Safety recommendations, recipients, status, and linked accident/report context.
What Is This Collection?
When an NTSB investigation exposes a fixable problem, the Board issues formal safety recommendations to the FAA, manufacturers, and operators. These records track each recommendation, who received it, and how they responded. Many of the rules you train under started here.
Nov 28, 2012
From the Document
In the past six years, the National Transportation Safety Board (NTSB) has conducted or participated in the investigations of three catastrophic in-flight cargo fires aboard cargo airplanes. These investigations and a recent cargo container fire study conducted by NTSB investigators have revealed that current fire protection regulations for these aircraft are inadequate. As a result of these accident investigations and the study, the NTSB is…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Develop fire detection system performance requirements for the early detection of fires originating within cargo containers and pallets and, once developed, implement the new requirements. (This safety recommendation supersedes Safety Recommendation A-07-98)
Response Status: Open - Acceptable Response
Recipient: FAA
Nov 28, 2012
From the Document
In the past six years, the National Transportation Safety Board (NTSB) has conducted or participated in the investigations of three catastrophic in-flight cargo fires aboard cargo airplanes. These investigations and a recent cargo container fire study conducted by NTSB investigators have revealed that current fire protection regulations for these aircraft are inadequate. As a result of these accident investigations and the study, the NTSB is…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Ensure that cargo container construction materials meet the same flammability requirements as all other cargo compartment materials in accordance with Title 14 Code of Federal Regulations 25.855.
Response Status: Open - Acceptable Response
Recipient: FAA
Nov 28, 2012
From the Document
In the past six years, the National Transportation Safety Board (NTSB) has conducted or participated in the investigations of three catastrophic in-flight cargo fires aboard cargo airplanes. These investigations and a recent cargo container fire study conducted by NTSB investigators have revealed that current fire protection regulations for these aircraft are inadequate. As a result of these accident investigations and the study, the NTSB is…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require the installation and use of active fire suppression systems in all aircraft cargo compartments or containers, or both, such that fires are not allowed to develop.
Response Status: Open - Acceptable Response
Recipient: FAA
Nov 1, 2012
From the Document
Many airplanes are equipped with ejection seats, ballistic recovery systems (BRS), and inflatable restraints that contain explosive components to activate the safety devices, and the number is increasing as newly certificated aircraft with BRS and after-market inflatable restraints become more prevalent. The five accidents discussed below are examples of accidents that the National Transportation Safety Board (NTSB) has investigated in which the…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require aircraft owners, during each triennial re-registration with the Federal Aviation Administration’s aircraft registry, to identify the presence and type of safety devices (such as ejection seats, ballistic recovery systems, or inflatable restraints) that contain explosive components on the aircraft.
Study Focus: Review qualification and recent-experience requirements.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Nov 1, 2012
From the Document
Many airplanes are equipped with ejection seats, ballistic recovery systems (BRS), and inflatable restraints that contain explosive components to activate the safety devices, and the number is increasing as newly certificated aircraft with BRS and after-market inflatable restraints become more prevalent. The five accidents discussed below are examples of accidents that the National Transportation Safety Board (NTSB) has investigated in which the…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Make the information about the presence and type of safety devices that contain explosive components on aircraft that was collected in response to Safety Recommendation A-12-64 readily available to first responders and accident investigators by displaying it on the Federal Aviation Administration’s online aircraft registry.
Study Focus: Review qualification and recent-experience requirements.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Nov 1, 2012
From the Document
Many airplanes are equipped with ejection seats, ballistic recovery systems (BRS), and inflatable restraints that contain explosive components to activate the safety devices, and the number is increasing as newly certificated aircraft with BRS and after-market inflatable restraints become more prevalent. The five accidents discussed below are examples of accidents that the National Transportation Safety Board (NTSB) has investigated in which the…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require aircraft owners who have installed a safety device that contains an explosive component under a supplemental type certificate since the most recent triennial re-registration to submit a new Federal Aviation Administration Form 8050-1A, providing updated information regarding the newly installed device.
Study Focus: Review qualification and recent-experience requirements.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Nov 1, 2012
From the Document
Many airplanes are equipped with ejection seats, ballistic recovery systems (BRS), and inflatable restraints that contain explosive components to activate the safety devices, and the number is increasing as newly certificated aircraft with BRS and after-market inflatable restraints become more prevalent. The five accidents discussed below are examples of accidents that the National Transportation Safety Board (NTSB) has investigated in which the…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Issue and distribute a publicly available safety bulletin to all 14 Code of Federal Regulations Part 139-certificated airports and to representative organizations of off-airport first responders, such as the International Association of Fire Chiefs and the National Fire Protection Association, to (1) inform first responders of the risks posed by the potential presence of all safety devices that contain…
Study Focus: Review qualification and recent-experience requirements.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Jul 12, 2012
From the Document
Experimental amateur-built (E-AB) aircraft represent nearly 10 percent of the U.S. general aviation fleet, but these aircraft accounted for approximately 15 percent of the total-and 21 percent of the fatal-U.S. general aviation (GA) accidents in 2011. Experimental amateur-built aircraft represent a growing segment of the United States' general aviation fleet-a segment that now numbers nearly 33,000 aircraft. The National Transportation Safety…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Develop and publish an advisory circular, or similar guidance, for the issuance of a Letter of Deviation Authority to conduct flight instruction in an experimental aircraft, to include sample documentation and sample training materials.
Study Focus: Review training practices and proficiency.
Response Status: Open - Unacceptable Response
Recipient: FAA
Jul 12, 2012
From the Document
Experimental amateur-built (E-AB) aircraft represent nearly 10 percent of the U.S. general aviation fleet, but these aircraft accounted for approximately 15 percent of the total-and 21 percent of the fatal-U.S. general aviation (GA) accidents in 2011. Experimental amateur-built aircraft represent a growing segment of the United States' general aviation fleet-a segment that now numbers nearly 33,000 aircraft. The National Transportation Safety…
Requested Action: TO THE EXPERIMENTAL AIRCRAFT ASSOCIATION: Work with your membership, aircraft kit manufacturers, and avionics manufacturers to develop standards for the recording of data in electronic flight displays, engine instruments, or other recording devices to be used in support of flight tests or continued airworthiness of experimental amateur-built aircraft.
Study Focus: Review aircraft-system operation, limitations and failure awareness.
Response Status: Open - Acceptable Response
Recipient: Experimental Aircraft Association
Jul 12, 2012
From the Document
Experimental amateur-built (E-AB) aircraft represent nearly 10 percent of the U.S. general aviation fleet, but these aircraft accounted for approximately 15 percent of the total-and 21 percent of the fatal-U.S. general aviation (GA) accidents in 2011. Experimental amateur-built aircraft represent a growing segment of the United States' general aviation fleet-a segment that now numbers nearly 33,000 aircraft. The National Transportation Safety…
Requested Action: TO THE EXPERIMENTAL AIRCRAFT ASSOCIATION: Complete planned action to create a coalition of kit manufacturers, type clubs, and pilot and owner groups and (1) develop transition training resources and (2)identify and apply incentives to encourage both builders of experimental amateur-built aircraft and purchasers of used experimental amateur-built aircraft to complete the training that is developed.
Study Focus: Review training practices and proficiency.
Response Status: Open - Acceptable Response
Recipient: Experimental Aircraft Association
Jul 3, 2012
From the Document
December 29, 2010, incident involving American Airlines flight 2253, a Boeing 757-200, N668AA, which ran off the departure end of runway 19 and came to a stop in deep snow after landing at Jackson Hole Airport (JAC), Jackson Hole, Wyoming. The occupants were not injured, and the airplane sustained minor damage. The National Transportation Safety Board determines that the probable cause of this incident was a manufacturing defect in a clutch…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require all newly type-certificated 14 Code of Federal Regulations Part 25 airplanes to have a clearly distinguishable and intelligible alert that warns pilots when the speedbrakes have not deployed during the landing roll.
Study Focus: Review surface awareness and decisions during taxi, takeoff and landing.
Response Status: Open Acceptable Alternate Response
Recipient: FAA
Jun 26, 2012
From the Document
On January 27, 2009, about 0437 central standard time, an Avions de Transport Regional (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, Lubbock, Texas. The captain sustained serious injuries, and the first officer sustained minor injuries. The airplane was substantially damaged. The…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require that Avions de Transport Régional (ATR) 42-series airplanes operating in the United States incorporate a revised stick pusher activation angle of attack (AOA), such that the stick pusher activates before the stall AOA in the presence of airframe ice accretions.
Study Focus: Review surface awareness and decisions during taxi, takeoff and landing.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Jun 26, 2012
From the Document
On January 27, 2009, about 0437 central standard time, an Avions de Transport Regional (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, Lubbock, Texas. The captain sustained serious injuries, and the first officer sustained minor injuries. The airplane was substantially damaged. The…
Requested Action: TO THE EUROPEAN AVIATION SAFETY AGENCY: Evaluate all European Aviation Safety Agency-certificated transport-category airplanes equipped with stick pushers to ensure that the stick pusher activates at an angle of attack that will provide adequate stall protection in the presence of airframe ice accretions.
Study Focus: Review surface awareness and decisions during taxi, takeoff and landing.
Response Status: Open - Acceptable Response
Recipient: European Aviation Safety Agency
May 19, 2011
From the Document
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.…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require that role-playing or simulator-based exercises that teach first officers to assertively voice their concerns and that teach captains to develop a leadership style that supports first officer assertiveness be included as part of the already required crew resource management training for 14 Code of Federal Regulations Part 121, 135, and 91 subpart K pilots.
Study Focus: Review surface awareness and decisions during taxi, takeoff and landing.
Response Status: Closed - Unacceptable Action
Recipient: FAA
May 19, 2011
From the Document
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.…
Requested Action: 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.
Study Focus: Review surface awareness and decisions during taxi, takeoff and landing.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Mar 2, 2011
From the Document
On October 19, 2009, about 0605 eastern daylight time, a Boeing 767, N185DN, operating as Delta Air Lines flight 60, landed on taxiway M at Hartsfield-Jackson Atlanta International Airport (ATL), Atlanta, Georgia. The flight was operating as a 14 Code of Federal Regulations Part 121 flight from Rio de Janeiro/Galeão-Antônio Carlos Jobim International Airport to ATL with 11 crewmembers and 182 passengers. No injuries to the crew or passengers…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Perform a technical review of Airport Surface Detection Equipment–Model X (ASDE-X) to determine if the capability exists systemwide to detect improper operations such as landings on taxiways.
Study Focus: Review surface awareness and decisions during taxi, takeoff and landing.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Mar 2, 2011
From the Document
On October 19, 2009, about 0605 eastern daylight time, a Boeing 767, N185DN, operating as Delta Air Lines flight 60, landed on taxiway M at Hartsfield-Jackson Atlanta International Airport (ATL), Atlanta, Georgia. The flight was operating as a 14 Code of Federal Regulations Part 121 flight from Rio de Janeiro/Galeão-Antônio Carlos Jobim International Airport to ATL with 11 crewmembers and 182 passengers. No injuries to the crew or passengers…
Requested Action: tO THE FEDERAL AVIATION ADMINISTRATION: At those installation sites where the technical review recommended in Safety Recommendation A-11-12 determines it is feasible, implement modifications to Airport Surface Detection Equipment–Model X (ASDE-X) to detect improper operations, such as landings on taxiways, and provide alerts to air traffic controllers that these potential collision risks exist.
Study Focus: Review surface awareness and decisions during taxi, takeoff and landing.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Dec 27, 2010
From the Document
On August 5, 2008, about 1941 Pacific daylight time, a Sikorsky S-61N helicopter, N612AZ, impacted trees and terrain during the initial climb after takeoff from Helispot 44 (H-44),1 located at an elevation of about 6,000 feet in mountainous terrain near Weaverville, California. The pilot-in-command, the safety crewmember,2 and seven firefighters were fatally injured; the copilot and three firefighters were seriously injured. Impact forces and a…
Requested Action: TO THE UNITED STATES DEPARTMENT OF AGRICULTURE, FOREST SERVICE: Review and revise policies regarding the type and use of gloves by firefighting personnel during transport operations, including but not limited to, compatibility with passenger restraints and opening emergency exits.
Study Focus: Review preparation and response to abnormal or emergency situations.
Response Status: Closed - Exceeds Recommended Action
Recipient: United States Department of Agriculture, Forest Service
Nov 23, 2010
From the Document
On January 4, 2009, about 1409 central standard time, a dual-engine Sikorsky S-76C++ helicopter, N748P, registered to and operated by PHI, Inc., departed controlled flight and crashed into marshy terrain about 7 minutes after takeoff. Both pilots and six passengers on board were fatally injured, and one passenger was seriously injured. The helicopter was substantially damaged. The helicopter departed Lake Palourde Base Heliport in Amelia,…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require operators to include simultaneous dual-engine power loss scenarios in both initial and recurrent ground and simulator training for pilots of dual-engine helicopters.
Study Focus: Review aircraft-system operation, limitations and failure awareness.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Aug 4, 2010
From the Document
On November 12, 2001, about 0916 eastern standard time, an Airbus A300-605R,1 N14053, operated as American Airlines flight 587, crashed into a residential area of Belle Harbor, New York, shortly after takeoff from John F. Kennedy International Airport, Jamaica, New York.2 Following an encounter with wake turbulence from a preceding Boeing 747 (747), the first officer made a series of full alternating rudder pedal inputs before the airplane’s…
Requested Action: TO THE EUROPEAN AVIATION SAFETY AGENCY: After the yaw axis certification standard recommended in Safety Recommendation A-10-119 has been established, review the designs of existing airplanes to determine if they meet the standard. For existing airplane designs that do not meet the standard, the European Aviation Safety Agency (EASA) should determine if the airplanes would be adequately protected from the adverse effects of a potential…
Study Focus: Review qualification and recent-experience requirements.
Response Status: Open - Acceptable Response
Recipient: European Aviation Safety Agency
Jul 29, 2010
From the Document
On December 20, 2008, about 1818 mountain standard time, Continental Airlines flight 1404, a Boeing 737-500, N18611, departed the left side of runway 34R during takeoff from Denver International Airport (DEN), Denver, Colorado. A postcrash fire ensued. The captain and 5 of the 110 passengers were seriously injured; the first officer, 2 cabin crewmembers, and 38 passengers received minor injuries; and 1 cabin crewmember and 67 passengers (3 of…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Once realistic, gusty crosswind profiles as asked for in Safety Recommendation A-10-110 are developed, develop a standard methodology, including pilot-in-the-loop testing, for transport-category airplane manufacturers to establish empirically based, type-specific maximum-gusting-crosswind limitations for transport-category airplanes that account for wind gusts.
Study Focus: Review surface awareness and decisions during taxi, takeoff and landing.
Response Status: Open Acceptable Alternate Response
Recipient: FAA
Jul 29, 2010
From the Document
On December 20, 2008, about 1818 mountain standard time, Continental Airlines flight 1404, a Boeing 737-500, N18611, departed the left side of runway 34R during takeoff from Denver International Airport (DEN), Denver, Colorado. A postcrash fire ensued. The captain and 5 of the 110 passengers were seriously injured; the first officer, 2 cabin crewmembers, and 38 passengers received minor injuries; and 1 cabin crewmember and 67 passengers (3 of…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Once a methodology as asked for in Safety Recommendation A-10-112 has been developed, require manufacturers of transport-category airplanes to develop type-specific, maximum-crosswind takeoff limitations that account for wind gusts.
Study Focus: Review surface awareness and decisions during taxi, takeoff and landing.
Response Status: Open Acceptable Alternate Response
Recipient: FAA
May 21, 2010
From the Document
On January 15, 2009, about 1527 eastern standard time,1 US Airways flight 1549, an Airbus Industrie A320-214, N106US, experienced an almost total loss of thrust in both engines after encountering a flock of birds and was subsequently ditched on the Hudson River about 8.5 miles from LaGuardia Airport (LGA), New York City, New York. The flight was en route to Charlotte Douglas International Airport (CLT), Charlotte, North Carolina, and had…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Modify the 14 Code of Federal Regulations 33.76(c) small and medium flocking bird certification test standard to require that the test be conducted using the lowest expected fan speed, instead of 100-percent fan speed, for the minimum climb rate.
Study Focus: Review qualification and recent-experience requirements.
Response Status: Closed - Acceptable Alternate Action
Recipient: FAA
May 21, 2010
From the Document
On January 15, 2009, about 1527 eastern standard time,1 US Airways flight 1549, an Airbus Industrie A320-214, N106US, experienced an almost total loss of thrust in both engines after encountering a flock of birds and was subsequently ditched on the Hudson River about 8.5 miles from LaGuardia Airport (LGA), New York City, New York. The flight was en route to Charlotte Douglas International Airport (CLT), Charlotte, North Carolina, and had…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require manufacturers of turbine-powered aircraft to develop a checklist and procedure for a dual-engine failure occurring at a low altitude.
Study Focus: Review aircraft-system operation, limitations and failure awareness.
Response Status: Closed - Acceptable Alternate Action
Recipient: FAA
May 21, 2010
From the Document
On January 15, 2009, about 1527 eastern standard time,1 US Airways flight 1549, an Airbus Industrie A320-214, N106US, experienced an almost total loss of thrust in both engines after encountering a flock of birds and was subsequently ditched on the Hudson River about 8.5 miles from LaGuardia Airport (LGA), New York City, New York. The flight was en route to Charlotte Douglas International Airport (CLT), Charlotte, North Carolina, and had…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Once the development of the checklist and procedure for a dual-engine failure occurring at a low altitude has been completed, as asked for in Safety Recommendation A-10-66, require 14 Code of Federal Regulations Part 121, Part 135, and Part 91 Subpart K operators of turbine-powered aircraft to implement the checklist and procedure.
Study Focus: Review aircraft-system operation, limitations and failure awareness.
Response Status: Closed - Unacceptable Action
Recipient: FAA
May 21, 2010
From the Document
On January 15, 2009, about 1527 eastern standard time,1 US Airways flight 1549, an Airbus Industrie A320-214, N106US, experienced an almost total loss of thrust in both engines after encountering a flock of birds and was subsequently ditched on the Hudson River about 8.5 miles from LaGuardia Airport (LGA), New York City, New York. The flight was en route to Charlotte Douglas International Airport (CLT), Charlotte, North Carolina, and had…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Develop and validate comprehensive guidelines for emergency and abnormal checklist design and development. The guidelines should consider the order of critical items in the checklist (for example, starting the auxiliary power unit), the use of opt outs or gates to minimize the risk of flight crewmembers becoming stuck in an inappropriate checklist or portion of a checklist, the length of the checklist, the…
Study Focus: Review preparation and response to abnormal or emergency situations.
Response Status: Closed - Unacceptable Action
Recipient: FAA
May 21, 2010
From the Document
On January 15, 2009, about 1527 eastern standard time,1 US Airways flight 1549, an Airbus Industrie A320-214, N106US, experienced an almost total loss of thrust in both engines after encountering a flock of birds and was subsequently ditched on the Hudson River about 8.5 miles from LaGuardia Airport (LGA), New York City, New York. The flight was en route to Charlotte Douglas International Airport (CLT), Charlotte, North Carolina, and had…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121, Part 135, and Part 91 Subpart K operators to include a dual-engine failure scenario occurring at a low altitude in initial and recurrent ground and simulator training designed to improve pilots‘ critical-thinking, task-shedding, decision-making, and workload-management skills.
Study Focus: Review aircraft-system operation, limitations and failure awareness.
Response Status: Closed - Unacceptable Action
Recipient: FAA
May 21, 2010
From the Document
On January 15, 2009, about 1527 eastern standard time,1 US Airways flight 1549, an Airbus Industrie A320-214, N106US, experienced an almost total loss of thrust in both engines after encountering a flock of birds and was subsequently ditched on the Hudson River about 8.5 miles from LaGuardia Airport (LGA), New York City, New York. The flight was en route to Charlotte Douglas International Airport (CLT), Charlotte, North Carolina, and had…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require applicants for aircraft certification to demonstrate that their ditching parameters can be attained without engine power by pilots without the use of exceptional skill or strength.
Study Focus: Review qualification and recent-experience requirements.
Response Status: Closed - Acceptable Action
Recipient: FAA
May 21, 2010
From the Document
On January 15, 2009, about 1527 eastern standard time, US Airways flight 1549, an Airbus Industrie A320-214, N106US, experienced an almost total loss of thrust in both engines after encountering a flock of birds and was subsequently ditched on the Hudson River about 8.5 miles from LaGuardia Airport (LGA), New York City, New York. The flight was en route to Charlotte Douglas International Airport, Charlotte, North Carolina, and had departed LGA…
Requested Action: TO THE UNITED STATES DEPARTMENT OF AGRICULTURE: Develop and implement, in conjunction with the Federal Aviation Administration, innovative technologies that can be installed on aircraft that would reduce the likelihood of a bird strike.
Response Status: Open - Acceptable Response
Recipient: United States Department of Agriculture
Apr 14, 2010
From the Document
During recent investigative testing, the National Transportation Safety Board (NTSB) learned that a failure within a helicopter’s radio altimeter system could prevent the look-ahead feature of a Honeywell MK XXII Enhanced Ground Proximity Warning System (EGPWS) from functioning during flight and that the pilot would possibly be unaware that this feature within the system is not operational. The look-ahead feature provides visual and aural…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require Honeywell to revise the software logic within the MK XXII Enhanced Ground Proximity Warning System so that a fault in the radio altimeter system would not prevent the look-ahead feature from functioning without notification to the pilot.
Study Focus: Review communication and coordination procedures.
Response Status: Closed - Acceptable Action
Recipient: FAA
Apr 14, 2010
From the Document
During recent investigative testing, the National Transportation Safety Board (NTSB) learned that a failure within a helicopter’s radio altimeter system could prevent the look-ahead feature of a Honeywell MK XXII Enhanced Ground Proximity Warning System (EGPWS) from functioning during flight and that the pilot would possibly be unaware that this feature within the system is not operational. The look-ahead feature provides visual and aural…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Once Honeywell revises the MK XXII Enhanced Ground Proximity Warning System (EGPWS) software logic (as described in Safety Recommendation A-10-60), require all operators using the Honeywell MK XXII EGPWS to install the revised software.
Study Focus: Review communication and coordination procedures.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Feb 23, 2010
From the Document
On February 12, 2009, about 2217 eastern standard time,1 a Colgan Air, Inc., Bombardier DHC-8-400 (Q400),2 N200WQ, operating as Continental Connection flight 3407, was on an instrument approach to Buffalo-Niagara International Airport, Buffalo, New York, when it crashed into a residence in Clarence Center, New York, about 5 nautical miles northeast of the airport. The 2 pilots, 2 flight attendants, and 45 passengers aboard the airplane were…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to review their standard operating procedures to verify that they are consistent with the flight crew monitoring techniques described in Advisory Circular (AC) 120-71A, "Standard Operating Procedures for Flight Deck Crewmembers"; if the procedures are found not to be consistent, revise the procedures according to the AC guidance to…
Study Focus: Review instrument planning, procedures and operating decisions.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Feb 23, 2010
From the Document
On February 12, 2009, about 2217 eastern standard time,1 a Colgan Air, Inc., Bombardier DHC-8-400 (Q400),2 N200WQ, operating as Continental Connection flight 3407, was on an instrument approach to Buffalo-Niagara International Airport, Buffalo, New York, when it crashed into a residence in Clarence Center, New York, about 5 nautical miles northeast of the airport. The 2 pilots, 2 flight attendants, and 45 passengers aboard the airplane were…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to (1) routinely download and analyze all available sources of safety information, as part of their flight operational quality assurance program, to identify deviations from established norms and procedures; (2) provide appropriate protections to ensure the confidentiality of the deidentified aggregate data; and (3) ensure that this…
Study Focus: Review instrument planning, procedures and operating decisions.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Sep 24, 2009
From the Document
Calendar year 2008 was the deadliest year on record for the helicopter emergency medical services (HEMS) industry, with 12 accidents (8 fatal accidents) and 29 fatalities. As a result of this increase in fatal accidents involving HEMS operations, the National Transportation Safety Board (NTSB) placed the issue of HEMS safety on its Most Wanted List of Transportation Safety Improvements on October 28, 2008, and also conducted a 4-day public…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Conduct a systematic evaluation and issue a report on the requirements necessary for a viable low-altitude airspace infrastructure that can accommodate safe helicopter emergency medical services (HEMS) operations. The evaluation should consider improved collection and dissemination of weather data, the role of automatic dependent surveillance-broadcast (ADS-B), approaches to helipad and designated landing…
Study Focus: Review weather hazards and how they affect planning and flight decisions.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Sep 24, 2009
From the Document
This recommendation letter addresses the helicopter emergency medical services (HEMS) industry and is derived from testimony provided at the NTSB’s public hearing concerning this industry, as well as investigations of recent HEMS accidents. As a result, the NTSB is issuing four safety recommendations to the Department of Health and Human Services’ Centers for Medicare & Medicaid Services (CMS). Information supporting these recommendations is…
Requested Action: TO THE CENTERS FOR MEDICARE AND MEDICAID (UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES): Develop minimum safety accreditation standards for helicopter emergency medical services (HEMS) operators that augment the operating standards of 14 Code of Federal Regulations Part 135 by including, for all flights with medical personnel on board, (a) scenario-based pilot training, (b) implementation of preflight risk evaluation programs, (c)…
Study Focus: Review the information and decisions needed before departure.
Response Status: Closed - Reconsidered
Recipient: United States Department of Health and Human Services
Jul 8, 2009
From the Document
On June 28, 2008, about 2215 Pacific daylight time, an ABX Air Boeing 767-200, N799AX, operating as flight 1611 from San Francisco International Airport (SFO), San Francisco, California, experienced a ground fire before engine startup. The captain and the first officer evacuated the airplane through the cockpit windows and were not injured, and the airplane was substantially damaged. The cargo flight was operating under the provisions of 14 Code…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require operators to replace electrically conductive combustible oxygen hoses with electrically nonconductive hoses so that the internal hose spring cannot be energized.
Study Focus: Review aircraft-system operation, limitations and failure awareness.
Response Status: Closed - Acceptable Action
Recipient: FAA
Jul 8, 2009
From the Document
On June 28, 2008, about 2215 Pacific daylight time, an ABX Air Boeing 767-200, N799AX, operating as flight 1611 from San Francisco International Airport (SFO), San Francisco, California, experienced a ground fire before engine startup. The captain and the first officer evacuated the airplane through the cockpit windows and were not injured, and the airplane was substantially damaged. The cargo flight was operating under the provisions of 14 Code…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Prohibit the use of electrically conductive combustible oxygen hoses unless the conductivity of the hose is an intentional and approved parameter in the design.
Study Focus: Review aircraft-system operation, limitations and failure awareness.
Response Status: Closed - Acceptable Action
Recipient: FAA
Jul 8, 2009
From the Document
On June 28, 2008, about 2215 Pacific daylight time, an ABX Air Boeing 767-200, N799AX, operating as flight 1611 from San Francisco International Airport (SFO), San Francisco, California, experienced a ground fire before engine startup. The captain and the first officer evacuated the airplane through the cockpit windows and were not injured, and the airplane was substantially damaged. The cargo flight was operating under the provisions of 14 Code…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require airplane manufacturers and operators to ensure that oxygen system tubing in proximity to electrical wiring is made of, sleeved with, or coated with nonconductive material or that the tubing is otherwise physically isolated from potential electrical sources.
Study Focus: Review aircraft-system operation, limitations and failure awareness.
Response Status: Closed - Acceptable Alternate Action
Recipient: FAA
Jul 8, 2009
From the Document
On June 28, 2008, about 2215 Pacific daylight time, an ABX Air Boeing 767-200, N799AX, operating as flight 1611 from San Francisco International Airport (SFO), San Francisco, California, experienced a ground fire before engine startup. The captain and the first officer evacuated the airplane through the cockpit windows and were not injured, and the airplane was substantially damaged. The cargo flight was operating under the provisions of 14 Code…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Develop minimum electrical grounding requirements for oxygen system components and include these requirements as part of the certification process for new airplanes and approved supplemental type certificate modifications to existing airplanes.
Study Focus: Review qualification and recent-experience requirements.
Response Status: Closed - Acceptable Action
Recipient: FAA
Jul 8, 2009
From the Document
On June 28, 2008, about 2215 Pacific daylight time, an ABX Air Boeing 767-200, N799AX, operating as flight 1611 from San Francisco International Airport (SFO), San Francisco, California, experienced a ground fire before engine startup. The captain and the first officer evacuated the airplane through the cockpit windows and were not injured, and the airplane was substantially damaged. The cargo flight was operating under the provisions of 14 Code…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Once electrical grounding requirements for oxygen system components are developed, as requested in Safety Recommendation A-09-48, require airplane operators and modifiers to inspect their airplanes for compliance with these criteria and modify those airplanes not in compliance accordingly.
Study Focus: Review aircraft-system operation, limitations and failure awareness.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Jul 8, 2009
From the Document
On June 28, 2008, about 2215 Pacific daylight time, an ABX Air Boeing 767-200, N799AX, operating as flight 1611 from San Francisco International Airport (SFO), San Francisco, California, experienced a ground fire before engine startup. The captain and the first officer evacuated the airplane through the cockpit windows and were not injured, and the airplane was substantially damaged. The cargo flight was operating under the provisions of 14 Code…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Develop inspection criteria or service life limits for flexible oxygen hoses to ensure that they meet current certification and design standards.
Study Focus: Review qualification and recent-experience requirements.
Response Status: Closed - Acceptable Action
Recipient: FAA
Jul 8, 2009
From the Document
On June 28, 2008, about 2215 Pacific daylight time, an ABX Air Boeing 767-200, N799AX, operating as flight 1611 from San Francisco International Airport (SFO), San Francisco, California, experienced a ground fire before engine startup. The captain and the first officer evacuated the airplane through the cockpit windows and were not injured, and the airplane was substantially damaged. The cargo flight was operating under the provisions of 14 Code…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Once inspection criteria or service life limits for flexible oxygen hoses have been developed, as requested in Safety Recommendation A-09-50, require airplane operators to replace those hoses that do not meet the inspection criteria or that exceed the service life limits.
Study Focus: Review aircraft-system operation, limitations and failure awareness.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Jul 8, 2009
From the Document
On June 28, 2008, about 2215 Pacific daylight time, an ABX Air Boeing 767-200, N799AX, operating as flight 1611 from SFO, experienced a ground fire before engine startup. The captain and the first officer evacuated the airplane through the cockpit windows and were not injured, and the airplane was substantially damaged. The cargo flight was operating under the provisions of 14 Code of Federal Regulations Part 121. At the time of the fire, the…
Requested Action: TO ABX AIR: Modify your continuing analysis and surveillance program so that all identified chronic discrepancies, such as those affecting the oxygen system on the accident airplane, are effectively resolved.
Study Focus: Review aircraft-system operation, limitations and failure awareness.
Response Status: Closed - Acceptable Action
Recipient: Airborne Express, Inc.
Oct 20, 2008
From the Document
On December 29, 2007, about 1531 central standard time, a Bell 206L1 helicopter, N211EL, operated by Air Logistics, LLC, impacted the water while approaching South Pass Block 38 (SP38), an offshore platform in the Gulf of Mexico, with a commercial pilot and three passengers aboard. All four occupants survived the crash, but one passenger died while awaiting rescue. The pilot was seriously injured, and the two other passengers received minor…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require operators of turbine-powered helicopters with externally mounted liferafts to install a placard for each external T-handle that clearly identifies the location of and provides activation instructions for the handle.
Response Status: Closed - Acceptable Alternate Action
Recipient: FAA
Oct 20, 2008
From the Document
On December 29, 2007, about 1531 central standard time, a Bell 206L1 helicopter, N211EL, operated by Air Logistics, LLC, impacted the water while approaching South Pass Block 38 (SP38), an offshore platform in the Gulf of Mexico, with a commercial pilot and three passengers aboard. All four occupants survived the crash, but one passenger died while awaiting rescue. The pilot was seriously injured, and the two other passengers received minor…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require all operators of turbine-powered helicopters to include, in pilot preflight safety briefings to passengers before each takeoff, information about the location and activation of all flotation equipment, including internal or external liferafts (depending on which system has been installed on the helicopter).
Study Focus: Review the information and decisions needed before departure.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Jan 7, 2008
From the Document
On February 7, 2006, a United Parcel Service Company (UPS) cargo aircraft had an in-flight cargo fire and made an emergency landing at Philadelphia International Airport. Although the cause of the in-flight fire could not be determined in the UPS accident, the presence of a significant quantity of electronic equipment in the containers where the fire most likely originated led the Safety Board to closely examine safety issues involving the…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION AND THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: In collaboration with air carriers, manufacturers of lithium batteries and electronic devices, air travel associations, and other appropriate government and private organizations, establish a process to ensure wider, highly visible, and continuous dissemination of guidance and information to the air-traveling public, including flight crews,…
Study Focus: Review preparation and response to abnormal or emergency situations.
Response Status: Closed - Acceptable Action
Recipient: PHMSA, FAA
Jan 7, 2008
From the Document
On February 7, 2006, a United Parcel Service Company (UPS) cargo aircraft had an in-flight cargo fire and made an emergency landing at Philadelphia International Airport. Although the cause of the in-flight fire could not be determined in the UPS accident, the presence of a significant quantity of electronic equipment in the containers where the fire most likely originated led the Safety Board to closely examine safety issues involving the…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION AND THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: In collaboration with air carriers, manufacturers of lithium batteries and electronic devices, air travel associations, and other appropriate government and private organizations, establish a process to periodically measure the effectiveness of your efforts to educate the air-traveling public, including flight crews, about the safe carriage of…
Study Focus: Review preparation and response to abnormal or emergency situations.
Response Status: Closed - Acceptable Action
Recipient: PHMSA, FAA
Dec 17, 2007
From the Document
On February 7, 2006, about 2359 eastern standard time, United Parcel Service Company (UPS) flight 1307, a McDonnell Douglas DC-8-71F, N748UP, landed at its destination airport, Philadelphia International Airport (PHL), Philadelphia, Pennsylvania, after a cargo smoke indication in the cockpit. The captain, first officer, and flight engineer evacuated the airplane after landing. The flight crewmembers sustained minor injuries, and the airplane and…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Provide clear guidance to operators of passenger and cargo aircraft operating under 14 Code of Federal Regulations Parts 121, 135, and 91K on flight crew procedures for responding to evidence of a fire in the absence of a cockpit alert based on the guidance developed by the 2004 smoke, fire, and fumes industry initiative.
Response Status: Closed - Acceptable Action
Recipient: FAA
Dec 17, 2007
From the Document
On February 7, 2006, about 2359 eastern standard time, United Parcel Service Company (UPS) flight 1307, a McDonnell Douglas DC-8-71F, N748UP, landed at its destination airport, Philadelphia International Airport (PHL), Philadelphia, Pennsylvania, after a cargo smoke indication in the cockpit. The captain, first officer, and flight engineer evacuated the airplane after landing. The flight crewmembers sustained minor injuries, and the airplane and…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Ensure that the performance requirements for smoke and fire detection systems account for the effects of cargo and cargo containers on airflow around the detection sensors and on the containment of smoke from a fire inside a container and should establish standardized methods of demonstrating compliance with those requirements. (Superseded by safety recommendation A-12-68)
Response Status: Closed - Acceptable Action/Superseded
Recipient: FAA
Dec 17, 2007
From the Document
On February 7, 2006, about 2359 eastern standard time, United Parcel Service Company (UPS) flight 1307, a McDonnell Douglas DC-8-71F, N748UP, landed at its destination airport, Philadelphia International Airport (PHL), Philadelphia, Pennsylvania, after a cargo smoke indication in the cockpit. The captain, first officer, and flight engineer evacuated the airplane after landing. The flight crewmembers sustained minor injuries, and the airplane and…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require that fire suppression systems be installed in the cargo compartments of all cargo airplanes operating under 14 Code of Federal Regulations Part 121.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Dec 17, 2007
From the Document
On February 7, 2006, about 2359 eastern standard time, United Parcel Service Company (UPS) flight 1307, a McDonnell Douglas DC-8-71F, N748UP, landed at its destination airport, Philadelphia International Airport (PHL), Philadelphia, Pennsylvania, after a cargo smoke indication in the cockpit. The captain, first officer, and flight engineer evacuated the airplane after landing. The flight crewmembers sustained minor injuries, and the airplane and…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Provide guidance to aircraft rescue and firefighting personnel on the best training methods to obtain and maintain proficiency with the high-reach extendable turret with skin-penetrating nozzle.
Study Focus: Review training practices and proficiency.
Response Status: Closed - Acceptable Action
Recipient: FAA
Dec 17, 2007
From the Document
On February 7, 2006, about 2359 eastern standard time, United Parcel Service Company (UPS) flight 1307, a McDonnell Douglas DC-8-71F, N748UP, landed at its destination airport, Philadelphia International Airport (PHL), Philadelphia, Pennsylvania, after a cargo smoke indication in the cockpit. The captain, first officer, and flight engineer evacuated the airplane after landing. The flight crewmembers sustained minor injuries, and the airplane and…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require airport inspectors to ensure that Part 139 airports with cargo operations include cargo aircraft in their aircraft rescue and firefighting aircraft familiarization training programs.
Study Focus: Review training practices and proficiency.
Response Status: Closed - Acceptable Action
Recipient: FAA
Dec 17, 2007
From the Document
On February 7, 2006, about 2359 eastern standard time, United Parcel Service Company (UPS) flight 1307, a McDonnell Douglas DC-8-71F, N748UP, landed at its destination airport, Philadelphia International Airport (PHL), Philadelphia, Pennsylvania, after a cargo smoke indication in the cockpit. The captain, first officer, and flight engineer evacuated the airplane after landing. The flight crewmembers sustained minor injuries, and the airplane and…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require cargo operators to designate at least one floor level door as a required emergency exit and equip the door with an evacuation slide, when appropriate.
Study Focus: Review preparation and response to abnormal or emergency situations.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Dec 17, 2007
From the Document
On February 7, 2006, about 2359 eastern standard time, United Parcel Service Company (UPS) flight 1307, a McDonnell Douglas DC-8-71F, N748UP, landed at its destination airport, Philadelphia International Airport (PHL), Philadelphia, Pennsylvania, after a cargo smoke indication in the cockpit. The captain, first officer, and flight engineer evacuated the airplane after landing. The flight crewmembers sustained minor injuries, and the airplane and…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require all emergency exits on cargo aircraft that are operable from the outside to have a 2-inch contrasting colored band outlining the exit.
Study Focus: Review preparation and response to abnormal or emergency situations.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Dec 17, 2007
From the Document
On February 7, 2006, about 2359 eastern standard time, United Parcel Service Company (UPS) flight 1307, a McDonnell Douglas DC-8-71F, N748UP, landed at its destination airport, Philadelphia International Airport (PHL), Philadelphia, Pennsylvania, after a cargo smoke indication in the cockpit. The captain, first officer, and flight engineer evacuated the airplane after landing. The flight crewmembers sustained minor injuries, and the airplane and…
Requested Action: TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Require aircraft operators to implement measures to reduce the risk of primary lithium batteries becoming involved in fires on cargo-only aircraft, such as transporting such batteries in fire resistant containers and/or in restricted quantities at any single location on the aircraft.
Response Status: Closed - Reconsidered
Recipient: PHMSA
Dec 17, 2007
From the Document
On February 7, 2006, about 2359 eastern standard time, United Parcel Service Company (UPS) flight 1307, a McDonnell Douglas DC-8-71F, N748UP, landed at its destination airport, Philadelphia International Airport (PHL), Philadelphia, Pennsylvania, after a cargo smoke indication in the cockpit. The captain, first officer, and flight engineer evacuated the airplane after landing. The flight crewmembers sustained minor injuries, and the airplane and…
Requested Action: TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Until fire suppression systems are required on cargo-only aircraft, as asked for in Safety Recommendation A-07-99, require that cargo shipments of secondary lithium batteries, including those contained in or packed with equipment, be transported in crew-accessible locations where portable fire suppression systems can be used.
Response Status: Closed - Reconsidered
Recipient: PHMSA
Dec 17, 2007
From the Document
On February 7, 2006, about 2359 eastern standard time, United Parcel Service Company (UPS) flight 1307, a McDonnell Douglas DC-8-71F, N748UP, landed at its destination airport, Philadelphia International Airport (PHL), Philadelphia, Pennsylvania, after a cargo smoke indication in the cockpit. The captain, first officer, and flight engineer evacuated the airplane after landing. The flight crewmembers sustained minor injuries, and the airplane and…
Requested Action: TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Require aircraft operators that transport hazardous materials to immediately provide consolidated and specific information about hazardous materials on board an aircraft, including proper shipping name, hazard class, quantity, number of packages, and location, to on-scene emergency responders upon notification of an accident or incident.
Study Focus: Review preparation and response to abnormal or emergency situations.
Response Status: Closed - Acceptable Action
Recipient: PHMSA
Dec 17, 2007
From the Document
On February 7, 2006, about 2359 eastern standard time, United Parcel Service Company (UPS) flight 1307, a McDonnell Douglas DC-8-71F, N748UP, landed at its destination airport, Philadelphia International Airport (PHL), Philadelphia, Pennsylvania, after a cargo smoke indication in the cockpit. The captain, first officer, and flight engineer evacuated the airplane after landing. The flight crewmembers sustained minor injuries, and the airplane and…
Requested Action: TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Require commercial cargo and passenger operators to report to the Pipeline and Hazardous Materials Safety Administration all incidents involving primary and secondary lithium batteries, including those contained in or packed with equipment, that occur either on board or during loading or unloading operations and retain the failed items for evaluation purposes.
Response Status: Closed - Acceptable Alternate Action
Recipient: PHMSA
Dec 17, 2007
From the Document
On February 7, 2006, about 2359 eastern standard time, United Parcel Service Company (UPS) flight 1307, a McDonnell Douglas DC-8-71F, N748UP, landed at its destination airport, Philadelphia International Airport (PHL), Philadelphia, Pennsylvania, after a cargo smoke indication in the cockpit. The captain, first officer, and flight engineer evacuated the airplane after landing. The flight crewmembers sustained minor injuries, and the airplane and…
Requested Action: TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Analyze the causes of all thermal failures and fires involving secondary and primary lithium batteries and, based on this analysis, take appropriate action to mitigate any risks determined to be posed by transporting secondary and primary lithium batteries, including those contained in or packed with equipment, on board cargo and passenger aircraft as cargo; checked baggage; or…
Response Status: Closed - Acceptable Alternate Action
Recipient: PHMSA