NTSB · Safety Recommendation
Safety Recommendation A-17-005
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: After Embraer issues the operations bulletin as recommended in Safety Recommendation A-17-3, notify operators of Embraer aircraft that the use of binder brackets to hold chart binders could cause a hazardous condition if a binder becomes dislodged from the bracket and encourage operators to comply with the Embraer operations bulletin.
Safety Issue and Context
On June 7, 2013, about 0925 coordinated universal time, an EMB-145LR, registration B-3052, operating as China Eastern Airlines flight MU2947, departed the left side of runway 18L onto taxiway A2 while landing at Hongqiao International Airport, Shanghai, China, in moderate rain. The flight originated from Huai’an Lianshui Airport, Jiangsu, China.
The 25 crewmembers and 44 passengers were uninjured, and the nose landing gear sustained minor damage.2 After this incident, the nosewheel steering manifold assembly and electrohydraulic servo valve (EHSV) were tested by the components’ manufacturers (Parker Aerospace and Woodward HRT, respectively) according to their returned component acceptance test protocols, which are the same tests that newly manufactured components would undergo before delivery.
Response History
January 3, 2024 · NTSB Correspondence · FAA
We note that, because you believe operators of Embraer EMB 135, 140, and 145 airplanes should be notified directly about this safety issue, you determined a safety alert for operators was not an appropriate solution. We also note that, on February 3, 2022, you issued an FAA memorandum to your certificate-holding district office managers instructing them to notify all operators of affected Embraer airplanes that the use of binder brackets is not approved by Embraer, nor the FAA, and encourage them to comply with Embraer’s operations bulletin. We believe the policy memorandum satisfies the intent of Safety Recommendation A-17-5, which is classified CLOSED-- ACCEPTABLE ACTION.
Thank you for your efforts to improve aviation safety.
July 10, 2023 · Recipient Response · FAA
-From Polly Trottenberg, Acting Administrator: After further review, the Federal Aviation Administration (FAA) decided existing, targeted communication sufficiently addresses this recommendation. As a result, we are suspending our plan to issue a safety alert for operators. The FAA believes targeted communication is a more effective approach in this scenario, reaching the involved stakeholders directly. This communication includes:
• The February 3, 2022, FAA memo (attached) to the Certificate-Holding District Office Managers for Embraer EMB 135/145 Operators, instructing the managers to notify all operators that the use of binder brackets is not approved by Embraer, nor the FAA, and encourage operators to comply with the Embraer operations bulletin;
• The March 14, 2017, Embraer Field Report GFS-006-17, advising operators of the ERJ-145 airplane to not install or use binder brackets that are not approved by the appropriate aviation authority; and
• The articles created by Embraer in its operational newsletters and technical updates, addressing the potential dangers of using binder brackets in Embraer airplanes. The format of the operational newsletter and technical updates permits a more detailed description of the occurrence, investigation, and findings and includes pictures to aid in further understanding.
Based on the communication noted above, I believe the FAA has effectively addressed Safety Recommendation A-17-5 and consider our actions complete.
May 26, 2021 · NTSB Correspondence · FAA
As you mentioned, we considered Embraer’s decision to issue Field Report GFS-006-17, among other actions, to be more appropriate than an operations bulletin and, therefore, an acceptable alternate solution to Safety Recommendation A-17-3. We believe your plan to issue a safety alert for operators (SAFO) about Embraer’s report will increase awareness among Embraer pilots and operators about the potential danger of using binder brackets to hold chart binders and, therefore, represents an acceptable alternative solution to this recommendation. Pending our review of the issued SAFO, Safety Recommendation A-17-3 is classified OPEN-- ACCEPTABLE ALTERNATE RESPONSE.
November 6, 2020 · Recipient Response · FAA
-From Steve Dickson, Administrator: The closure of this recommendation is based upon the handling and closure of Safety Recommendation A-17-3. In response to recommendation A-17-3, Embraer stated, “As opposed to issuing operational bulletins, which are more formal and whose distribution is limited, Embraer completed several alternative actions that the Board considered acceptable.”
Embraer chose to create articles, addressing the potential dangers of using binder brackets in Embraer airplanes, in its operational newsletters and technical updates. The format of the operational newsletter and technical updates permits a more detailed description of the occurrence, investigation, and findings, and includes pictures to aid in further understanding. Embraer also issued Embraer Field Report GFS-006-17 on March 14, 2017, to advise operators of the ERJ-145 airplane to not install or use binder brackets that are not approved by the appropriate aviation authority.
The FAA has elected to issue a Safety Alert for Operators (SAFO) advising operators of Embraer’s Field Report GFS-006-17. The FAA anticipates the publication of the SAFO by Spring 2021.
September 21, 2017 · NTSB Correspondence · FAA
We note that, once Embraer’s operations bulletin has been issued, you will notify operators of Embraer’s actions and emphasize the hazards of using binder brackets to hold chart binders. Pending completion of the recommended action, Safety Recommendation A-17-5 is classified OPEN--ACCEPTABLE RESPONSE.
April 13, 2017 · Recipient Response · FAA
-From Michael P. Huerta, Administrator: Based on Embraer' s response to Safety Recommendation A-17-03, the FAA will determine the best method for advising Embraer aircraft operators of Embraer's actions and emphasize that the use of binder brackets could cause a hazardous condition. The FAA will encourage operators to evaluate its system in accordance with the proposed Embraer operations bulletin. We will also inform operators of Embraer EMB-135, EMB-140, and EMB-145 airplanes that they should incorporate training for uncommanded swerving on landing in their initial and recurrent simulator training programs.
I believe the FAA has effectively addressed Safety Recommendation A-1 7-04 and consider our actions complete. I will keep the Board informed of the F AA's progress on Safety Recommendations A-17-05 and -06, and provide an update by February 2018.
February 1, 2017 · NTSB Correspondence · FAA
On January 26, 2017, the National Transportation Safety Board (NTSB) adopted our safety recommendation report concerning uncommanded nosewheel steering anomalies during landing in Embraer EMB-145 regional jets. Additional information may be found in the safety recommendation report, which can be accessed at our website (www.ntsb.gov) under report number ASR-17-02.
As a result, we issued five new recommendations, including two to Embraer and the following three recommendations to the Federal Aviation Administration.