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NTSB · Safety Recommendation

Safety Recommendation A-24-027

Recommendation

TO THE BOEING COMPANY: Instruct operators of Boeing 737NG and 737MAX airplanes with Collins Aerospace SVO-730 rudder rollout guidance actuators with incorrectly assembled bearings to notify flight crews that the rudder control system might become jammed or restricted in flight or during landing due to moisture that could accumulate and freeze in the actuators. (Urgent)

Safety Issue and Context

The National Transportation Safety Board (NTSB) is providing the following information to urge The Boeing Company and the Federal Aviation Administration (FAA) to take immediate action on the safety recommendations in this report concerning the potential for a jammed or restricted rudder control system on certain Boeing 737 airplanes. We identified these issues during our ongoing investigation of the rudder pedal anomaly involving a Boeing 737-8, N47280, while landing at Newark Liberty International Airport (EWR), Newark, New Jersey, on February 6, 2024.

On the basis of the results of postincident testing conducted in July 2024 and information from Boeing and Collins Aerospace, the NTSB is concerned that Boeing’s mitigation to overcome a jammed or restricted rudder control system during landing could also result in a large input to the rudder pedals and a sudden, large and undesired rudder deflection sufficient to cause loss of control or departure from the runway.

A jammed or restricted rudder scenario could become even more concerning if a high crosswind or an engine-out condition were simultaneously occurring with a jammed or restricted rudder, not only because the amount of rudder available to respond to these conditions might be insufficient to maintain control of the airplane if the jam is not cleared—but also because excessive rudder input may result if the jam is cleared by responding with Boeing’s mitigation. As a result, the NTSB is issuing two urgent safety recommendations to The Boeing Company and two urgent safety recommendations to the FAA.

Response History

June 17, 2025 · NTSB Correspondence · Boeing Company

On October 4, 2024, Boeing distributed the following multi-operator messages (MOMs) to operators of affected Boeing 737NG and 737MAX airplanes:

• MOM-MOM-24-0142 informed operators about these recommendations and encouraged flight crews to follow the Jammed or Restricted Flight Controls Non-Normal Checklist (NNC) if a rudder restriction condition is encountered in flight. If encountered on the ground, the MOM encouraged flight crews to use differential braking and/or tiller to maintain runway centerline. • MOM-MOM-24-0442 informed operators about Collins Aerospace RRGA, part number SVO-730, Notice of Escapement concerning clutch bearing installation errors on a portion of the 737NG and 737 MAX fleet.

On October 9 and 10, 2024, Boeing distributed Flight Crew Operations Manual Bulletins (OMBs) TBC-125 (737NG) and TBC-38 R1 (737MAX), respectively. The OMBs inform flight crews that, because rudder application is typically unnecessary throughout most of the flight, a frozen RRGA and associated jammed or restricted rudder may not be evident until the approach and landing phases.

The OMBs recommend that flight crews perform the Jammed or Restricted Flight Controls NNC if a jammed or restricted rudder condition is experienced during flight; however, if encountered prior to touchdown, flight crews should perform the Go-Around and Missed Approach Procedure and climb to a safe altitude before performing the Jammed or Restricted Flight Controls NNC. Finally, if restricted flight controls are encountered after touchdown and rollout is continued, the OMBs recommend that flight crews apply differential braking to maintain runway centerline and avoid using nosewheel steering above 100 knots unless necessary to prevent overcontrol.

During our March 17, 2025, meeting, representatives from Boeing answered questions my staff had about the guidance contained in Boeing’s MOMs and OMBs. However, we remain concerned about this safety issue, which is also the subject of one of our open investigations. Because we are still reviewing information to determine if Boeing has sufficiently addressed these recommendations, we will reevaluate Boeing’s actions and classify these recommendations in our final report. In the meantime, the Board has voted to keep Safety Recommendations A-24-27 and -28 classified OPEN-- INITIAL RESPONSE RECEIVED.

Read Recommendation

Recommendation Facts

Status
Open - Initial Response Received
Issued
September 26, 2024
Priority
CLASS I
Recipient
Boeing Company
Adopted
September 26, 2024
Related Investigation
DCA24LA094
Related Report
AIR-24-06
October 24, 2024 · Recipient Response · Boeing Company

-From Stella Weidner, Director, Product Safety: As a party to the NTSB investigation of this event, Boeing has worked to keep operators informed while complying with the NTSB requirements regarding release of information by publishing Multi-Operator Messages (MOMs) as noted below. The MOMs referenced were coordinated with the NTSB prior to their release and all MOMs have been provided to the NTSB.

• On March 12, 2024 Boeing published MOM-MOM-24-0142 to inform all 737NG and 737 MAX operators of the event and the NTSB preliminary report. • On August 23, 2024 Boeing published MOM-MOM-24-0442 to inform all 737NG and 737 MAX operators of the Notice of Escapement (NoE) regarding the bearing installation referenced in NTSB safety recommendations A-24-27 and A-24-28. • On October 4th, 2024 Boeing provided an update to MOM-MOM-24-0142 to inform all 737NG and 737 MAX operators of the NTSB report and safety recommendations. • On October 4, 2024 Boeing also updated MOM-MOM-24-0442 to provide operators information on the Collins Service Bulletins to resolve the NoE condition.

Subsequently, Boeing released the reference (c) and (d) Operations Manual Bulletins (OMB) as part of the Boeing 737 Flight Crew Operations Manual to all operators of 737NG and 737 MAX aircraft that are equipped with the Rudder Rollout Guidance Actuator (RRGA). The OMBs provide recommended guidance to flight crews if they encounter a rudder pedal restriction due to moisture accumulated within the RRGA. The OMBs include background information and guidance to flight crews on steps to perform if a rudder restriction is encountered in flight or after landing.

In addition, Boeing has released the reference (b) Multi-Operator Message (MOM) to operators of aircraft equipped with the RRGA. This MOM provides operators with awareness and background information on the release of the OMBs and instructions to operators to incorporate the referenced OMBs into their Operations Manuals.

September 26, 2024 · NTSB Correspondence · Boeing Company

The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in the other modes of transportation—railroad, transit, highway, marine, pipeline, and commercial space. We determine the probable causes of the accidents and events we investigate and issue safety recommendations aimed at preventing future occurrences. In addition, we conduct transportation safety research studies and offer information and other assistance to family members and survivors for each accident or event we investigate.

We also serve as the appellate authority for enforcement actions involving aviation and mariner certificates issued by the Federal Aviation Administration (FAA) and US Coast Guard, and we adjudicate appeals of civil penalty actions taken by the FAA.

We are providing the following information to urge The Boeing Company to act on the safety recommendations in this letter because we believe your organization can help reduce the risk of future accidents.

This letter also includes information about our September 26, 2024, report Mitigate Safety Concerns Involving Boeing 737 Airplanes with Collins Aerospace SVO-730 Rudder Rollout Guidance Actuators (NTSB/AIR-24-06). The details of this ongoing incident investigation and the resulting urgent safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov.

As a result of the NTSB’s preliminary findings in this investigation, we identified the following safety issues:

• the potential for jammed or restricted rudder systems on Boeing 737NG and 737MAX airplanes due to incorrectly assembled Collins Aerospace SVO-730 rudder rollout guidance actuators that allow moisture to accumulate and freeze; • the potential for uninformed flight crews of affected Boeing 737NG and 737MAX airplanes to apply rudder pedal force in an attempt to clear a jammed or restricted rudder control system but that also results in a large, sudden, and undesired input to the rudder and loss of airplane control; and

• the need to determine and disseminate guidance on appropriate flight crew responses if the affected Collins actuators on Boeing 737NG and 737MAX airplanes become jammed or restricted in flight or during landing. Accordingly, the NTSB makes the following urgent safety recommendations to The Boeing Company:

• Instruct operators of Boeing 737NG and 737MAX airplanes with Collins Aerospace SVO-730 rudder rollout guidance actuators with incorrectly assembled bearings to notify flight crews that the rudder control system might become jammed or restricted in flight or during landing due to moisture that could accumulate and freeze in the actuators. (A 24 27) (Urgent)

• For 737NG and 737MAX airplanes with Collins Aerospace SVO-730 rudder rollout guidance actuators with incorrectly assembled bearings, determine appropriate flight crew responses, besides applying maximum rudder pedal force, if the condition described in Safety Recommendation A 24 27 were encountered in flight or during landing and then notify operators to disseminate this information to flight crews of these airplanes. (A 24 28) (Urgent)

The NTSB is vitally interested in these urgent recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 30 days of the date of this letter, detailing the actions you have taken or intend to take to implement these urgent recommendations. When replying, please refer to the safety recommendations by number (Safety Recommendations A 24 27 and A 24 28). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. For your convenience, please refer to additional guidance on responding to our safety recommendations on our website.

If your reply, including attachments, exceeds 20 megabytes, please e mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response.

All communications regarding safety recommendations are stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to these recommendations. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. In the likely event that your company uses auto generated and/or preformatted confidentiality statements on letterhead or outgoing e-mails, please include a statement in your letter indicating that the information can be publicly released. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov.

The NTSB is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in the other modes of transportation—railroad, transit, highway, marine, pipeline, and commercial space. We determine the probable cause of the accidents and events we investigate, and issue safety recommendations aimed at preventing future occurrences. In addition, we conduct transportation safety research studies and offer information and other assistance to family members and survivors for any accident or event investigated by the agency.

We also serve as the appellate authority for enforcement actions involving aviation and mariner certificates issued by the Federal Aviation Administration (FAA) and US Coast Guard, and we adjudicate appeals of civil penalty actions taken by the FAA.

The attached letter from the NTSB Chair provides information about the NTSB’s report Mitigate Safety Concerns Involving Boeing 737 Airplanes with Collins Aerospace SVO-730 Rudder Rollout Guidance Actuators (AIR-24-06). The details of this accident investigation and the resulting urgent safety recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary.

The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 30 days of the date of this letter detailing the actions you have taken or intend to take to implement these urgent recommendations. When replying, please refer to the safety recommendation by number (for example, A-24-27 and A-24-28). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply exceeds 20 megabytes, including attachments, please e mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response.

All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov.

From the aviation investigation report Safety Concerns Involving Boeing 737 Airplanes with Collins Aerospace SVO-730 Rudder Rollout Guidance Actuators (AIR-24-06):

Background and Analysis On February 6, 2024, about 1555 eastern standard time, the flight crew of United Airlines flight 1539, a Boeing 737-8, N47280, experienced a rudder pedal anomaly while landing at EWR. In a postincident statement, the captain reported that, during the landing rollout, the rudder pedals were “stuck” in their neutral position and did not move in response to the “normal” application of foot pressure to maintain alignment with the runway centerline. The flight was operating under the provisions of Title 14 Code of Federal Regulations Part 121 as a scheduled int