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NTSB · Safety Recommendation

Safety Recommendation A-25-006

Recommendation

TO THE FEDERAL AVIATION ADMINISTRATION: Require all operators of Boeing 727 and 737 airplane models that use the same bannis latch design as Boeing 757 airplanes (757-200, -200CB, and 300 series) to update their aircraft maintenance manuals (AMM) in accordance with the revised Boeing AMMs and illustrated parts catalogs recommended in Safety Recommendation A-25-9.

Safety Issue and Context

On October 4, 2023, about 2347 eastern daylight time, the flight crew of FedEx flight 1376, a Boeing 757-236, received an engine indication and crew alerting system message indicating a failure of the left hydraulic system shortly after takeoff from Chattanooga Metropolitan Airport-Lovell Field (CHA), Chattanooga, Tennessee. The flight crew turned the airplane back to CHA but was unable to lower the landing gear. After multiple attempts to extend the gear were unsuccessful, the crew declared an emergency and performed an emergency gear up landing.

After the airplane came to a complete stop, the flight crew performed the evacuation checklist in the Quick Reference Handbook, and a jumpseat occupant onboard the airplane attempted to open the left (L1) door. The door rotated halfway open but would not open fully, and the slide did not deploy.

Response History

March 11, 2026 · NTSB Correspondence · FAA

On June 18, 2025, Acting FAA Administrator Christopher J. Rocheleau informed us that Safety Recommendations A-25-3 through -6 had been assigned to the FAA's Aircraft Certification Service to determine the best course of action. These recommendations are currently classified Open-Initial Response Received. We look forward to receiving more detailed information about the FAA's plans for addressing these recommendations in its next update, which Acting Administrator Rocheleau reported would be provided by the end of July 2026. The Board will classify the response at that time.

June 18, 2025 · Recipient Response · FAA

-From Christopher J. Rocheleau, Acting Administrator: The FAA assigned these safety recommendations to our Aircraft Certification Service (AIR), which will evaluate the NTSB report and determine the best course of action in addressing the safety recommendations.

I anticipate providing an update to these safety recommendations by July 31, 2026.

April 3, 2025 · NTSB Correspondence · FAA

This letter provides information about the National Transportation Safety Board’s (NTSB) March 27, 2025, report Address Noncompliant Evacuation Slide Components on Boeing Airplanes (NTSB/AIR-25-02). The details of this ongoing 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 the NTSB’s preliminary findings in this investigation, we identified the following safety issues:

• Unairworthy bannis latches that don’t comply with Airworthiness Directives 86-09-09 and 2001-15-01 may be installed on other in-service Boeing 757-200, -200CB, and -300 series airplanes, which could lead to delayed evacuation during an emergency should the slide become jammed.

• Because the same bannis latch design used on certain Boeing 757 airplanes (757-200, -200CB, and -300 series) is also used on Boeing 727 and 737 airplanes, these airplane models could also have bannis latches installed that are not the correct configuration.

• Ensuring operators’ maintenance documentation contains consistent, accurate depictions of the correct configuration of the bannis latch assembly would help prevent the use of noncompliant components that could lead to delayed evacuation during an emergency should the slide become jammed.

Accordingly, the NTSB makes the following safety recommendations to the Federal Aviation Administration:

• Require all Boeing 757 operators to inspect the bannis latches on Boeing 757-200, -200CB, and -300 series airplane doors and, if necessary, modify or replace them so they comply with the correct configuration. (A-25-3)

• Require all operators of Boeing 727 and 737 airplane models that use the same bannis latch design as Boeing 757 airplanes (757-200, -200CB, and -300 series) to inspect and, if necessary, modify or replace the bannis latches as advised in the Boeing service bulletin recommended in Safety Recommendation A-25-8. (A-25-4)

• Require all Boeing 757 operators to update their Boeing 757 200, 200CB, and -300 series airplane aircraft maintenance manuals (AMM) in accordance with the revised Boeing AMM and illustrated parts catalogs. (A-25-5)

Read Recommendation

Recommendation Facts

Status
Open - Initial Response Received
Issued
April 3, 2025
Priority
CLASS II
Recipient
FAA
Adopted
March 27, 2025
Related Investigation
DCA24FA002
Related Report
AIR-25-02

• Require all operators of Boeing 727 and 737 airplane models that use the same bannis latch design as Boeing 757 airplanes (757-200, -200CB, and -300 series) to update their aircraft maintenance manuals (AMM) in accordance with the revised Boeing AMMs and illustrated parts catalogs recommended in Safety Recommendation A-25-9. (A-25-6)

The NTSB also issued Safety Recommendations A-25-7 through -9 to The Boeing Company.

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 of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (Safety Recommendations A 25 3 through A 25 6). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. 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.

The attached letter from the NTSB Chairman provides information about the Address Noncompliant Evacuation Slide Components on Boeing Airplanes, Chattanooga, Tennessee, October 4, 2023, NTSB/AIR-25-02. 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.

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 of the date of this letter detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (for example, A-25-3 through -6). 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.

From the report "Address Noncompliant Evacuation Slide Components on Boeing Airplanes" Report Number AIR-25-02, published on April 3, 2025:

On October 4, 2023, about 2347 eastern daylight time, the flight crew of FedEx flight 1376, a Boeing 757-236, received an engine indication and crew alerting system message indicating a failure of the left hydraulic system shortly after takeoff from Chattanooga Metropolitan Airport-Lovell Field (CHA), Chattanooga, Tennessee. The flight crew turned the airplane back to CHA but was unable to lower the landing gear. After multiple attempts to extend the gear were unsuccessful, the crew declared an emergency and performed an emergency gear up landing.

After the airplane came to a complete stop, the flight crew performed the evacuation checklist in the Quick Reference Handbook, and a jumpseat occupant onboard the airplane attempted to open the left (L1) door. The door rotated halfway open but would not open fully, and the slide did not deploy.

The jumpseat occupant then attempted to open the right (R1) door, but it lodged on the slide pack. The jumpseat occupant used force to open the R1 door, and the slide deployed normally (see figure 1). The flight crew and the jumpseat occupant exited the airplane via the R1 door and slide. Both flight crewmembers and the jumpseat occupant were uninjured. The event was classified as an accident because the airplane sustained substantial damage. The flight was operating under the provisions of Title 14 Code of Federal Regulations Part 121 as a non-scheduled domestic cargo flight from CHA to Memphis International Airport (MEM), Memphis, Tennessee.

Preliminary findings from the NTSB’s ongoing investigation indicate different reasons for the jumpseat occupant’s difficulty opening the L1 and R1 doors to deploy the respective evacuation slides. Postaccident examination of the R1 door found that the R1 bannis latch (which releases the slide pack when an armed door is opened) did not conform to the then-current configuration of the release cable assembly. Specifically, the assembly is supposed to have three links added with two spacers and hardware, as required by FAA Airworthiness Directive (AD) 86-09-09 by reference to Boeing Service Bulletin (SB) 757-25A0058, dated April 18, 1986 (see figure 2).

Instead, the R1 bannis latch on the accident airplane had only one link and lacked other required hardware (see figure 3), which caused the slide pack to jam before the jumpseat occupant was eventually able to force the door to open. Postaccident examination of the L1 door found that, although its bannis latch conformed to required modifications, the deployment strap was incorrectly routed, which prevented the door from opening.

After the CHA accident, FedEx inspected the L1 and R1 doors on the 97 other airplanes in its Boeing 757 fleet and found no other instances of a misrouted deployment strap. However, the inspection found 46 doors (about 24%) that were not compliant with either AD 86-09-09 or AD 2001-15-01 (applicable to Boeing 727, 737 100 through -800, and 757-200, -200CB, and -300 series airplanes because these models used the same bannis latch design). AD 2001-15-01 required bannis latch modifications recommended in two other Boeing SBs applicable to 757 airplanes (757-25A0108 and 757-25-0217).

The diagrams in each successive AD and SB indicated the modifications to the configuration covered in that document but missed parts of prior modifications so that none of the diagrams were fully correct. As a