival landing distance assessments before every landing based on a standardized methodology involving approved performance data, actual arrival conditions, a means of correlating the airplane’s braking ability with runway surface conditions using the most conservative interpretation available, and including a minimum safety margin of 15 percent. (A-07-61)

This recommendation, A-07-61, was issued following the December 2005 runway excursion accident involving a Boeing 737-700 at Chicago-Midaway Airport.

More information:

FAA issues icing rule, addressing long standing NTSB recommendation

August 19, 2011

The U.S. Federal Aviation Administration (FAA) issued a new rule requiring scheduled airlines to install ice detection equipment in their existing fleets or to update their flight manuals to make sure crews know when they should activate their ice protection systems.

For aircraft equipped with an ice-detection system, the new rule mandates that the system alert the crew every time they need to activate ice protection. The system can either automatically turn on the ice protection or pilots can manually activate it.

For aircraft without ice-detection equipment, the crew must activate the protection system based on cues listed in their airplane’s flight manual during climb and descent, and at the first sign of icing when at cruising altitude.

The rule applies only to in-service aircraft that weigh less than 60,000 pounds because studies show smaller planes are more affected by undetected icing or late activation of the ice protection system. Larger commercial aircraft already have ice detection equipment.

This rule addresses a longstanding National Transportation Safety Board recommendation.

More information:

NTSB issues recommendations on accessibility of flight deck fire extinguishers

August 15, 2011

Fire damage on the captain's windshield of this Boeing 757 (photo: NTSB)

The National Transportation Safety Board (NTSB) issued three safety recommendations on flight crews’ ease of access to fire extinguishers while oxygen masks are donned.

These recommendations were made following the Boards investigation into an incident in which the crew of a Boeing 757 were face with a fire at the windshield heat terminal connection in the cockpit. The flight crew diverted to Washington Dulles International Airport, VA, and landed without further incident. No evacuation was conducted, and none of the 7 crewmembers or 105 passengers sustained injuries.
In addition to the factors that led to the fire, NTSB’s investigation of this incident revealed a safety issue concerning 14 CFR Part 121 flight crews’ ability to readily access fire extinguishing equipment while wearing the oxygen masks and goggles that they are instructed to don at the first indication of smoke, fire, or fumes. During postincident interviews, the flight crewmembers of the incident flight indicated that they immediately donned oxygen masks and smoke goggles in accordance with the United Airlines Boeing 757 Smoke, Fire or Fumes checklist.
The captain reported that he left his seat because the flames were in front of him and he needed to immediately reach the fire extinguisher, located on the back wall of the cockpit next to the jumpseat.
The captain stated that, as he moved toward the fire extinguisher, his oxygen mask and smoke goggles were “torn off” because he had reached the end of the hose attached to the oxygen mask. He removed the fire extinguisher, put the mask and goggles back on, and discharged the extinguisher until it was empty. The captain reported that the fire was suppressed but reignited within seconds and that, as he moved toward the cockpit door to retrieve a second extinguisher from the cabin crew, his mask and goggles came off again. He retrieved the extinguisher, put his mask and goggles back on, and discharged the extinguisher, fully extinguishing the fire.

Therefore, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration:

Require that the length of oxygen mask hoses in the cockpits of airplanes used in 14 Code of Federal Regulations Part 121 operations be increased, as necessary, to allow flight crews access to all required emergency equipment in the cockpit, as 6 well as to additional emergency equipment provided by the cabin crew via the cockpit door, while oxygen masks are donned. (A-11-79)

Amend Advisory Circular 120-80, “In-Flight Fires,” to provide clear guidance to flight crews concerning the type of breathing equipment to wear when combating a cockpit fire, taking into consideration the limitations of portable protective breathing equipment in both passenger and cargo operations. (A-11-80)

Amend Advisory Circulars 20-42D, “Hand Fire Extinguishers for Use in Aircraft”; 25-17A, “Transport Airplane Cabin Interiors Crashworthiness Handbook”; and 25-22, “Certification of Transport Airplane Mechanical Systems” to indicate that hand fire extinguishers in the cockpit must be reachable by at least one flight crewmember while wearing an oxygen mask. (A-11-81)

More information:


ANSV issues safety recommendation on An-124 engines

August 11, 2011

The Italian accident investigation bureau ANSV issued a safety recommendation regarding certain Ivchenko Progress D18T jet engines used on Antonov 124 cargo aircraft.

On September 9th 2010, at Turin-Caselle Airport, Italy, an Antonov An-124-100 (RA-82079) was taking-off from runway 36. During the take-off run, at about 50 kts, the crew experienced the engine #4 (outer right) failure followed by an uncommanded shut down. the crew rejected the take-off. During the applicalion of the thrust reversers, the crew experienced an uncommanded shut down of engine #1 (outer left) too.
The aircraft stopped safely on the runway and the emergency services on the airport approached the aircraft after witnesses saw flames and smoke from the exhaust of the engines. No aircraft or airport damages and no injuries were reported.

The engine manufacturer reported that the problem noted on engine #4 was known. A modification document had been issued which called for alterations during the next engine shop visit.  In the course of their investigation of this serious incident, ANSV concluded that this measure was insufficient and decided to issue a safety recommendation to the Russian Interstate Aviation Committee:

The serious incident occurred on Turin-Caselle airport demonstrates that engine failsafe operation on model D18T series is not guaranteed at all on the ones not yet modified.
ANSV – considering the very high MTOW of the aircraft on which D18T engine series are installed, considering the safety level of an uncommanded engine shut down during take-off on those aircraft, considering the Temporary Change 559 that is not supported by analysis related to the “fatigue progression” on HPC 5th stage (the document was issued by the Operator) recommends Interstate Aviation Committee that the modification stated on the engine Designer documents (D18T-1567 and 18T25446) must be completely carried out on each engine installed onboard an aircraft before it could be airworthy. The solution adopted by engine Designer (modification to the successive scheduled shop visit) appears to be not acceptable and not sufficient at all.

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Indonesia: Investigators issue interim safety recommendations after Merpati crash

May 21, 2011

The Indonesian National Transportation Safety Committee (NTSC) issued three interim recommendations in the light of the May 7, 2011 fatal accident involving a Merpati passenger plane.

A Xian MA60 airplane crashed during a visual approach to Kaimana  Airport (KNG), Indonesia in weather conditions below VFR minima. All 25 on board were killed in the accident.

The investigation is still on-going, but the NTSC published three immediate safety recommendations based on their findings so far:

A. to Merpati Nusantara Airlines:
Ensure that visual flight is being conducted in accordance with VFR conditions, and conduct training on the MA60 Crew Simulator with an emphasis on CRM in the face of the bad weather.

B. to the Director General of Civil Aviation:
Monitor the implementation of the recommendations in point A , to be carried out  by Merpati Nusantara Airlines.

C. to Directorate General of Civil Aviation and Directorate of Airports:
Review the provisions of the use of facilities / equipment, especially the airport runway lights to enhance the safety of flight operations, especially in low visibility conditions.

More information:

Report: ATR-72 control difficulties following rudder maintenance

April 18, 2011

The U.K. AAIB published a Special Bulletin including three safety recommendations regarding control difficulties that were encountered by the crew of an ATR-72 during a post-maintance flight.

The aircraft had undergone routine maintenance at an engineering facility at Edinburgh Airport immediately prior to the incident flight.
Everything appeared normal during the crew’s pre-flight checks, which included a full-and-free check of the flying controls.
The aircraft took off at 21:22 from runway 24 at Edinburgh, with the co-pilot acting as the handling pilot.
After carrying out a standard instrument departure the crew climbed the aircraft to FL 230 at a speed of 170 kt with the autopilot engaged. As the aircraft levelled and accelerated through about 185 kt, the crew felt the aircraft roll to the left by about 5 to 10° and they noticed that the slip ball and rudder trim were both indicating fully right. The co-pilot disengaged the autopilot and applied right rudder in an attempt to correct the sideslip and applied aileron to correct the roll. He reported that the rudder felt unusually “spongy” and that the aircraft did not respond to his rudder inputs. Approximately 15° to 20° of right bank was required to hold a constant heading with the speed stabilised above 185 kt and a limited amount of aileron trim was applied to assist. Shortly after regaining directional control a FTL CTL caption appeared on the Crew Alert Panel (CAP) and the FLT CTL fault light illuminated on the overhead panel, indicating a fault with the rudder Travel Limitation Unit (TLU). The commander requested radar vectors from ATC for a return to Edinburgh, later declaring a PAN.

The crew carried out the required procedure from the Quick Reference Handbook (QRH). As part of the procedure they established that both Air Data Computers (ADC) were operating, before manually selecting the TLU switch to the LO SPD position. The aircraft had at this point temporarily slowed to below 180 kt. The co-pilot reported that on selection of LO SPD more roll control input was required to maintain heading and that roll authority to the right was further reduced. The commander therefore decided to return the TLU switch to AUTO and the required roll control input reduced. The green LO SPD indicator light did not illuminate.

An approach was made to runway 24, the aircraft was established on the ILS and was normally configured for a full flap landing. The crew added 10 kt to their approach speed, in accordance with the QRH. The co-pilot had to operate the control wheel with both hands in order to maintain directional control; the commander operated the power levers in the latter stages of the final approach. The co-pilot reported that the aircraft became slightly more difficult to control as the speed reduced, but remained controllable.

The aircraft landed just to the left of the runway centreline, whereupon the commander assumed control of the aircraft and applied reverse thrust. Despite the application of full right rudder pedal during the rollout, the aircraft diverged towards the left side of the runway. The commander re-established directional control using the steering wheel tiller. The aircraft was taxied clear of the runway and back to the engineering facility for inspection.

Th subsequent investigation and testing demonstrated that it is possible to incorrectly install the cams on the rear rudder quadrant shaft during maintenance. In this incident, the right hand cam was installed in the incorrect orientation and neither an independent inspection nor an operational test of the TLU system was performed. The incorrectly installed right hand cam was not detected prior to releasing the aircraft to service. When the TLU system automatically activated as the aircraft accelerated through 185 kt, the right hand roller encountered resistance as it came into contact with the upper lobe of the incorrectly installed cam, rather than slotting into the vee groove. This caused an uncommanded rudder input and associated control difficulties.

Three safety recommendations were made to the manufacturer, ATR.

The investigation is ongoing.

More information:

TSB critices Transport Canada on slow implementation of safety recommendation

April 11, 2011

A TSB investiation into a cabin smoke and passenger evacuation incident revealed that Transport Canada had not yet implemented an actual regulatory change after accepting a safety recommendation dated December 2007. The recommendation called for passenger safety briefings to include clear direction to leave all carry-on baggage behind during an evacuation.

On March 23, 2010 an Air Canada Airbus A320-211 (registration C-FTJO), operating as flight AC433, departed Montréal/Pierre Elliot Trudeau International Airport, Québec, for Toronto/Lester B. Pearson International Airport, Ontario, with 98 passengers and 6 crew members on board.
In cruise, 1 of the 3 hydraulic systems failed. The flight continued toward destination where the flight made an uneventful landing. While stopped on the runway awaiting a tow, smoke entered the cabin and an evacuation was ordered. Two crew members and 2 passengers received minor injuries during the evacuation.

The TSB concluded that:

  1. A leak from the number 1 yaw damper caused fluid to be ingested into the auxiliary power unit and sent through the air conditioning system, resulting in smoke entering the cabin.
  2. When the crew ordered the evacuation as a result of the smoke, several persons received minor injuries while exiting the aircraft via the emergency slides.

It appeared that many passengers deplaned with their carry-on luggage. It could not be determined whether this was due to the fact that they were not aware of the instructions given by the flight attendants and included in the safety card, or if they were aware, but chose to disregard them. Passengers would have been more aware of this restriction if information was included during the pre-takeoff and pre-landing passenger briefings, as per TSB recommendation A07-07.

The few injuries that did occur may have been aggravated by the fact that the slides were wet from the rain, and the resultant speed of the exiting persons was higher than normal. While the baggage did cause some minor injuries and delays at the bottom of the slides, it did not appreciably increase the evacuation time. Were this a higher level of threat or emergency, however, even a slight delay could have resulted in more serious consequences.

Transport Canada agreed with the Board’s recommendation (A07-07) that called for passenger safety briefings to include clear direction to leave all carry-on baggage behind during an evacuation. However, to date, no regulatory change has been implemented. Due to the extensive delay between TC’s acceptance of this recommendation and the implementation of actual regulatory change, identified safety dificiencies continue to persist.

More information:


NTSB recommends larger drain holes in Citation Excel tails

March 17, 2011

The U.S. NTSB recommends the FAA to issue an airworthiness directive to require that all Cessna 560XL operators comply with Cessna service letter 560XL-53-08, which asks operators to drill a drain hole in the bulkhead.

The National Transportation Safety Board (NTSB)  issued this recommendation in the light of the investigation of three incidents involving Cessna 560XL Citation Excel airplanes that experienced loss of rudder control after ice built up inside the tailcone.

Ice found in the bottom of the tailcone (photo: NTSB)

Preliminary findings indicate that water can collect inside the tailcone and then freeze around and restrict the movement of the rudder boost cables and pulleys. As long as the frozen ice impedes the cables and pulleys, the pilot may be unable to deflect the rudder, which is particularly dangerous when attempting to land in a crosswind or maneuver on the runway. Normally, a pilot would not use the rudder during cruise flight and would not detect that the rudder was frozen until just before or after landing.

Although the investigations are ongoing, the information gathered to date has raised serious concerns about the potential loss of rudder control when ice builds up inside the tailcone.

More information:



NTSB issues ASDE-X and airport lighting recommendations following Atlanta taxiway landing

March 3, 2011

On October 19, 2009, about 06:05 a Boeing 767, N185DN, operating as Delta Air Lines flight 60, landed on taxiway M at Atlanta-Hartsfield-Jackson International Airport (ATL), Georgia. No injuries to the 11 crew or 182 passengers were reported, and the airplane was not damaged. Night visual meteorological conditions prevailed.

During the descent and approach, the flight crew was assigned a number of runway changes; the last of which occurred near the final approach fix for runway 27L. While the flight was on final approach, the crew was offered and accepted a clearance to sidestep to runway 27R for landing. Although the flight crew had previously conducted an approach briefing for runways 27L and 26R, they had not briefed the approach for runway 27R and were not aware that the approach light system and the ILS were not available to aid in identifying that runway.

The captain maneuvered for the sidestep from runway 27L to 27R and lined up on “the next brightest set of lights” he saw. The first officer was preoccupied during the final approach with attempting to tune and identify the ILS frequency for runway 27R. Just prior to the airplane touching down, the captain realized they were landing on a taxiway. The airplane landed on taxiway M, 200 feet north of, and parallel to, runway 27R. The local controller did not notice the crew’s error until after the airplane had landed. The taxiway was unoccupied, and the flight crew was able to stop the aircraft safely and taxi to the gate.

The National Transportation Safety Board (NTSB) determined that the probable cause of this incident was the flight crew’s failure to identify the correct landing surface due to fatigue.
Contributing to the cause of the incident were:

  1. the flight crew’s decision to accept a late runway change,
  2. the unavailability of the approach light system and the instrument landing system for the runway of intended landing, and
  3. the combination of numerous taxiway signs and intermixing of light technologies on the taxiway.


The National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration:

Perform a technical review of Airport Surface Detection Equipment-Model X to determine if the capability exists systemwide to detect improper operations such as landings on taxiways. (A-11-12)

At those installation sites where the technical review recommended in Safety Recommendation A-11-12 determines it is feasible, implement modifications to Airport Surface Detection Equipment-Model X to detect improper operations, such as landings on taxiways, and provide alerts to air traffic controllers that these potential collision risks exist. (A-11-13)

Amend Federal Aviation Administration (FAA) Order 7210.3, “Facility Operation and Administration,” to direct that, at airports with air traffic control towers equipped with airport lighting control panels that do not provide direct indication of airport lighting intensities, the air traffic manager annually reviews and compares, with the airport operator, the preset selection settings configured in the tower lighting control system to verify that they comply with FAA requirements. (A-11-14)

Revise Advisory Circular 150/5345-56A, “Specification for L- 890 Airport Lighting Control and Monitoring System (ALCMS)” to state that airport operators should inform air traffic managers of variances for, or modifications to, airfield lighting preset standards prescribed in Federal Aviation Administration requirements. (A-11-15)

More information:


NTSB issues safety recommendations to prevent B737 elevator jam due to FOD

February 14, 2011

The U.S. National Transportation Safety Board (NSTB) issued five safety recommendations to the Federal Aviation Administration (FAA) to prevent the elevator of certain Boeing 737 models to become jammed as a result of foreign object damage to the elevator power control unit input arm assembly.

The recommendations were issued as a result of an incident involving a Boeing 737-400 in June 2009.

On June 14, 2009, a Boeing 737-400, registration number TC-TLA, operated as Tailwind Airlines  flight OHY036, experienced an uncommanded pitch-up event at 20 feet above the ground during approach to Diyarbakir Airport (DIY), Turkey. The flight crew performed a go-around maneuver and controlled the airplane’s pitch with significant column force, full nose-down stabilizer trim, and thrust. During the second approach, the flight crew controlled the airplane and landed by inputting very forceful control column inputs to maintain pitch control. Both crewmembers sustained injuries during the go-around maneuver; none of the 159 passengers or cabin crewmembers reported injuries. The airplane was undamaged during the scheduled  commercial passenger flight.

An investigation found that the incident was caused by an uncommanded elevator deflection as a result of a left elevator power control unit (PCU) jam due to foreign object debris (FOD). The FOD was a metal roller element (about 0.2 inches long and 0.14 inches in diameter) from an elevator bearing. During  its investigation of this incident, the NTSB identified safety issues relating to the protection of the elevator PCU input arm assembly, design of the 737 elevator control system, guidance and training for 737 flight crews on a jammed elevator control system, and upset recovery training.

The National Transportation Safety Board recommends that the Federal Aviation Administration:

Require Boeing to develop a method to protect the elevator power control unit input arm assembly on 737-300 through -500 series airplanes from foreign object debris. (A-11-7)

Once Boeing has developed a method to protect the elevator power control unit input arm assembly on 737-300 through -500 series airplanes from foreign object debris as requested in Safety Recommendation A-11-7, require operators to modify their airplanes with this method of protection. (A-11-8)

Require Boeing to redesign the 737-300 through -500 series airplane elevator control system such that a single-point jam will not restrict the movement of the elevator control system and prevent continued safe flight and landing. (A-11-9)

Once the 737-300 through -500 series airplane elevator control system is redesigned as requested in Safety Recommendation A-11-9, require operators to implement the new design. (A-11-10)

Require Boeing to develop recovery strategies (for example, checklists, procedures, or memory items) for pilots of 737 airplanes that do not have a mechanical override feature for a jammed elevator in the event of a full control deflection of the elevator system and incorporate those strategies into pilot guidance. Within those recovery strategies, the consequences of removing all hydraulic power to the airplane as a response to any uncommanded control surface should be clarified. (A-11-11)


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