NTSB · Safety Recommendation
Safety Recommendation A-11-042
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Develop a method to quickly communicate information regarding the number of persons on board and the presence of hazardous materials to emergency responders when airport emergency response or search and rescue is activated.
Safety Issue and Context
On January 27, 2009, about 0437 central standard time, an Avions de Transport Régional (ATR) Aerospatiale Alenia ATR 42-320 (ATR 42), N902FX, operating as Empire Airlines flight 8284, was on an instrument approach when it crashed short of the runway at Lubbock Preston Smith International Airport (LBB), Lubbock, Texas.2 The captain sustained serious injuries, and the first officer sustained minor injuries. The airplane was substantially damaged. The airplane was registered to FedEx Corporation and operated by Empire Airlines, Inc., as a 14 Code of Federal Regulations (CFR) Part 121 supplemental cargo flight. The flight departed from Fort Worth Alliance Airport, Fort Worth, Texas, about 0313.
Instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed. The National Transportation Safety Board (NTSB) determined that the probable cause of this accident was the flight crew’s failure to monitor and maintain a minimum safe airspeed while executing an instrument approach in icing conditions, which resulted in an aerodynamic stall at low altitude.
Contributing to the accident were (1) the flight crew’s failure to follow published standard operating procedures (SOP) in response to a flap anomaly, (2) the captain’s decision to continue with the unstabilized approach, (3) the flight crew’s poor crew resource management (CRM), and (4) fatigue due to the time of day in which the accident occurred and a cumulative sleep debt, which likely impaired the captain’s performance.
Response History
May 7, 2020 · NTSB Correspondence · FAA
You reported that, on October 18, 2018, the Pipeline and Hazardous Materials Safety Administration (PHMSA) published the final rule, Hazardous Materials: Notification of the Pilot-in-Command and Response to Air Related Petitions for Rulemaking, which requires operators to provide flight dispatchers with the same information as the pilot-in-command regarding the nature, amounts, and locations of HAZMAT prior to an aircraft moving under its own power.
We note that you believe the current system required under the load manifest requirements contained in Title 14 Code of Federal Regulations Part 121 section 693 is adequate because you believe that emergency responders and flight dispatchers have quicker access to dangerous goods information for each flight, which supports and relieves the pilot-in-command from being solely responsible for communicating this information to air traffic control (ATC) and aircraft rescue and firefighting (ARFF).
The actions that you described are not responsive to this recommendation. We continue to believe that emergency responders should have rapid access to the number of people on board an aircraft and be informed if HAZMAT is present. Emergency responders should not have to wait either for flight crews to relay this information to the ATC, who has a direct line to the ARFF, or for ATC to contact the certificate holder’s operations center to obtain this information.
Although we continue to believe a method needs to be developed that provides emergency responders rapid access to this key information upon initial notification of an accident, because you consider your actions complete, Safety Recommendation A-11-42 is classified CLOSED--UNACCEPTABLE ACTION.
February 12, 2020 · Recipient Response · FAA
-From Steve Dickson, Administrator: The FAA coordinated with the Pipeline and Hazardous Materials Safety Administration (PHMSA) to publish the final rule. Hazardous Materials: Notification of the Pilot-in-Command and Response to Air Related Petitions for Rulemaking (RRR) (83 FR 52878) in October 2018. The final rule is available at the following website: