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.
Dec 21, 1995
From the Document
ON 2/21/95, AN ISRAEL AIRCRAFT INDUSTRIES (IAI) 1124 9WESTWIND I). N66JE, SUSTAINED SUBSTANTIAL FIRE DAMAGE WHILE PARKED AT THE DENVER-STAPLETON INTERNATIONAL AIRPORT. THE FIRE ABOARD THE TWIN FAN-JET OCCURRED DURING A ROUTINE AIRCRAFT INTERIOR/COCKPIT PREFLIGHT CHECK AND WAS CAUSED BY A FAULTY OXYGEN SYSTEM. ALTHOUGH NODODY WAS INJURED IN THIS EVENT, THE BOARD IS CONCERNED THAT A RECURRENCE OF THIS KIND, PARTICULARLY IN FLIGHT, COULD RESULT IN…
Requested Action: THE NTSB RECOMMENDS THAT THE FAA: ISSUE AN AIRWORTHINESS DIRECTIVE APPLICABLE TO ALL EMERGENCY EQUIPMENT LAST SERVICE BY TEC-AIR SERVICES, INC., INCLUDING OXYGEN SUPPLY CYLINDERS AND OXYGEN SYSTEM PRESSURE REDUCER-REGULATOR ASSEMBLIES, REQURING DETAILED INSPECTION, TESTING, AND SERVICING AS NECESSARY TO ENSURE ITS CONTINUED AIRWORTHINESS.
Study Focus: Review maintenance and airworthiness responsibilities.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Feb 23, 1995
From the Document
ON 7/31/94, AT 1550 PACIFIC DAYLIGHT TIME, A FLOAT-EQUIPPED PIPER PA-12, N2368M, COLLIDED WITH A 16-FOOT CANOE ON THE WILLAMETTE RIVER 10 MILES NORTH OF SALEM, OREGON. TWO ADULTS IN THE CANOE WERE FATALLY INJURED; TWO CHILDREN IN THE CANOE WERE NOT INJURED.
Requested Action: THE NTSB RECOMMENDS THAT THE FAA: REVISE ADVISORY CIRCULAR 91-69, SEAPLANE SAFETY FOR FAR PART 91 OPERATORS, TO PROVIDE COMPREHENSIVE INFO CONCERNING OPERATIONAL HAZARDS AND THE RESPONSIBILITIES OF SEAPLANE OPERATORS WHEN NAVIGATING ON THE WATER. THIS INFO SHOULD INCLUDE ALL APPLICABLE FAA AND USCG REQUIREMENTS.
Response Status: Closed - Acceptable Action
Recipient: FAA
Feb 23, 1995
From the Document
ON 7/31/94, AT 1550 PACIFIC DAYLIGHT TIME, A FLOAT-EQUIPPED PIPER PA-12, N2368M, COLLIDED WITH A 16-FOOT CANOE ON THE WILLAMETTE RIVER 10 MILES NORTH OF SALEM, OREGON. TWO ADULTS IN THE CANOE WERE FATALLY INJURED; TWO CHILDREN IN THE CANOE WERE NOT INJURED.
Requested Action: THE NTSB RECOMMENDS THAT THE FAA: DEVELOP AND DISTRIBUTE, IN CONJUNCTION WITH THE SEAPLANE PILOTS ASSOCIATION AND THE NATIONAL ASSOCIATION OF STATE BOATING LAW ADMINISTRATORS, MATERIALS TO EDUCATE SEAPLANE OPERATORS ABOUT REVISED FEDERAL AVIATION REGULATIONS, ADVISORY CIRCULARS, AND VARIOUS STATE REQUIREMENTS REGARDING OPERATING THEIR PLANES ON WATER.
Response Status: Closed - Acceptable Action
Recipient: FAA
Feb 23, 1995
From the Document
ON 7/31/94, AT 1550 PACIFIC DAYLIGHT TIME, A FLOAT-EQUIPPED PIPER PA-12, N2368M, COLLIDED WITH A 16-FOOT CANOE ON THE WILLAMETTE RIVER 10 MILES NORTH OF SALEM, OREGON. TWO ADULTS IN THE CANOE WERE FATALLY INJURED; TWO CHILDREN IN THE CANOE WERE NOT INJURED.
Requested Action: THE NTSB RECOMMENDS THAT THE SEAPLANE PILOTS ASSOCIATION: DEVELOP AND DISTRIBUTE, IN CONJUNCTION WITH THE FAA AND THE NATIONAL ASSOCIATION OF STATE BOATING LAW ADMINISTRATORS, MATERIALS TO EDUCATE SEAPLANE OPERATORS ABOUT REVISED FEDERAL AVIATION REGULATIONS, ADVISORY CIRCULARS, AND VARIOUS STATE REQUIREMENTS REGARDING OPERATING THEIR PLANES ON WATER.
Response Status: Closed - Acceptable Action
Recipient: Seaplane Pilots Association
May 18, 1994
From the Document
On august 18, 1993, at 1656 eastern daylight time (EDT), a Douglas DC-8-61 freighter, N814CK, registered to American International Airways (AIA), in., d/b/a Connine Kalitta Services, Inc., and operating as AIA flight 808, collided with level terrain approximately 1/4 mile from the approach end of runway 10, after the captain lost control of the airplane while approaching the Leeward Point Airfield at the U.S. Naval Air Station, Guantanamo Bay,…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Expedite the review and upgrade of flight/duty time limitations of the Federal Aviation Regulations to ensure that they incorporate the results of the latest research on fatigue and sleep issues. (Superseded by A-95-110 through -113)
Study Focus: Review surface awareness and decisions during taxi, takeoff and landing.
Response Status: Closed - Acceptable Action/Superseded
Recipient: FAA
Mar 17, 1994
From the Document
ON DECEMBER 7, 1992, ABOUT 1036 COORDINATED UNIVERSAL TIME, A MCDONNEL DOUGLAS MD-11, TIAWAN REGISTRATION B-150, CHINA AIRLINES, FLIGHT CI-012, ENCOUNTERED MODERATE TURBULENCE AT FLIGHT LEVEL 330. THE AIRPLANE SUBSEQUENTLY DEPARTED CONTROLLED FLIGHT AND SUSTAINED DAMAGED TO THE LEFT AND RIGHT OUTBOARD ELEVATOR SKIN ASSEMBLIES, PORTIONS OF WHICH SEPARATED FROM THE AIRPLANE. THE AIRPLANE WAS OPERATING UNDER THE PROVISIONS OF TITLE 14, CODE OF…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: ESTABLISH CERTIFICATION REQUIREMENTS FOR FLIGHT CONTROL HANDLING CHARACTERISTICS, SUCH AS STICK FORCE PER G LIMITS, AND REQUIRE FLIGHT DEMONSTRATIONS TO ENSURE THAT PILOTS CAN SAFELY RECOVER FROM ABRUPT HIGH ALTITUDE, HIGH SPEED UPSETS IN TRANSPORT-CATEGORY AIRPLANES.
Study Focus: Review qualification and recent-experience requirements.
Response Status: Closed - Acceptable Action
Recipient: FAA
Aug 17, 1993
From the Document
ON FEBRUARY 9, 1993, ABOUT 0930 EASTERN STANDARD TIME, THE LAUNCH SEQUENCE FOR AN ORBITAL SCIENCES CORPORATION (OSC) PEGASUS EXPENDABLE LAUNCH VEHICLE (ELV) WAS ABORTED BY THE NATIONAL AERONAUTICS AND SPACE ADMINISTRATION (NASA) RANGE SAFETY OFFICERS, IN ACCORDANCE WITH A PREVIOUSLY ESTABLISHED LAUNCH CONSTRAINT. SEVERAL SECONDS LATER, THE LAUNCH SEQUENCE WAS REINITIATED BY THE OSC TEST CONDUCTOR, AND THE MISSILE SEPARATED UNEVENTFULLY FROM ITS…
Requested Action: THE NTSB RECOMMENDS THAT THE DEPARTMENT OF TRANSPORTATION: REQUIRE THAT, AS A CONDITION FOR LICENSE FOR COMMERCIAL SPACE LAUNCHES, AS A MINIMUM, THE COMPANY APPLYING FOR THE LICENSE INCLUDE IN ITS LICENSE APPLICATION: CLEARLY DELINEATED STATEMENTS OF AUTHORITY FOR ALL PARTIES AND KEY INDIVIDUALS INVOLVED IN THE LAUNCH, INCLUDING INDIVIDUALS (OR POSITIONS) AUTHORIZED TO ABORT THE MISSION, HOLD THE COUNTDOWN, OR RESUME THE COUNTDOWN, FOLLOWING A…
Response Status: Closed - Acceptable Action
Recipient: DOT
Aug 17, 1993
From the Document
ON FEBRUARY 9, 1993, ABOUT 0930 EASTERN STANDARD TIME, THE LAUNCH SEQUENCE FOR AN ORBITAL SCIENCES CORPORATION (OSC) PEGASUS EXPENDABLE LAUNCH VEHICLE (ELV) WAS ABORTED BY THE NATIONAL AERONAUTICS AND SPACE ADMINISTRATION (NASA) RANGE SAFETY OFFICERS, IN ACCORDANCE WITH A PREVIOUSLY ESTABLISHED LAUNCH CONSTRAINT. SEVERAL SECONDS LATER, THE LAUNCH SEQUENCE WAS REINITIATED BY THE OSC TEST CONDUCTOR, AND THE MISSILE SEPARATED UNEVENTFULLY FROM ITS…
Requested Action: THE NTSB RECOMMENDS THAT THE DEPARTMENT OF TRANSPORTATION: REQUIRE THAT, AS A CONDITION FOR LICENSE FOR COMMERCIAL SPACE LAUNCHES, AS A MINIMUM, THE COMPANY APPLYING FOR THE LICENSE INCLUDE IN ITS LICENSE APPLICATION: SPECIFIC DETAILS AND CRITERIA FOR LAUNCH READINESS REVIEWS AND LAUNCH DRESS REHEARSALS.
Response Status: Closed - Acceptable Action
Recipient: DOT
Aug 17, 1993
From the Document
ON FEBRUARY 9, 1993, ABOUT 0930 EASTERN STANDARD TIME, THE LAUNCH SEQUENCE FOR AN ORBITAL SCIENCES CORPORATION (OSC) PEGASUS EXPENDABLE LAUNCH VEHICLE (ELV) WAS ABORTED BY THE NATIONAL AERONAUTICS AND SPACE ADMINISTRATION (NASA) RANGE SAFETY OFFICERS, IN ACCORDANCE WITH A PREVIOUSLY ESTABLISHED LAUNCH CONSTRAINT. SEVERAL SECONDS LATER, THE LAUNCH SEQUENCE WAS REINITIATED BY THE OSC TEST CONDUCTOR, AND THE MISSILE SEPARATED UNEVENTFULLY FROM ITS…
Requested Action: THE NTSB RECOMMENDS THAT THE DEPARTMENT OF TRANSPORTATION: REQUIRE THAT, AS A CONDITION FOR LICENSE FOR COMMERCIAL SPACE LAUNCHES, AS A MINIMUM, THE COMPANY APPLYING FOR THE LICENSE INCLUDE IN ITS LICENSE APPLICATION: A PLAN FOR THE APPROVAL OF CHECKLISTS FOR THE LAUNCH, INCLUDING A PROVISION FOR ENSURING THE CURRENCY AND CONSISTENCY OF EACH PARTICIPANT'S CHECKLIST DURING THE DRESS REHEARSAL FOR THE LAUNCH.
Study Focus: Review qualification and recent-experience requirements.
Response Status: Closed - Acceptable Action
Recipient: DOT
Aug 17, 1993
From the Document
ON FEBRUARY 9, 1993, ABOUT 0930 EASTERN STANDARD TIME, THE LAUNCH SEQUENCE FOR AN ORBITAL SCIENCES CORPORATION (OSC) PEGASUS EXPENDABLE LAUNCH VEHICLE (ELV) WAS ABORTED BY THE NATIONAL AERONAUTICS AND SPACE ADMINISTRATION (NASA) RANGE SAFETY OFFICERS, IN ACCORDANCE WITH A PREVIOUSLY ESTABLISHED LAUNCH CONSTRAINT. SEVERAL SECONDS LATER, THE LAUNCH SEQUENCE WAS REINITIATED BY THE OSC TEST CONDUCTOR, AND THE MISSILE SEPARATED UNEVENTFULLY FROM ITS…
Requested Action: THE NTSB RECOMMENDS THAT THE DEPARTMENT OF TRANSPORTATION: REQUIRE THAT, AS A CONDITION FOR LICENSE FOR COMMERCIAL SPACE LAUNCHES, AS A MINIMUM, THE COMPANY APPLYING FOR THE LICENSE INCLUDE IN ITS LICENSE APPLICATION: A PROVISION FOR MANDATORY REST PERIODS BEFORE THE LAUNCH FOR KEY PARTICIPANTS THAT PROVIDE FOR AN ADEQUATE AND SPECIFIED TIME PERIOD FOR UNINTERRUPTED SLEEP. THE QUANTITATIVE CRITERIA FOR SUCH REST PERIODS SHOULD BE DEVELOPED BY…
Response Status: Closed - Acceptable Alternate Action
Recipient: DOT
Aug 17, 1993
From the Document
ON FEBRUARY 9, 1993, ABOUT 0930 EASTERN STANDARD TIME, THE LAUNCH SEQUENCE FOR AN ORBITAL SCIENCES CORPORATION (OSC) PEGASUS EXPENDABLE LAUNCH VEHICLE (ELV) WAS ABORTED BY THE NATIONAL AERONAUTICS AND SPACE ADMINISTRATION (NASA) RANGE SAFETY OFFICERS, IN ACCORDANCE WITH A PREVIOUSLY ESTABLISHED LAUNCH CONSTRAINT. SEVERAL SECONDS LATER, THE LAUNCH SEQUENCE WAS REINITIATED BY THE OSC TEST CONDUCTOR, AND THE MISSILE SEPARATED UNEVENTFULLY FROM ITS…
Requested Action: THE NTSB RECOMMENDS THAT THE DEPARTMENT OF TRANSPORTATION: REQUIRE THAT, AS A CONDITION FOR LICENSE FOR COMMERICAL SPACE LAUNCHES, AS A MINIMUM, THE COMPANY APPLYING FOR THE LICENSE INCLUDE IN ITS LICENSE APPLICATION A COMMUNICATIONS PLAN FOR: A PROVISION THAT INTERPHONE OR OTHER COMMUNICATION ASSIGNMENTS BE APPORTIONED TO ALLOW DECISION MAKERS FROM EACH PARTY DIRECT ACCESS TO THE DECISION MAKERS OF OTHER PARTIES AND THAT PROPER RADIO-TELEPHONE…
Study Focus: Review communication and coordination procedures.
Response Status: Closed - Acceptable Action
Recipient: DOT
Aug 17, 1993
From the Document
ON FEBRUARY 9, 1993, ABOUT 0930 EASTERN STANDARD TIME, THE LAUNCH SEQUENCE FOR AN ORBITAL SCIENCES CORPORATION (OSC) PEGASUS EXPENDABLE LAUNCH VEHICLE (ELV) WAS ABORTED BY THE NATIONAL AERONAUTICS AND SPACE ADMINISTRATION (NASA) RANGE SAFETY OFFICERS, IN ACCORDANCE WITH A PREVIOUSLY ESTABLISHED LAUNCH CONSTRAINT. SEVERAL SECONDS LATER, THE LAUNCH SEQUENCE WAS REINITIATED BY THE OSC TEST CONDUCTOR, AND THE MISSILE SEPARATED UNEVENTFULLY FROM ITS…
Requested Action: THE NTSB RECOMMENDS THAT THE DEPARTMENT OF TRANSPORTATION: REQUIRE THAT, AS A CONDITION FOR LICENSE FOR COMMERCIAL SPACE LAUNCHES, AS A MINIMUM, THE COMPANY APPLYING FOR THE LICENSE INCLUDE IN ITS LICENSE APPLICATION: A PLAN FOR APPROVAL OF A SAFETY DIRECTIVE OR SAFETY NOTEBOOK FOR THE LAUNCH TO EMPHASIZE THE SAFETY ASPECTS OF THE LAUNCH OPERATION AND TO CLEARLY LIST AND CONSOLIDATE MISSION CONSTRAINTS, RULES AND SPECIAL LAUNCH RULES, AS WELL AS…
Response Status: Closed - Acceptable Action
Recipient: DOT
Aug 17, 1993
From the Document
ON FEBRUARY 9, 1993, ABOUT 0930 EASTERN STANDARD TIME, THE LAUNCH SEQUENCE FOR AN ORBITAL SCIENCES CORPORATION (OSC) PEGASUS EXPENDABLE LAUNCH VEHICLE (ELV) WAS ABORTED BY THE NATIONAL AERONAUTICS AND SPACE ADMINISTRATION (NASA) RANGE SAFETY OFFICERS, IN ACCORDANCE WITH A PREVIOUSLY ESTABLISHED LAUNCH CONSTRAINT. SEVERAL SECONDS LATER, THE LAUNCH SEQUENCE WAS REINITIATED BY THE OSC TEST CONDUCTOR, AND THE MISSILE SEPARATED UNEVENTFULLY FROM ITS…
Requested Action: THE NTSB RECOMMENDS THAT THE DEPARTMENT OF TRANSPORTATION: REQUIRE THAT, AS A CONDITION FOR LICENSE FOR COMMERCIAL SPACE LAUNCHES, AS A MINIMUM, THE COMPANY APPLYING FOR THE LICENSE INCLUDE IN ITS LICENSE APPLICATION: FOR LAUNCHES FROM REMOTE SITES OR AIRCRAFT, A PLAN TO ASSURE THAT ESSENTIAL COMMUNICATIONS INTERRUPTIONS RESULTING FROM ANTENNA PATTERNS ARE IMPROBABLE. PRACTICAL CONSIDERATIONS SHOULD BE GIVEN FOR TOLERABLE INTERRUPTIONS THAT MAY…
Response Status: Closed--No Longer Applicable
Recipient: DOT
Aug 17, 1993
From the Document
ON FEBRUARY 9, 1993, ABOUT 0930 EASTERN STANDARD TIME, THE LAUNCH SEQUENCE FOR AN ORBITAL SCIENCES CORPORATION (OSC) PEGASUS EXPENDABLE LAUNCH VEHICLE (ELV) WAS ABORTED BY THE NATIONAL AERONAUTICS AND SPACE ADMINISTRATION (NASA) RANGE SAFETY OFFICERS, IN ACCORDANCE WITH A PREVIOUSLY ESTABLISHED LAUNCH CONSTRAINT. SEVERAL SECONDS LATER, THE LAUNCH SEQUENCE WAS REINITIATED BY THE OSC TEST CONDUCTOR, AND THE MISSILE SEPARATED UNEVENTFULLY FROM ITS…
Requested Action: THE NTSB RECOMMENDS THAT THE NATIONAL AERONUTICS AND SPACE ADMINISTRATION: STUDY THE FEASIBILITY OF INSTALLING AT THE WALLOPS FLIGHT FACILITY INDICATOR LIGHTS ON COMMUNICATIONS CONSOLES THAT ILLUMINATE WHENEVER AN INTERCOM CHANNEL IS IN USE.
Response Status: Closed - Acceptable Action
Recipient: National Aeronautics and Space Administration
Aug 17, 1993
From the Document
ON FEBRUARY 9, 1993, ABOUT 0930 EASTERN STANDARD TIME, THE LAUNCH SEQUENCE FOR AN ORBITAL SCIENCES CORPORATION (OSC) PEGASUS EXPENDABLE LAUNCH VEHICLE (ELV) WAS ABORTED BY THE NATIONAL AERONAUTICS AND SPACE ADMINISTRATION (NASA) RANGE SAFETY OFFICERS, IN ACCORDANCE WITH A PREVIOUSLY ESTABLISHED LAUNCH CONSTRAINT. SEVERAL SECONDS LATER, THE LAUNCH SEQUENCE WAS REINITIATED BY THE OSC TEST CONDUCTOR, AND THE MISSILE SEPARATED UNEVENTFULLY FROM ITS…
Requested Action: THE NTSB RECOMMENDS THAT THE NATIONAL AERONAUTICS AND SPACE ADMINISTRATION: STUDY THE FEASIBILITY OF ALLOWING THE RANGE SAFETY OFFICER DIRECT RADIO ACCESS TO THE LAUNCH AIRPLANE FOR PEGASUS LAUNCHES.
Study Focus: Review communication and coordination procedures.
Response Status: Closed - Acceptable Action
Recipient: National Aeronautics and Space Administration
Aug 17, 1993
From the Document
ON FEBRUARY 9, 1993, ABOUT 0930 EASTERN STANDARD TIME, THE LAUNCH SEQUENCE FOR AN ORBITAL SCIENCES CORPORATION (OSC) PEGASUS EXPENDABLE LAUNCH VEHICLE (ELV) WAS ABORTED BY THE NATIONAL AERONAUTICS AND SPACE ADMINISTRATION (NASA) RANGE SAFETY OFFICERS, IN ACCORDANCE WITH A PREVIOUSLY ESTABLISHED LAUNCH CONSTRAINT. SEVERAL SECONDS LATER, THE LAUNCH SEQUENCE WAS REINITIATED BY THE OSC TEST CONDUCTOR, AND THE MISSILE SEPARATED UNEVENTFULLY FROM ITS…
Requested Action: THE NTSB RECOMMENDS THAT NATIONAL AERONAUTICS AND SPACE ADMINISTRATION: TEST THE OPERABILITY OF ALL RECORDING SYSTEMS PRIOR TO EACH LAUNCH FROM THE WALLOPS FLIGHT FACILITY.
Response Status: Closed - Acceptable Action
Recipient: National Aeronautics and Space Administration
Aug 17, 1993
From the Document
ON FEBRUARY 9, 1993, ABOUT 0930 EASTERN STANDARD TIME, THE LAUNCH SEQUENCE FOR AN ORBITAL SCIENCES CORPORATION (OSC) PEGASUS EXPENDABLE LAUNCH VEHICLE (ELV) WAS ABORTED BY THE NATIONAL AERONAUTICS AND SPACE ADMINISTRATION (NASA) RANGE SAFETY OFFICERS, IN ACCORDANCE WITH A PREVIOUSLY ESTABLISHED LAUNCH CONSTRAINT. SEVERAL SECONDS LATER, THE LAUNCH SEQUENCE WAS REINITIATED BY THE OSC TEST CONDUCTOR, AND THE MISSILE SEPARATED UNEVENTFULLY FROM ITS…
Requested Action: The NTSB recommends that the Orbital Sciences Corporation: Require, as part of ELV launch planning documentation: Clearly delineated statements of authority for all parties and key individuals involved in the launch, including individuals (or positions) authorized to abort the mission, hold the countdown, or resume the countdown, following a hold.
Response Status: Closed - Acceptable Action
Recipient: Orbital Sciences Corporation
Aug 17, 1993
From the Document
ON FEBRUARY 9, 1993, ABOUT 0930 EASTERN STANDARD TIME, THE LAUNCH SEQUENCE FOR AN ORBITAL SCIENCES CORPORATION (OSC) PEGASUS EXPENDABLE LAUNCH VEHICLE (ELV) WAS ABORTED BY THE NATIONAL AERONAUTICS AND SPACE ADMINISTRATION (NASA) RANGE SAFETY OFFICERS, IN ACCORDANCE WITH A PREVIOUSLY ESTABLISHED LAUNCH CONSTRAINT. SEVERAL SECONDS LATER, THE LAUNCH SEQUENCE WAS REINITIATED BY THE OSC TEST CONDUCTOR, AND THE MISSILE SEPARATED UNEVENTFULLY FROM ITS…
Requested Action: THE NTSB RECOMMENDS THAT THE ORBITAL SCIENCES CORPORATION: REQUIRE, AS PART OF ELV LAUNCH PLANNING DOCUMENTATION: SPECIFIC DETAILS AND CRITERIA FOR LAUNCH READINESS REVIEWS AND DRESS REHEARSALS.
Response Status: Closed - Acceptable Action
Recipient: Orbital Sciences Corporation
Aug 17, 1993
From the Document
ON FEBRUARY 9, 1993, ABOUT 0930 EASTERN STANDARD TIME, THE LAUNCH SEQUENCE FOR AN ORBITAL SCIENCES CORPORATION (OSC) PEGASUS EXPENDABLE LAUNCH VEHICLE (ELV) WAS ABORTED BY THE NATIONAL AERONAUTICS AND SPACE ADMINISTRATION (NASA) RANGE SAFETY OFFICERS, IN ACCORDANCE WITH A PREVIOUSLY ESTABLISHED LAUNCH CONSTRAINT. SEVERAL SECONDS LATER, THE LAUNCH SEQUENCE WAS REINITIATED BY THE OSC TEST CONDUCTOR, AND THE MISSILE SEPARATED UNEVENTFULLY FROM ITS…
Requested Action: THE NTSB RECOMMENDS THAT THE ORBITAL SCIENCES CORPORATION: REQUIRE, AS PART OF ELV LAUNCH PLANNING DOCUMENTATION: COMPREHENSIVE PREVIOUSLY REVIEWED, CHECKLISTS FOR THE LAUNCH, INCLUDING A PROVISION FOR ENSURING THE CURRENCY AND CONSISTENCY OF EACH PARTICIPANT'S CHECKLIST DURING THE DRESS REHEARSAL FOR THE LAUNCH.
Study Focus: Review qualification and recent-experience requirements.
Response Status: Closed - Acceptable Action
Recipient: Orbital Sciences Corporation
Aug 17, 1993
From the Document
ON FEBRUARY 9, 1993, ABOUT 0930 EASTERN STANDARD TIME, THE LAUNCH SEQUENCE FOR AN ORBITAL SCIENCES CORPORATION (OSC) PEGASUS EXPENDABLE LAUNCH VEHICLE (ELV) WAS ABORTED BY THE NATIONAL AERONAUTICS AND SPACE ADMINISTRATION (NASA) RANGE SAFETY OFFICERS, IN ACCORDANCE WITH A PREVIOUSLY ESTABLISHED LAUNCH CONSTRAINT. SEVERAL SECONDS LATER, THE LAUNCH SEQUENCE WAS REINITIATED BY THE OSC TEST CONDUCTOR, AND THE MISSILE SEPARATED UNEVENTFULLY FROM ITS…
Requested Action: THE NTBS RECOMMENDS THAT THE ORBITAL SCIENCES CORPORATION: REQUIRE, AS PART OF ELV LAUNCH PLANNING DOCUMENTATION: MANDATORY REST PERIODS BEFORE THE LAUNCH FOR KEY PARTICIPANTS THAT PROVIDE FOR AN ADEQUATE AND SPECIFIED TIME PERIOD FOR UNINTERRUPTED SLEEP. THE QUANTITATIVE CRITERIA FOR SUCH REST PERIODS SHOULD BE DEVELOPED BY APPROPRIATE HUMAN PERFORMANCE EXPERTS TO ENSURE APPLICABILITY TO THE ASSIGNED TASKS.
Response Status: Closed - Acceptable Action
Recipient: Orbital Sciences Corporation
Aug 17, 1993
From the Document
ON FEBRUARY 9, 1993, ABOUT 0930 EASTERN STANDARD TIME, THE LAUNCH SEQUENCE FOR AN ORBITAL SCIENCES CORPORATION (OSC) PEGASUS EXPENDABLE LAUNCH VEHICLE (ELV) WAS ABORTED BY THE NATIONAL AERONAUTICS AND SPACE ADMINISTRATION (NASA) RANGE SAFETY OFFICERS, IN ACCORDANCE WITH A PREVIOUSLY ESTABLISHED LAUNCH CONSTRAINT. SEVERAL SECONDS LATER, THE LAUNCH SEQUENCE WAS REINITIATED BY THE OSC TEST CONDUCTOR, AND THE MISSILE SEPARATED UNEVENTFULLY FROM ITS…
Requested Action: THE NTSB RECOMMENDS THAT THE ORBITAL SCIENCES CORPORATION: REQUIRE, AS PART OF ELV LAUNCH PLANNING DOCUMENTATION: A COMMUNICATIONS PLAN THAT WOULD INCLUDE, AT A MINIMUM: A PROVISION THAT INTERPHONE OR OTHER COMMUNICATION ASSIGNMENTS BE APPORTIONED TO ALLOW DECISION MAKERS FROM EACH PARTY DIRECT ACCESS TO THE DECISION MAKERS OF OTHER PARTIES AND THE PROPER RADIO-TELEPHONE COMMUNICATION PHRASEOLOGY ARE USED, AND A PROVISION THAT KEY PARTICIPANTS…
Study Focus: Review communication and coordination procedures.
Response Status: Closed - Acceptable Action
Recipient: Orbital Sciences Corporation
Aug 17, 1993
From the Document
ON FEBRUARY 9, 1993, ABOUT 0930 EASTERN STANDARD TIME, THE LAUNCH SEQUENCE FOR AN ORBITAL SCIENCES CORPORATION (OSC) PEGASUS EXPENDABLE LAUNCH VEHICLE (ELV) WAS ABORTED BY THE NATIONAL AERONAUTICS AND SPACE ADMINISTRATION (NASA) RANGE SAFETY OFFICERS, IN ACCORDANCE WITH A PREVIOUSLY ESTABLISHED LAUNCH CONSTRAINT. SEVERAL SECONDS LATER, THE LAUNCH SEQUENCE WAS REINITIATED BY THE OSC TEST CONDUCTOR, AND THE MISSILE SEPARATED UNEVENTFULLY FROM ITS…
Requested Action: THE NTSB RECOMMENDS THAT THE ORBITAL SCIENCES CORPORATION: REQUIRE, AS PART ELV LAUNCH PLANNING DOCUMENTATION: A SAFETY DIRECTIVE OR SAFETY NOTEBOOK FOR THE LAUNCH TO EMPHASIZE THE SAFETY ASPECTS OF THE LAUNCH OPERATION AND TO CLEARLY LIST AND CONSOLIDATE MISSION CONSTRAINTS, RULES, AND SPECIAL LAUNCH RULES, AS WELL AS ABORT PROCEDURES.
Response Status: Closed - Acceptable Action
Recipient: Orbital Sciences Corporation
Aug 17, 1993
From the Document
ON FEBRUARY 9, 1993, ABOUT 0930 EASTERN STANDARD TIME, THE LAUNCH SEQUENCE FOR AN ORBITAL SCIENCES CORPORATION (OSC) PEGASUS EXPENDABLE LAUNCH VEHICLE (ELV) WAS ABORTED BY THE NATIONAL AERONAUTICS AND SPACE ADMINISTRATION (NASA) RANGE SAFETY OFFICERS, IN ACCORDANCE WITH A PREVIOUSLY ESTABLISHED LAUNCH CONSTRAINT. SEVERAL SECONDS LATER, THE LAUNCH SEQUENCE WAS REINITIATED BY THE OSC TEST CONDUCTOR, AND THE MISSILE SEPARATED UNEVENTFULLY FROM ITS…
Requested Action: THE NTSB RECOMMENDS THAT THE ORBITAL SCIENCES CORPORATION: REQUIRE, AS PART OF ELV LAUNCH PLANNING DOCUMENTATION: FOR LAUNCHES FROM REMOTE SITES OR AIRCRAFT, A PLAN TO ASSURE THAT ESSENTIAL COMMUNICATIONS INTERRUPTIONS RESULTING FROM ANTENNA PATTERNS ARE IMPROBABLE. PRACTICAL CONSIDERATION SHOULD BE GIVEN FOR TOLERABLE INTERRUPTIONS THAT MAY BE ASSOCIATED WITH TRANSIENT CONDITIONS SUCH AS AIRCRAFT MANEUVERS.
Response Status: Closed - Acceptable Action
Recipient: Orbital Sciences Corporation
Aug 2, 1993
From the Document
ON MARCH 26, 1991, A BEECH F33A, N7224L, FELL THROUGH THE TAXIWAY PAVEMENT WHILE TAXIING AT PEACHTREE DEKALB AIRPORT IN CHAMBLEE, GEORGIA. THE PILOT STATED THAT AS HE WAS TAXIING TO THE RUNWAY, THE LEFT MAIN WHEEL FELL THROUGH THE PAVEMENT, AND THE AIRPLANE MADE A VIOLENT LEFT TURN AND CAME TO A STOP. AFTER EXITING THE AIRPLANE, THE PILOT SAID HE COULD SEE THAT THE PAVEMENT HAD GIVEN WAY AND THAT THE WHEEL HAD FALLEN THROUGH THE HOLE IN THE…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: INFORM AIRPORT OPERATORS OF THE CIRCUMSTANCES OF THIS ACCIDENT AND ALERT THEM OF THE POTENTIAL FOR EROSION NEAR UNDERGROUND PIPELINES, AND URGE THEM TO RESTRICT OPERATIONS ON ANY AREAS THAT ARE IDENTIFIED AS POTENTIALLY HAZARDOUS UNTIL THEY ARE REPAIRED.
Study Focus: Review surface awareness and decisions during taxi, takeoff and landing.
Response Status: Closed - Acceptable Action
Recipient: FAA
Aug 2, 1993
From the Document
ON MARCH 26, 1991, A BEECH F33A, N7224L, FELL THROUGH THE TAXIWAY PAVEMENT WHILE TAXIING AT PEACHTREE DEKALB AIRPORT IN CHAMBLEE, GEORGIA. THE PILOT STATED THAT AS HE WAS TAXIING TO THE RUNWAY, THE LEFT MAIN WHEEL FELL THROUGH THE PAVEMENT, AND THE AIRPLANE MADE A VIOLENT LEFT TURN AND CAME TO A STOP. AFTER EXITING THE AIRPLANE, THE PILOT SAID HE COULD SEE THAT THE PAVEMENT HAD GIVEN WAY AND THAT THE WHEEL HAD FALLEN THROUGH THE HOLE IN THE…
Requested Action: THE NTSB RECOMMENDS THAT THE AMERICAN ASSOCIATION OF AIRPORT EXECUTIVES: INFORM AIRPORT OPERATORS OF THE CIRCUMSTANCES OF THIS ACCIDENT AND ALERT THEM OF THE POTENTIAL FOR EROSION NEAR UNDERGROUND PIPELINES, AND URGE THEM TO RESTRICT OPERATIONS ON ANY AREAS THAT ARE IDENTIFIED AS POTENTIALLY HAZARDOUS UNTIL THEY ARE REPAIRED.
Study Focus: Review surface awareness and decisions during taxi, takeoff and landing.
Response Status: Closed - Acceptable Action
Recipient: American Association of Airport Executives
Aug 2, 1993
From the Document
ON MARCH 26, 1991, A BEECH F33A, N7224L, FELL THROUGH THE TAXIWAY PAVEMENT WHILE TAXIING AT PEACHTREE DEKALB AIRPORT IN CHAMBLEE, GEORGIA. THE PILOT STATED THAT AS HE WAS TAXIING TO THE RUNWAY, THE LEFT MAIN WHEEL FELL THROUGH THE PAVEMENT, AND THE AIRPLANE MADE A VIOLENT LEFT TURN AND CAME TO A STOP. AFTER EXITING THE AIRPLANE, THE PILOT SAID HE COULD SEE THAT THE PAVEMENT HAD GIVEN WAY AND THAT THE WHEEL HAD FALLEN THROUGH THE HOLE IN THE…
Requested Action: THE NTSB RECOMMENDS THAT THE AIRPORT COUNCIL INTERNATIONAL-NORTH AMERICA: INFORM AIRPORT OPERATORS OF THE CIRCUMSTANCES OF THIS ACCIDENT AND ALERT THEM OF THE POTENTIAL FOR EROSION NEAR UNDERGROUND PIPELINES, AND URGE THEM TO RESTRICT OPERATIONS ON ANY AREAS THAT ARE IDENTIFIED AS POTENTIALLY HAZARDOUS UNTIL THEY ARE REPAIRED.
Study Focus: Review surface awareness and decisions during taxi, takeoff and landing.
Response Status: Closed - Acceptable Action
Recipient: Airports Council International
Aug 12, 1992
From the Document
IN SEVERAL RECENT ACCIDENT INVESTIGATIONS, THE SAFETY BOARD FOUND THAT ALTHOUGH FLIGHT ATTENDANTS PROVIDED VALUABLE ASSISTANCE TO PASSENGERS DURING EMERGENCY SITUATIONS, THEY DID NOT ALWAYS FOLLOW THEIR AIR CARRIER'S APPROVED EMERGENCY PROCEDURES OR PERFORM THEIR DUTIES IN ACCORDANCE WITH TRAINING. THE SAFETY BOARD REVIEWED ITS INVESTIGATIONS OF ACCIDENTS AND INCIDENTS WHERE INFORMATION WAS AVAILABLE ON FLIGHT ATTENDANT PERFORMANCE DURING…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: ENSURE THAT FLIGHT ATTENDANT TRAINING PROGRAMS PROVIDE DETAILED GUIDANCE ON THE RELATIVE PROBABILITY OF HAZARDS ASSOCIATED WITH EMERGENCY SITUATIONS SUCH AS FIRE, TOXIC SMOKE, AND EXPLOSION.
Study Focus: Review preparation and response to abnormal or emergency situations.
Response Status: Closed - Acceptable Action
Recipient: FAA
Aug 12, 1992
From the Document
IN SEVERAL RECENT ACCIDENT INVESTIGATIONS, THE SAFETY BOARD FOUND THAT ALTHOUGH FLIGHT ATTENDANTS PROVIDED VALUABLE ASSISTANCE TO PASSENGERS DURING EMERGENCY SITUATIONS, THEY DID NOT ALWAYS FOLLOW THEIR AIR CARRIER'S APPROVED EMERGENCY PROCEDURES OR PERFORM THEIR DUTIES IN ACCORDANCE WITH TRAINING. THE SAFETY BOARD REVIEWED ITS INVESTIGATIONS OF ACCIDENTS AND INCIDENTS WHERE INFORMATION WAS AVAILABLE ON FLIGHT ATTENDANT PERFORMANCE DURING…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: UPDATE AND REISSUE ACOB 76-4 REGARDING THE OPERATIONAL CHARACTERISTICS OF CHEMICALLY GENERATED PASSENGER SUPPLEMENTAL OXYGEN SYSTEMS.
Study Focus: Review preparation and response to abnormal or emergency situations.
Response Status: Closed - Acceptable Action
Recipient: FAA
Dec 3, 1991
From the Document
ON FEBRUARY 1, 1991, AT 1807 PACIFIC STANDARD TIME, USAIR FLIGHT 1493 (USA1493), N388US, A BOEING 737-300 (B-737), COLLIDED WITH SKYWEST FLIGHT 5569(SKW5569), N683A, V, A FAIRCHILD METROLINER (SA-227-AC), WHILE USA1493 WAS LANDING ON RUNWAY 24 LEFT AT LOS ANGELES INTERNATIONAL AIRPORT (LAX), LOS ANGLES, CALIFORNIA. SKW5569 WAS POSITIONED ON THE SAME RUNWAY, AT INTERSECTION 45, AWAITING CLEARANCE FOR TAKEOFF. AS A RESULT OF THE COLLISION, BOTH…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: UNDERTAKE A THOROUGH RISK-BASED EVALUATION OF AIR TRAFFIC CONTROL PROCEDURES AT THE LOS ANGELES INTERNATIONAL AIRPORT, EVALUATE WHETHER CHANGES ARE REQUIRED, AND IMPLEMENT NECESSARY CHANGES. THE EVALUATION SHOULD CONSIDER AT LEAST THE FOLLOWING ISSUES: (A) RUNWAY INTERSECTION TAKEOFFS; (B) POSITION-AND-HOLD CLEARANCES; (C) DISPLACED RUNWAY THRESHOLDS; (D) HAZARDS ASSOCIATED WITH…
Study Focus: Review surface awareness and decisions during taxi, takeoff and landing.
Response Status: Closed - Acceptable Action
Recipient: FAA
Aug 14, 1991
From the Document
ON MARCH 17, 1991, AT 1618 ATLANTIC STANDARD TIME, DELTA AIR LINES FLIGHT 15, LOCKHEED L-1011-385-3, N753DA, WAS EN ROUTE FROM FRANKFURT, GERMANY TO ATLANTA, GEORGIA AT FLIGHT LEVEL (FL) 330 WHEN IT EXPERIENCED A FIRE BELOW THE AFT CABIN FLOOR AND IN THE CABIN. THE FLIGHT WAS CONDUCTED UNDER THE OPERATING RULES OF PART 121 OF TITLE 14 CODE OF FEDERAL REGULATIONS (CFR) AND CARRIED 218 PASSENGERS, 10 FLIGHT ATTENDANTS, 2 PILOTS, AND 1 FLIGHT…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: NOTIFY PRINCIPAL MAINTENANCE INSPECTORS AND OPERATORS OF TRANSPORT CATEGORY AIRCRAFT OF THE FIRE HAZARD POSED BY ACCUMULATIONS OF LINT AND OTHER DEBRIS ON WIRE BUNDLES.
Study Focus: Review maintenance and airworthiness responsibilities.
Response Status: Closed - Acceptable Action
Recipient: FAA
Jun 12, 1991
From the Document
ON JANUARY 18, 1990, AT 1904 EASTERN STANDARD TIME, EASTERN AIRLINES FLIGHT 111 (EA 111), N8867E, A BOEING 727-225A, COLLIDED WITH N44UE, AN EPPS AIR SERVICE BEECHCRAFT KING AIR A100, WHILE EA 111 WAS LANDING ON RUNWAY 26 RIGHT AT THE WILLIAM B. HARTSFIELD INTERNATIONAL AIRPORT, ATLANTA, GEORGIA, AND AS THE KING AIR A100 WAS PREPARING TO TURN OFF THE RUNWAY AFTER HAVING LANDED AHEAD OF EA 111. BOTH AIRPLANES WERE IN RADIO COMMUNICATION WITH THE…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Conduct research and development efforts to provide airports that are not scheduled to receive airport surface detection equipment (ASDE) with an alternate, cost effective, system to bring controller and pilot attention to pending runway incursions in time to prevent ground collisions. (Superseded by A-95-94)
Study Focus: Review surface awareness and decisions during taxi, takeoff and landing.
Response Status: Closed - Acceptable Action/Superseded
Recipient: FAA
Jun 12, 1991
From the Document
ON JANUARY 18, 1990, AT 1904 EASTERN STANDARD TIME, EASTERN AIRLINES FLIGHT 111 (EA 111), N8867E, A BOEING 727-225A, COLLIDED WITH N44UE, AN EPPS AIR SERVICE BEECHCRAFT KING AIR A100, WHILE EA 111 WAS LANDING ON RUNWAY 26 RIGHT AT THE WILLIAM B. HARTSFIELD INTERNATIONAL AIRPORT, ATLANTA, GEORGIA, AND AS THE KING AIR A100 WAS PREPARING TO TURN OFF THE RUNWAY AFTER HAVING LANDED AHEAD OF EA 111. BOTH AIRPLANES WERE IN RADIO COMMUNICATION WITH THE…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: INCORPORATE INTO THE TRAINING SYLLABUS AT THE FEDERAL AVIATION ADMINISTRATION'S ACADEMY AT OKLAHOMA CITY, OKLAHOMA, MATERIALS WHICH STRESS THE IMPORTANCE OF AND THE NEED FOR GIVING TRAFFIC INFORMATION WHEN ISSUING AN ANTICIPATED SEPARATION LANDING CLEARANCE. STRESS THAT THIS INFORMATION WILL ENHANCE PILOT AWARENESS AND VISUAL ACQUISITION OF PRECEDING TRAFFIC, THEREBY PROVIDING A…
Study Focus: Review surface awareness and decisions during taxi, takeoff and landing.
Response Status: Closed - Acceptable Action
Recipient: FAA
Jun 25, 1990
From the Document
ON OCTOBER 14,1989, ABOUT 1411 MOUNTAIN DAYLIGHT TIME, A FIRE ERUPTED ON N530DA, A BOEING 727-232 THAT HAD BEEN PARKED AT GATE C4 AT SALT LAKE CITY INTERNATIONAL AIRPORT (SLC), SALT LAKE CITY, UTAH. THE AIRPLANE HAD BEEN OPERATED UNDER TITLE 14 CODE OF FERDERA REGULATIONS (CFR) PART 121 AS DELTA AIR LINES FLIGHT 1558, A SCHEDULED INTERNATIONAL REVENUE PASSENGER FLIGHT FROM LOS ANGELES, CALIFORNIA, TO EDMONTON, ALBERTA, CANADA, WITH A STOP AT…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: PROHIBIT AIR CARRIERS FROM SERVICING OXYGEN SYSTEMS WHILE PASSENGERS ARE ON THE AIRCRAFT.
Response Status: Closed - Acceptable Alternate Action
Recipient: FAA
Jun 25, 1990
From the Document
ON OCTOBER 14,1989, ABOUT 1411 MOUNTAIN DAYLIGHT TIME, A FIRE ERUPTED ON N530DA, A BOEING 727-232 THAT HAD BEEN PARKED AT GATE C4 AT SALT LAKE CITY INTERNATIONAL AIRPORT (SLC), SALT LAKE CITY, UTAH. THE AIRPLANE HAD BEEN OPERATED UNDER TITLE 14 CODE OF FERDERA REGULATIONS (CFR) PART 121 AS DELTA AIR LINES FLIGHT 1558, A SCHEDULED INTERNATIONAL REVENUE PASSENGER FLIGHT FROM LOS ANGELES, CALIFORNIA, TO EDMONTON, ALBERTA, CANADA, WITH A STOP AT…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REVIEW AIRLINE MAINTENANCE-RELATED TREND-ANALYSIS PROGRAMS TO VERIFY THAT SUCH PROGRAMS CAN DETECT LEAKING OXYGEN SYSTEMS.
Study Focus: Review maintenance and airworthiness responsibilities.
Response Status: Closed - Acceptable Action
Recipient: FAA
Jun 25, 1990
From the Document
ON OCTOBER 14,1989, ABOUT 1411 MOUNTAIN DAYLIGHT TIME, A FIRE ERUPTED ON N530DA, A BOEING 727-232 THAT HAD BEEN PARKED AT GATE C4 AT SALT LAKE CITY INTERNATIONAL AIRPORT (SLC), SALT LAKE CITY, UTAH. THE AIRPLANE HAD BEEN OPERATED UNDER TITLE 14 CODE OF FERDERA REGULATIONS (CFR) PART 121 AS DELTA AIR LINES FLIGHT 1558, A SCHEDULED INTERNATIONAL REVENUE PASSENGER FLIGHT FROM LOS ANGELES, CALIFORNIA, TO EDMONTON, ALBERTA, CANADA, WITH A STOP AT…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REQUIRE AIR CARRIERS TO PERFORM A ONE-TIME INSPECTION OF THE OXYGEN SYSTEMS ON THEIR AIRPLANES AND PROMPTLY REPAIR ALL LEAKS.
Study Focus: Review maintenance and airworthiness responsibilities.
Response Status: Closed - Acceptable Alternate Action
Recipient: FAA
Nov 3, 1988
From the Document
ON NOVEMBER 15, 1987, CONTINENTAL AIRLINES, INC., FLIGHT 1713, A MCDONNELL DOUGLAS DC-9-14, N626TX, WAS OPERATING AS A REGULARLY SCHEDULED, PASSENGER-CARRYING FLIGHT BETWEEN DENVER, COLORADO, AND BOISE, IDAHO. THE AIRPLANE WAS CLEARED TO TAKE OFF FOLLOWING A DELAY OF APPROXIMATELY 27 MINUTES AFTER DEICING. THE TAKEOFF ROLL WAS UNEVENTFUL, BUT FOLLOWING A RAPID ROTATION, THE AIRPLANE CRASHED OFF THE RIGHT SIDE OF RUNWAY 35 LEFT. BOTH PILOTS, 1…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Require commercial operators to conduct substantive background checks of pilot applicants which include verification of personal flight records and examination of training, performance, and disciplinary records of previous employers and Federal Aviation Administration safety and enforcement records. (Superseded by A-90-141)
Study Focus: Review surface awareness and decisions during taxi, takeoff and landing.
Response Status: Closed - Unacceptable Action/Superseded
Recipient: FAA
Oct 24, 1988
From the Document
ON FEBRUARY 3, 1988, AMERICAN AIRLINES FLIGHT 132, A MCDONNELL DOUGLAS DC-9-83, DEPARTED DALLAS/FORT WORTH INTERNATIONAL AIRPORT, TEXAS, FOR NASHVILLE METROPOLITAN AIRPORT, TENNESSEE. IN ADDITION TO THE PASSENGER LUGGAGE IN THE MIDCARGO COMPARTMENT, FLIGHT 132 WAS LOADED WITH A 104 POUND FIBER DRUM OF TEXTILE TREATMENT CHEMICALS. UNDECLARED AND IMPROPERLY PACKAGED HAZARDOUS MATERIALS INSIDE THE FIBER DRUM INCLUDED 5 GALLONS OF HYDROGEN PEROXIDE…
Requested Action: THE NTSB RECOMMENDS THAT AMERICAN AIRLINES: REVISE PROCEDURES FOR ACCEPTING GENERAL FREIGHT PACKAGES FOR TRANSPORTATION TO INCLUDE QUESTIONS DEVELOPED TO AID IN IDENTIFYING HAZARDOUS MATERIALS IN PACKAGES THAT ARE NOT DECLARED BY SHIPPERS.
Response Status: Closed - Acceptable Action
Recipient: American Airlines, Inc.
Oct 24, 1988
From the Document
ON FEBRUARY 3, 1988, AMERICAN AIRLINES FLIGHT 132, A MCDONNELL DOUGLAS DC-9-83, DEPARTED DALLAS/FORT WORTH INTERNATIONAL AIRPORT, TEXAS, FOR NASHVILLE METROPOLITAN AIRPORT, TENNESSEE. IN ADDITION TO THE PASSENGER LUGGAGE IN THE MIDCARGO COMPARTMENT, FLIGHT 132 WAS LOADED WITH A 104 POUND FIBER DRUM OF TEXTILE TREATMENT CHEMICALS. UNDECLARED AND IMPROPERLY PACKAGED HAZARDOUS MATERIALS INSIDE THE FIBER DRUM INCLUDED 5 GALLONS OF HYDROGEN PEROXIDE…
Requested Action: THE NTSB RECOMMENDS THAT AMERICAN AIRLINES: IMPROVE THE DESIGN, CONTENT, AND POSTED LOCATION OF HAZARDOUS MATERIALS RESTRICTION NOTICES TO ATTRACT THE ATTENTION OF PASSENGERS AND SHIPPERS AND TO INCREASE THE EFFECTIVENESS OF THE WARNING NOTICE.
Response Status: Closed - Acceptable Action
Recipient: American Airlines, Inc.
Oct 24, 1988
From the Document
ON FEBRUARY 3, 1988, AMERICAN AIRLINES FLIGHT 132, A MCDONNELL DOUGLAS DC-9-83, DEPARTED DALLAS/FORT WORTH INTERNATIONAL AIRPORT, TEXAS, FOR NASHVILLE METROPOLITAN AIRPORT, TENNESSEE. IN ADDITION TO THE PASSENGER LUGGAGE IN THE MIDCARGO COMPARTMENT, FLIGHT 132 WAS LOADED WITH A 104 POUND FIBER DRUM OF TEXTILE TREATMENT CHEMICALS. UNDECLARED AND IMPROPERLY PACKAGED HAZARDOUS MATERIALS INSIDE THE FIBER DRUM INCLUDED 5 GALLONS OF HYDROGEN PEROXIDE…
Requested Action: THE NTSB RECOMMENDS THAT THE RESEARCH AND SPECIAL PROGRAMS ADMINISTRATION: REQUIRE HAZARDOUS MATERIALS RESTRICTION NOTICES TO BE POSTED AT ALL AIR TRANSPORTATION FREIGHT ACCEPTANCE FACILITIES INCLUDING AIR FREIGHT FORWARDER FACILITIES.
Response Status: Closed - Acceptable Action
Recipient: RSPA
Oct 24, 1988
From the Document
ON FEBRUARY 3, 1988, AMERICAN AIRLINES FLIGHT 132, A MCDONNELL DOUGLAS DC-9-83, DEPARTED DALLAS/FORT WORTH INTERNATIONAL AIRPORT, TEXAS, FOR NASHVILLE METROPOLITAN AIRPORT, TENNESSEE. IN ADDITION TO THE PASSENGER LUGGAGE IN THE MIDCARGO COMPARTMENT, FLIGHT 132 WAS LOADED WITH A 104 POUND FIBER DRUM OF TEXTILE TREATMENT CHEMICALS. UNDECLARED AND IMPROPERLY PACKAGED HAZARDOUS MATERIALS INSIDE THE FIBER DRUM INCLUDED 5 GALLONS OF HYDROGEN PEROXIDE…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: DEVELOP WRITTEN GUIDELINES FOR USE BY PERSONS RESPONSIBLE FOR INSPECTING AIR CARRIER FACILITIES, REQUIRE THOSE PERSONS TO DETERMINE IF HAZARDOUS MATERIALS WARNING NOTICES ARE "PROMINENTLY DISPLAYED" IN ALL REQUIRED LOCATIONS, AND REQUIRE CORRECTIVE ACTIONS AS NECESSARY.
Response Status: Closed - Acceptable Action
Recipient: FAA
Oct 24, 1988
From the Document
ON FEBRUARY 3, 1988, AMERICAN AIRLINES FLIGHT 132, A MCDONNELL DOUGLAS DC-9-83, DEPARTED DALLAS/FORT WORTH INTERNATIONAL AIRPORT, TEXAS, FOR NASHVILLE METROPOLITAN AIRPORT, TENNESSEE. IN ADDITION TO THE PASSENGER LUGGAGE IN THE MIDCARGO COMPARTMENT, FLIGHT 132 WAS LOADED WITH A 104 POUND FIBER DRUM OF TEXTILE TREATMENT CHEMICALS. UNDECLARED AND IMPROPERLY PACKAGED HAZARDOUS MATERIALS INSIDE THE FIBER DRUM INCLUDED 5 GALLONS OF HYDROGEN PEROXIDE…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: EVALUATE PROHIBITING THE TRANSPORTATION OF OXIDIZERS IN CARGO COMPARTMENTS THAT DO NOT HAVE FIRE/SMOKE DETECTION AND FIRE EXTINGUISHMENT SYSTEMS, AND DETERMINE IF OTHER CLASSES OF HAZARDOUS MATERIALS ALSO SHOULD BE EXCLUDED FROM CARGO COMPARTMENTS WITHOUT THESE SAFETY SYSTEMS.
Response Status: Closed - Acceptable Action
Recipient: FAA
Oct 24, 1988
From the Document
ON FEBRUARY 3, 1988, AMERICAN AIRLINES FLIGHT 132, A MCDONNELL DOUGLAS DC-9-83, DEPARTED DALLAS/FORT WORTH INTERNATIONAL AIRPORT, TEXAS, FOR NASHVILLE METROPOLITAN AIRPORT, TENNESSEE. IN ADDITION TO THE PASSENGER LUGGAGE IN THE MIDCARGO COMPARTMENT, FLIGHT 132 WAS LOADED WITH A 104 POUND FIBER DRUM OF TEXTILE TREATMENT CHEMICALS. UNDECLARED AND IMPROPERLY PACKAGED HAZARDOUS MATERIALS INSIDE THE FIBER DRUM INCLUDED 5 GALLONS OF HYDROGEN PEROXIDE…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: CONSIDER THE EFFECTS OF AUTHORIZED HAZARDOUS MATERIALS CARGO IN FIRES FOR ALL TYPES OF CARGO COMPARTMENTS, AND REQUIRE APPROPRIATE SAFETY SYSTEMS TO PROTECT THE AIRCRAFT AND OCCUPANTS.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Oct 24, 1988
From the Document
ON FEBRUARY 3, 1988, AMERICAN AIRLINES FLIGHT 132, A MCDONNELL DOUGLAS DC-9-83, DEPARTED DALLAS/FORT WORTH INTERNATIONAL AIRPORT, TEXAS, FOR NASHVILLE METROPOLITAN AIRPORT, TENNESSEE. IN ADDITION TO THE PASSENGER LUGGAGE IN THE MIDCARGO COMPARTMENT, FLIGHT 132 WAS LOADED WITH A 104 POUND FIBER DRUM OF TEXTILE TREATMENT CHEMICALS. UNDECLARED AND IMPROPERLY PACKAGED HAZARDOUS MATERIALS INSIDE THE FIBER DRUM INCLUDED 5 GALLONS OF HYDROGEN PEROXIDE…
Requested Action: THE NTSB RECOMMENDS THAT THE AIR TRANSPORT ASSOCIATION: DEVELOP, IN COORDINATION WITH MEMBERS, A PROGRAM TO MORE EFFECTIVELY INFORM AND WARN PASSENGERS AND SHIPPERS ABOUT RESTRICTIONS AND SAFETY REQUIREMENTS FOR HAZARDOUS MATERIALS AND TO IMPROVE METHODS OF DETECTING UNDECLARED HAZARDOUS MATERIALS OFFERED FOR AIR TRANSPORTATION.
Response Status: Closed - Acceptable Action
Recipient: Airlines for America (formerly Air Transport Association of America, Inc.)
Aug 8, 1988
From the Document
THE NATIONAL TRANSPORTATION SAFETY BOARD BELIEVES THAT RUNWAY INCURSIONS AND NEAR-MIDAIR COLLISIONS, WITH THEIR ASSOCIATED POTENTIAL FOR A CATASTROPHIC COLLISION, REPRESENT TWO OF THE MOST SERIOUS PROBLEMS INVOLVING THE SAFETY OF COMMERCIAL AVIATION OPERATIONS IN THE UNITED STATES TODAY. IN THE PAST 2 YEARS AND TO DATE DURING 1988, THERE HAS BEEN A SIGNIFICANT NUMBER OF AIR TRAFFIC CONTROLLER OPERATIONAL ERRORS AT THE CHICAGO O'HARE…
Requested Action: TO THE FEDERAL AVIATION ADMINISTRATION: Establish an independent national division that would be responsible for the quality assurance of the air traffic control system and that would report directly to the administrator of the Federal Aviation Administration. (Superseded by A-89-41 and A-89-90)
Study Focus: Review surface awareness and decisions during taxi, takeoff and landing.
Response Status: Closed - Superseded
Recipient: FAA
Nov 27, 1985
From the Document
THE NTSB IS CONTINUING TO PARTICIPATE IN THE INVESTIGATION OF THE CIRCUMSTANCES OF THE IN-FLIGHT FIRE WHICH WAS DETECTED ONBOARD A ROYAL JORDANIAN AIRLINES LOCKHEED L-1011 AIRPLANE WHILE THE AIRPLANE WAS DESCENDING TO LAND AT SINGAPORE ON OCTOBER 18, 1985. THE EXAMINATION OF THE AIRPLANE WAS CONDUCTED IN SINGAPORE BY AN INVESTIGATION TEAM THAT INCLUDED REPRESENTATIVES OF THE SAFETY BOARD. THE PRELIMINARY INVESTIGATION DISCLOSED THAT THE FIRE…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REQUIRE THAT A REVISED FUNCTIONAL TEST BE PREPARED AND ISSUE AN AIRWORTHINESS DIRECTIVE TO IMMEDIATELY EVALUATE THE CONDITION OF ALL COMPONENTS OF THE PASSENGER OXYGEN SYSTEM ON LOCKHEED L-1011 AIRCRAFT TO ENSURE OPERATION BOTH DURING AUTOMATIC ACTIVATION AND WHEN ACTIVATED FROM THE FLIGHT ENGINEER'S STATION. (URGENT)
Study Focus: Review maintenance and airworthiness responsibilities.
Response Status: Closed - Acceptable Action
Recipient: FAA
Nov 27, 1985
From the Document
THE NTSB IS CONTINUING TO PARTICIPATE IN THE INVESTIGATION OF THE CIRCUMSTANCES OF THE IN-FLIGHT FIRE WHICH WAS DETECTED ONBOARD A ROYAL JORDANIAN AIRLINES LOCKHEED L-1011 AIRPLANE WHILE THE AIRPLANE WAS DESCENDING TO LAND AT SINGAPORE ON OCTOBER 18, 1985. THE EXAMINATION OF THE AIRPLANE WAS CONDUCTED IN SINGAPORE BY AN INVESTIGATION TEAM THAT INCLUDED REPRESENTATIVES OF THE SAFETY BOARD. THE PRELIMINARY INVESTIGATION DISCLOSED THAT THE FIRE…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REVIEW THE DESIGN OF THE LOCKHEED L-1011 PASSENGER OXYGEN SYSTEM, AND REQUIRE CHANGES AS NEEDED SO THAT THERE IS NO POTENTIAL FOR FAULTS WHICH CAN DISABLE THE SYSTEM AND REMAIN UNDETECTED.
Response Status: Closed - Acceptable Action
Recipient: FAA
Apr 15, 1985
From the Document
ON AUGUST 2, 1984, A BRITTEN-NORMAN BN-2A6 AIRPLANE OPERATED BY VIEQUES AIR LINK (VAL) CRASHED INTO THE SEA NEAR THE VIEQUES AIRPORT, PUERTO RICO. THE AIRPLANE, WITH A PILOT AND EIGHT PASSENGERS ONBOARD, HAD JUST TAKEN OFF FROM THE VIEQUES AIRPORT WHEN, AT AN ALTITUDE OF ABOUT 200 FEET, IT TURNED BACK TO THE AIRPORT, LOST ALITUDE, AND CRASHED INTO THE WATER. THE AIRPLANE CAME TO REST IN ABOUT 20 FEET OF WATER, AND ALL PERSONS ONBOARD WERE KILLED.
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: ISSUE A TELEGRAPHIC ALERT TO SUPPLIERS AND OWNERS OF THE EASTERN AERO MARINE MODEL GA-12 FLOTATION DEVICES THAT THESE DEVICES MAY BE MISLABELED, THAT THE CO2 CYLINDERS MAY BE LOOSE, AND THAT THEY MAY NOT COMPLY WITH TSO-C72B BUOYANCY AND PRESSURE TEST CRITERIA; AND ADVISE SUPPLIERS AND OWNERS TO HAVE THESE DEVICES OVERHAULED IN ACCORDANCE WITH EASTERN AERO MARINE'S INSPECTION,…
Study Focus: Review maintenance and airworthiness responsibilities.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Jan 8, 1985
From the Document
ON DECEMBER 6, 1984, A PROVINCETOWN-BOSTON AIRLINES, INC., EMBRAER BANDEIRANTE (EMB-110), N96PB, OPERATING AS FLIGHT 1039, CRASHED SHORTLY AFTER TAKEOFF FROM THE JACKSONVILLE INTERNATIONAL AIRPORT, JACKSONVILLE, FLORIDA. ALL 13 PERSONS ON BOARD WERE KILLED, AND THE AIRPLANE WAS DESTROYED. THE NATIONAL TRANSPORTATION SAFETY BOARD'S CONTINUING INVESTIGATION HAS DISCLOSED THAT THE AIRPLANE'S ELEVATORS AND HORIZONTAL STABILIZER SEPARATED IN FLIGHT,…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: CONDUCT A DIRECTED SAFETY INVESTIGATION OF EMB-110P1 AND -110P2 MODEL AIRPLANES THAT HAVE BEEN MODIFIED IN ACCORDANCE WITH THE PROVISIONS OF AD 83-14-09, (AMENDMENT 39-4527, PARAGRAPH (D) OR (E)), TO DETERMINE WHETHER ANY STRUCTURAL DAMAGE HAS BEEN INFLICTED IN THE AREA WHERE THE HORIZONTAL STABILIZER ATTACHES TO BULKHEAD 33 AND TAKE THE CORRECTIVE ACTION INDICATED BY THE RESULTS OF…
Response Status: Closed - Acceptable Alternate Action
Recipient: FAA
Oct 31, 1983
From the Document
THE NATIONAL TRANSPORTATION SAFETY BOARD IS CONTINUING ITS INVESTIGATION OF THE ACCIDENT INVOLVING AIR CANADA FLIGHT 797 WHICH OCCURRED ON JUNE 2, 1983, WHEN THE FLIGHTCREW OF THE MCDONNELL DOUGLAS DC-9 AIRPLANE WAS FORCED TO MAKE AN EMERGENCY LANDING AT THE GREATER CINCINNATI AIRPORT BECAUSE OF AN IN-FLIGHT FIRE. THE INTERIOR MATERIALS OF THE AIRPLANE'S CABIN CONTINUED TO BURN AFTER THE LANDING. FIVE CREWMEMBERS AND 18 PASSENGERS WERE ABLE TO…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: EXPEDITE THE RESEARCH AT THE CIVIL AERO MEDICAL INSTITUTE NECESSARY TO DEVELOP THE TECHNOLOGY, EQUIPMENT STANDARDS, AND PROCEDURES TO PROVIDE PASSENGERS WITH RESPIRATORY PROTECTION FROM TOXIC ATMOSPHERES DURING IN-FLIGHT EMERGENCIES ABOARD TRANSPORT CATEGORY AIRPLANES. (Supersedes Safety Recommendations A-73-068, A-73-070, and A-74-005)
Study Focus: Review preparation and response to abnormal or emergency situations.
Response Status: Closed - Acceptable Action
Recipient: FAA
Oct 31, 1983
From the Document
THE NATIONAL TRANSPORTATION SAFETY BOARD IS CONTINUING ITS INVESTIGATION OF THE ACCIDENT INVOLVING AIR CANADA FLIGHT 797 WHICH OCCURRED ON JUNE 2, 1983, WHEN THE FLIGHTCREW OF THE MCDONNELL DOUGLAS DC-9 AIRPLANE WAS FORCED TO MAKE AN EMERGENCY LANDING AT THE GREATER CINCINNATI AIRPORT BECAUSE OF AN IN-FLIGHT FIRE. THE INTERIOR MATERIALS OF THE AIRPLANE'S CABIN CONTINUED TO BURN AFTER THE LANDING. FIVE CREWMEMBERS AND 18 PASSENGERS WERE ABLE TO…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: EVALUATE AND CHANGE AS NECESSARY THE PROCEDURES CONTAINED IN THE FAA-APPROVED AIRPLANE FLIGHT MANUALS (AFM) OF TRANSPORT CATEGORY AIRPLANES RELATING TO THE CONTROL AND REMOVAL OF SMOKE TO ASSURE THAT THESE PROCEDURES ADDRESS A CONTINUING SMOKE SOURCE AND ARE EXPLICIT WITH REGARD TO THE PRESENCE OF FIRE AND THE OPTIMUM USE OF CABIN PRESSURIZATION AND AIR CONDITIONING SYSTEMS.…
Study Focus: Review preparation and response to abnormal or emergency situations.
Response Status: Closed - Acceptable Action
Recipient: FAA
Oct 31, 1983
From the Document
THE NATIONAL TRANSPORTATION SAFETY BOARD IS CONTINUING ITS INVESTIGATION OF THE ACCIDENT INVOLVING AIR CANADA FLIGHT 797 WHICH OCCURRED ON JUNE 2, 1983, WHEN THE FLIGHTCREW OF THE MCDONNELL DOUGLAS DC-9 AIRPLANE WAS FORCED TO MAKE AN EMERGENCY LANDING AT THE GREATER CINCINNATI AIRPORT BECAUSE OF AN IN-FLIGHT FIRE. THE INTERIOR MATERIALS OF THE AIRPLANE'S CABIN CONTINUED TO BURN AFTER THE LANDING. FIVE CREWMEMBERS AND 18 PASSENGERS WERE ABLE TO…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REQUIRE THE INSTALLATION OF TACTILE AISLE MARKERS ON OVERHEAD STOWAGE BINS AND CABIN FLOORS OR SEATS OF ALL TRANSPORT CATEGORY AIRCRAFT WHICH WILL HELP PASSENGERS TO FIND THEIR WAY TO EMERGENCY EXITS IN EVACUATIONS WHEN VISIBILITY IN THE CABIN IS RESTRICTED OR WHEN THE CABIN ATMOSPHERE IS TOXIC, REQUIRING THE PASSENGERS TO REMAIN CLOSE TO THE FLOOR. (Supersedes Safety Recommendations…
Study Focus: Review preparation and response to abnormal or emergency situations.
Response Status: Closed - Acceptable Alternate Action
Recipient: FAA
May 19, 1983
From the Document
THE NATIONAL TRANSPORTATION SAFETY BOARD HAS COMPLETED ITS FOLLOWUP INVESTIGATION OF THE NATION'S AIR TRAFFIC CONTROL (ATC) SYSTEM. THE INVESTIGATION, WHICH WAS INITIATED ON SEPTEMBER 20, 1982, EXAMINED THE OPERATION OF THE ATC SYSTEM FROM AUGUST 3, 1981, TO DECEMBER 31, 1982. THE INVESTIGATION INCLUDED THE SURVEY OF 51 ATC FACILITIES, DURING WHICH ABOUT 350 CONTROLLERS AND OTHER ATC FACILITY STAFF AND MANAGERS WERE INTERVIEWED. THE BOARD'S…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: INSTITUTE AIR TRAFFIC CONTROL DIRECTIVES AND PROCEDURES TO REQUIRE, WHEN THE ASSIGNED FIRST-LINE SUPERVISOR IS OCCUPIED WORKING A CONTROL POSITION, THAT THERE IS APPROPRIATE AND ADEQUATE DIRECT SUPERVISION TO ENSURE THE DETECTION AND REPORTING OF ALL CONTROLLER ERRORS OR DEVIATIONS, THE DETECTION AND MONITORING OF FATIGUE AND/OR STRESS, AND THE CONTROL OF EACH CONTROLLER'S WORKLOAD.…
Study Focus: Review the human factors that influence safe decisions.
Response Status: Closed - Unacceptable Action
Recipient: FAA
Jul 13, 1982
From the Document
ON FEBRUARY 21, 1982, A PILGRIM AIRLINES DHC-6-100, N127PM, OPERATING AS FLIGHT 458 BETWEEN GROTON, CONNECTICUT, AND BOSTON, MASSACHUSETTS, WAS FORCED TO MAKE AN EMERGENCY DESCENT FROM CRUISING ALTITUDE BECAUSE OF AN IN-FLIGHT FIRE IN THE COCKPIT AND FORWARD CABIN AREAS. THE AIRCRAFT, WITH 10 PASSENGERS AND 2 CREWMEMBERS ON BOARD, CRASHLANDED ON THE FROZEN SURFACE OF THE SCITUATE RESERVOIR NEAR PROVIDENCE, RHODE ISLAND, THE FIRE CONTINUED TO…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: ISSUE AN AIRWORTHINESS DIRECTIVE TO REQUIRE A REDESIGN AND MODIFICATION OF ISOPROPYL ALCOHOL WINDSHIELD DEICING SYSTEMS INSTALLED ON DHC-6 AIRCRAFT TO ELIMINATE THE POTENTIAL FOR ALCOHOL LEAKAGE OR, IF PRACTICABLE, TO REQUIRE REPLACEMENT OF THESE SYSTEMS WITH THE ELECTRICALLY HEATED WINDSHIELDS OFFERED BY THE MANUFACTURER AS AN ALTERNATIVE INSTALLATION.
Study Focus: Review maintenance and airworthiness responsibilities.
Response Status: Closed - Acceptable Action
Recipient: FAA
Jul 13, 1982
From the Document
ON FEBRUARY 21, 1982, A PILGRIM AIRLINES DHC-6-100, N127PM, OPERATING AS FLIGHT 458 BETWEEN GROTON, CONNECTICUT, AND BOSTON, MASSACHUSETTS, WAS FORCED TO MAKE AN EMERGENCY DESCENT FROM CRUISING ALTITUDE BECAUSE OF AN IN-FLIGHT FIRE IN THE COCKPIT AND FORWARD CABIN AREAS. THE AIRCRAFT, WITH 10 PASSENGERS AND 2 CREWMEMBERS ON BOARD, CRASHLANDED ON THE FROZEN SURFACE OF THE SCITUATE RESERVOIR NEAR PROVIDENCE, RHODE ISLAND, THE FIRE CONTINUED TO…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REVIEW AND EVALUATE THE DESIGN OF ALL ISOPROPYL ALCOHOL WINDSHIELD DEICING SYSTEM INSTALLATIONS ON AIRCRAFT TO VERIFY COMPLIANCE WITH APPLICABLE FEDERAL AVIATION REGULATIONS PERTAINING TO FLAMMABLE FLUID FIRE PROTECTION, AND TAKE ACTION TO CORRECT ANY DEFICIENCIES FOUND.
Study Focus: Review preparation and response to abnormal or emergency situations.
Response Status: Closed - Acceptable Action
Recipient: FAA
May 28, 1980
From the Document
ON JULY 13, 1979, WARD AIR, JUNEAU, ALASKA, DISPATCHED A FLOAT-EQUIPPED BEECH C-18S AIRCRAFT ON A FLIGHT FROM JUNEAU TO DRAKE ISLAND, ALASKA, AND RETURN. FLIGHT TO DRAKE ISLAND, WAS UNEVENTFUL. THE AIRCRAFT HAD DEPARTED DRAKE ISLAND WHEN FIRE APPEARED BEHIND THE COPILOT SEAT. THE PILOT AND ONE PASSENGER USED A HANDHELD PORTABLE FIRE EXTINGUISHER TO PUT OUT THE FIRE. THE SAFETY BOARD'S INVESTIGATION DISCLOSED THAT A PRESSURIZED AEROSOL CAN OF…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: PUBLISH THE CIRCUMSTANCES OF THIS INCIDENT IN THE MAINTENANCE NOTES SECTION OF THE GENERAL AVIATION AIRWORTHINESS ALERTS, STRESSING THE FACT THAT PILOTS AND MAINTENANCE PERSONNEL SHARE A RESPONSIBILITY TO INSURE THERE ARE NO UNCOVERED OR UNPROTECTED ELECTRICAL TERMINAL STUDS EXPOSED IN AIRCRAFT. THE MAINTENANCE NOTE SHOULD ALSO REMIND PILOTS OF THE DANGER INVOLVED WHEN CARRYING…
Study Focus: Review aircraft-system operation, limitations and failure awareness.
Response Status: Closed - Acceptable Action
Recipient: FAA
Apr 4, 1980
From the Document
THE NTSB HAS LEARNED OF AN INCIDENT WHICH OCCURRED JANUARY 1, 1980, WHEREIN A FUEL LEAK WAS DISCOVERED IN THE TAILCONE SERVICE AREA OF A LEARJET-36 DURING A POSTFLIGHT INSPECTION. THE LEAK WAS TRACED TO THE LEFT MOTIVE FLOW VALVE (PN AV16E1182) (SNH46478) WHICH IS LOCATED IN THE TAILCONE SERVICE AREA WHERE THE BATTERIES AND OTHER ELECTRICAL COMPONENTS ARE POSITIONED. THE VALVE HAD OPERATED ABOUT 1,663 HOURS. IT WAS REPORTED THAT, WHEN THE VALVE…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: EXPEDITE THE DEVELOPMENT AND INSTALLATION OF A METHOD OF RESTRAINING AND VENTING OVERBOARD, FUEL AND FUEL VAPORS THAT MAY LEAK FROM THE MOTIVE FLOW VALVE DURING ITS NORMAL OPERATIONS.
Study Focus: Review aircraft-system operation, limitations and failure awareness.
Response Status: Closed - Acceptable Action
Recipient: FAA
Mar 14, 1980
From the Document
ON MARCH 8, 1980, A SWEARINGEN SA-226 AT, N720R, WITH A CREW OF TWO AND SIX PASSENGERS, EXPERIENCED A RAPID DECOMPRESSION AT 16,000 FEET WHEN MOST OF THE AFT CARGO COMPARTMENT DOOR SEPARATED IN FLIGHT. ABOUT 3/4 OF THE DOOR ALONG WITH INTERIOR FURNISHINGS, INCLUDING AN UNOCCUPIED PASSENGER SEAT, SEPARATED FROM THE AIRCRAFT. TWO PASSENGERS WERE INJURED SLIGHTLY DURING THE DECOMPRESSION AND THE EMPENNAGE WAS DAMAGED SLIGHTLY WHEN SOME OF THE…
Requested Action: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: ISSUE A TELEGRAPHIC AIRWORTHINESS DIRECTIVE REQUIRING AN IMMEDIATE INSPECTION OF THE DOOR LATCHING MECHANISM OF THE AFT CARGO DOORS ON ALL SWEARINGEN SA-226 AIRCRAFT TO ASSURE PROPER ADJUSTMENT AND STRUCTURAL INTEGRITY. (URGENT)
Study Focus: Review maintenance and airworthiness responsibilities.
Response Status: Closed - Acceptable Action
Recipient: FAA