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NTSB · Safety Recommendation

Safety Recommendation A-19-005

Recommendation

TO THE FEDERAL AVIATION ADMINISTRATION: Ensure the operators of Boeing DC-9/MD-80 series and 717 model airplanes have procedures that define who is responsible for monitoring the wind that affects parked airplanes and for notifying maintenance personnel when conditions could meet or exceed the ground gust criteria specified in the Aircraft Maintenance Manual.

Safety Issue and Context

This report discusses the March 8, 2017, accident involving Ameristar Air Cargo, Inc., dba Ameristar Charters, flight 9363, a Boeing MD-83 airplane, which overran the departure end of runway 23L at Willow Run Airport, Ypsilanti, Michigan, after the captain executed a rejected takeoff. The 110 passengers and 6 flight crewmembers evacuated the airplane via emergency escape slides; however, one slide failed to inflate and could not be used. One passenger received a minor injury, and the airplane sustained substantial damage.

Safety issues identified in this report include the lack of a means to enable flight crews of Boeing DC-9/MD-80 series and 717 model airplanes to verify before takeoff that the elevators are not jammed, the need for improved in-service inspection techniques for critical rotating parts of all engines, the need for lower ground gust criteria for elevator physical inspections and operational checks by maintenance personnel for Boeing DC 9/MD-80 series and 717 model airplanes, the potential inadequacy of ground gust limit loads for the certification of transport-category airplanes, the lack of procedures for operators of Boeing DC-9/MD-80 series and 717 model airplanes to monitor the wind that affects parked airplanes, the lack of procedures for weather observers related to sign off and backup augmentation responsibilities during a facility evacuation, and evacuation slide malfunction.

As a result of this investigation, the National Transportation Safety Board makes three safety recommendations to the Federal Aviation Administration and three recommendations to The Boeing Company.

Response History

March 5, 2024 · NTSB Correspondence · FAA

We note that, on June 14, 2022, you published Safety Alert for Operators 22001, which encourages owners and operators of Boeing DC-9/MD-80 series and B717 model airplanes to develop procedures that define who is responsible for monitoring the wind that affects parked airplanes and for notifying maintenance personnel when conditions could meet or exceed the ground gust criteria specified in the AMM. We are also aware that, on June 1, 2023, you published Notice 8900.657, which directs inspectors to verify that operators of these airplanes have incorporated the recommended procedures into their maintenance program or continuous airworthiness maintenance programs.

In addition, because notices expire after 1 year, you have incorporated this information into Order 8900.1, Volume 3, Chapter 32, section 11.

We believe these actions satisfy the intent of Safety Recommendation A-19-5, which is classified CLOSED-- ACCEPTABLE ACTION.

August 17, 2023 · Recipient Response · FAA

-From Kathryn Thomson, Deputy Administrator: The Federal Aviation Administration (FAA) published Safety Alert for Operators 22001, Recommended Procedures for Operators of Boeing DC-9/MD-80 Series and B717 Model Airplanes When Wind/Ground Gusts Meet or Exceed Criteria Specified in the Applicable Aircraft Maintenance Manual, on June 14, 2022, which is available at the following website:

https://www.faa.gov/sites/faa.gov/files/other_visit/aviation_industry/airline_operators/airline_saf ety/SAFO22001.pdf

We are in the final stages of updating Order 8900.1, Flight Standards Information Management System, and anticipate the publication of the corresponding notice by December 31, 2023, which is further delayed due to the need for additional internal coordination.

I will keep the Board informed of the FAA’s progress on Safety Recommendation A-19-5 and anticipate providing an update by March 31, 2024.

Read Recommendation

Recommendation Facts

Status
Closed - Acceptable Action
Issued
March 8, 2019
Priority
CLASS II
Recipient
FAA
Adopted
February 14, 2019
Closed
March 5, 2024
Related Investigation
DCA17FA076
Related Report
AAR-19-01
April 1, 2022 · NTSB Correspondence · FAA

We note that, although you have drafted a notice and safety alert for operators (SAFO), the publication of these documents has been delayed because additional internal coordination was needed. We look forward to reviewing the published SAFO, which should include guidance for operators of Boeing DC-9/MD-80 series and 717 model airplanes on including procedures within their Continuous Airworthiness Maintenance Program (CAMP) defining who is responsible for monitoring the wind that affects parked airplanes and who is responsible for notifying personnel when conditions meet or exceed the ground gust criteria specified in the AMM.

We also look forward to reviewing the published notice for inspectors and seeing how you will ensure that all operators of these airplanes have included these procedures in their CAMPs, given that notices are only valid for 1 year. Pending our review of the published documents and a plan for addressing this concern, Safety Recommendation A-19-5 remains classified OPEN-- ACCEPTABLE RESPONSE.

November 3, 2021 · Recipient Response · FAA

-From Steve Dickson, Administrator: The Federal Aviation Administration (FAA) finished drafting the previously mentioned notice and safety alert to ensure operators have appropriate procedures within their Continuous Airworthiness Maintenance Program to address this recommendation. The FAA originally stated that these documents would be published by June 30, 2020. However, further internal coordination delays have resulted in a projected publication date of March 31, 2022.

I will keep the Board informed on the FAA’s progress on A-19-5, and anticipate providing an update by June 30, 2022.

May 12, 2020 · NTSB Correspondence · FAA

We are encouraged to learn that you have provided guidance to ensure operators have procedures within their continuous airworthiness maintenance programs (CAMPs) that define who is responsible for monitoring the wind that affects parked airplanes and for notifying maintenance personnel when conditions could meet or exceed the ground gust criteria specified in the AMM. However, you did not indicate what those procedures are, exactly, or how you intend to ensure they are incorporated into operators’ CAMPs. Although your letter indicated that your agency planned to publish a notice informing inspectors of the guidance, we are concerned that notices are only valid for 1 year.

We also note that you intend to publish a safety alert for operators (SAFO); however, we point out that the guidance contained in SAFOs is voluntary.

Pending our review of the CAMP language, SAFO, and details on how you intend to ensure operators have defined and assigned wind monitoring responsibilities, Safety Recommendation A 19-5 remains classified OPEN--ACCEPTABLE RESPONSE.

February 18, 2020 · Recipient Response · FAA

-From Steve Dickson, Administrator: The Federal Aviation Administration (FAA) has provided guidance to ensure operators have procedures within their Continuous Airworthiness Maintenance Program (CAMP) defining who is responsible for monitoring the wind that affects parked airplanes and who is responsible for notifying maintenance personnel when conditions could meet or exceed the ground gust criteria specified in the Aircraft Maintenance Manual.

We anticipate publication of the notice and safety alerts for operator (SAFO) by June 2020, and will provide the Board with the documents upon publication.

I will keep the Board informed of the FAA's progress and anticipate providing an update by August 2020.

July 12, 2019 · NTSB Correspondence · FAA

We note that you are reviewing the existing operator procedures that define who is responsible for monitoring the wind that affects parked airplanes and for notifying maintenance personnel when conditions could meet or exceed the ground gust criteria specified in the AMM. Pending our review of that assessment, and a plan for implementing any improvements that are identified, Safety Recommendation A-19-5 is classified OPEN--ACCEPTABLE RESPONSE.

May 21, 2019 · Recipient Response · FAA

-From Daniel K. Elwell, Acting Administrator: The FAA is currently reviewing the existing operator procedures that define who is responsible for monitoring the wind that affects parked airplanes and for notifying maintenance personnel when conditions could meet or exceed the ground gust criteria specified in the Aircraft Maintenance Manual. Following this review, we will determine if further actions are necessary.

March 8, 2019 · NTSB Correspondence · FAA

On February 14, 2019, the NTSB adopted its report, Runway Overrun during Rejected Takeoff, Ameristar Air Cargo, Inc., dba Ameristar Charters, flight 9363, Boeing MD-83, N786TW, Ypsilanti, Michigan, March 8, 2017, NTSB AAR-19/01. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. As a result of this investigation, the NTSB identified the following safety issues: • Lack of a means to enable flight crews of Boeing DC-9/MD-80 series and 717 model airplanes to verify before takeoff that the elevators are not jammed.

• Need for lower ground gust criteria for elevator physical inspections and operational checks by maintenance personnel for Boeing DC 9/MD-80 series and 717 model airplanes. • Potential inadequacy of ground gust limit loads for the certification of transport category airplanes. • Lack of procedures for operators of Boeing DC-9/MD-80 series and 717 model airplanes to monitor the wind that affects parked airplanes. • Lack of procedures for weather observers related to sign off and backup augmentation responsibilities during a facility evacuation. • Evacuation slide malfunction.

Accordingly, the NTSB makes the following safety recommendations to the FAA. Additional information regarding these recommendations can be found in the noted sections of the report.

• Determine if the ground gust limit loads contained in Title 14 Code of Federal Regulations 25.415 adequately ensure that critical flight control systems are protected from hazards introduced by ground gusts that contain dynamic, vertical wind components. (A 19-4) (See section 2.4.1) • Ensure the operators of Boeing DC-9/MD-80 series and 717 model airplanes have procedures that define who is responsible for monitoring the wind that affects parked airplanes and for notifying maintenance personnel when conditions could meet or exceed the ground gust criteria specified in the Aircraft Maintenance Manual. (A-19-5) (See section 2.4.3.)

• Revise Order JO 7900.5D, Surface Weather Observing, Change 1, to specify sign off procedures and backup augmentation responsibilities for all types of weather-observing personnel when they are unable to perform their prescribed duties from their normal duty station during normal duty hours. (A-19-6) (See section 2.6.3.)

In our report on the March 8, 2017, accident in Ypsilanti, Michigan, we also classified two previously issued safety recommendations:

• Require all 14 Code of Federal Regulations Part 139 certificated airports to upgrade all runway safety areas that could, with feasible improvements, be made to meet the minimum standards established by Advisory Circular 150/5300-13, “Airport Design.” The upgrades should be made proactively, not only as part of other runway improvement projects. (A 03-11, classified “Closed—Acceptable Action” in Section 2.5)

• Require all 14 Code of Federal Regulations Part 139 certificated airports to install engineered materials arresting systems in each runway safety area available for air carrier use that could not, with feasible improvements, be made to meet the minimum standards established by Advisory Circular 150/5300-13, “Airport Design.” The systems should be installed proactively, not only as part of other runway improvement projects. (A-03-12, classified “Closed—Acceptable Action” in Section 2.5)

The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number. We encourage you to submit your response to correspondence@ntsb.gov. If your reply exceeds 20 megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.