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Safety Recommendation A-89-022
Details
Synopsis: ON FEBRUARY 8, 1989, INDEPENDENT AIR, INC., FLIGHT 1851, A BOEING 707-331B, N231T, WITH 3 FLIGHT CREWMEMBERS, 4 FLIGHT ATTENDANTS, AND 137 PASSENGERS ON BOARD, CRASHED WHILE ON DESCENT TO SANTA MARIA ISLAND ON THE AZORES, PORTUGAL. FLIGHT 1851 WAS A CHARTER FLIGHT, CONDUCTED UNDER THE PROVISIONS OF TITLE 14 CODE OF FEDERAL REGULATIONS (CFR) PART 121, OPERATING BETWEEN BERGAMMA, ITALY, AND THE DOMINICAN REPUBLIC, WITH A REFUELING STOP IN SANTA MARIA. ALL 144 PERSONS ON BOARD WERE KILLED, AND THE AIRPLANE WAS DESTROYED. ON FEBRUARY 19, 1989, FLYING TIGERS FLIGHT 066, A BOEING 747-200, N807FT, WITH THREE FLIGHT CREWMEMBERS AND ONE MECHANIC ABOARD, STUCK A HILL APPROXIMATELY 8 MILES SHORT OF RUNWAY 33 AT THE KUALA LUMPUR INTERNATIONAL AIRPORT, KUALA LUMPUR, MALAYSIA. FLIGHT 066 WAS A SCHEDULED CARGO FLIGHT, CONDUCTED UNDER THE PROVISIONS OF 14 CFR 121, OPERATING BETWEEN SINGAPORE AND HONG KONG, WITH A AN INTERMEDIATE STOP IN KUALA LUMPUR. ALL FOUR PERSONS ABOARD WERE KILLED, AND THE AIRPLANE WAS DESTROYED BY IMPACT FORCES AND THE POSTCRASH FIRE.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: ISSUE AN AIR CARRIER OPERATIONS BULLETIN REQUIRING PRINCIPAL OPERATIONS INSPECTORS ASSIGNED TO U.S. OPERATORS ENGAGED IN INTERNATIONAL FLIGHT OPERATIONS UNDER 14 CFR PART 121 TO EMPHASIZE TO THE OPERATORS THE UNIQUE CONDITIONS OF INSTRUMENT FLIGHT OPERATIONS AT FOREIGN AIRPORTS, AND THE NEED FOR INCREASED VIGILANCE BY FLIGHTCREWS WHEN CONDUCTING INSTRUMENT APPROACH AND DEPARTURE PROCEDURES AT FOREIGN AIRPORTS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Santa Maria Island, Portugal
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA89RA021
Accident Reports:
Report #: None
Accident Date: 2/8/1989
Issue Date: 4/26/1989
Date Closed: 12/11/1990
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 12/11/1990
Response: The Safety Board has reviewed ACOB 8-90-7 which was issued as a result of this safety recommendation. This ACOB accomplishes the intent of all three of the above safety recommendations by having the POI at each airline disseminate information on international operations and perform the recommended check of training programs. Safety Recommendations A-89-22, -23, and -45 have been classified as "Closed-- Acceptable Action."

From: FAA
To: NTSB
Date: 8/13/1990
Response: On June 12, 1990, the FAA published Air Carrier Operations Bulletin (ACOB) 8-90-7, International Operations. A copy of this ACOB was provided to the Board on July 18, 1990. Data Source: NTSB Recommendations to FAA and FAA Responses In addition to the information contained in ACOB 8-90-7, the FAA published ACOB 7- 90-1, Instrument Approach and Departures at Foreign Airports. This ACOB requests that principal operations inspectors review their assigned air carriers' training program for operations into foreign airports during low visibility terminal operations. I have enclosed a copy of ACOB 7-90-1 for the Board's information. I believe that ACOB 8-90-7, together with the information contained in ACOB 7-90-1, address these safety recommendations. I consider the FAA's action to be completed on this safety recommendation.

From: FAA
To: NTSB
Date: 7/18/1990
Response: (SUMMARIZED) THE FAA ISSUED ACOB 8-90-7 TO ADDRESS THE ISSUES OF THESE SAFETY RECOMMENDATIONS.

From: NTSB
To: FAA
Date: 5/17/1990
Response: Thank you for the FAA response of April 20, 1990, to the National Transportation Safety Board's Safety Recommendations A-89-22 and -23. Safety Recommendation A-89- 22 addresses the issuance of an air carrier operations bulletin (ACOB) to Part 121 principal operations inspectors regarding instrument flight operations at foreign airports. Safety Recommendation A-89-23 addresses a prompt one-time action by the principal operations inspectors to review their operators' training programs and operating procedures to verify that the programs and procedures are adequate to safely conduct instrument flight operations at foreign airports. The FAA's planned ACOB could accomplish the intent of both recommendations. Safety Recommendations A- 89-22 and -23 will be held in an "Open--Acceptable Action" status pending issuance of the ACOB.

From: FAA
To: NTSB
Date: 4/20/1990
Response: THE FAA WILL ISSUE AN ACOB TO ADDRESS THE ISSUES OF THESE SAFETY RECOMMENDATIONS. THE ACOB WILL INSTRUCT PRINCIPAL OPERATIONS INSPECTORS TO REVIEW THEIR OPERATORS' TRAINING PROGRAMS AND OPERATING PROCEDURES TO ENSURE THAT PROCEDURES TO IDENTIFY UNIQUE INSTRUMENT FLIGHT OPERATIONS AND THE NEED FOR INCREASED VIGILANCE DURING INSTRUMENT APPROACH AND DEPARTURE PROCEDURES AT FOREIGN AIRPORTS ARE INCLUDED. I WILL PROVIDE THE BOARD WITH A COPY OF THE ACOB AS SOON AS IT ISSUED.

From: NTSB
To: FAA
Date: 1/5/1990
Response: Because we believe the recommended near-term action of Safety Recommendation A-89-22 is not addressed in either FAA response, we have classified the safety recommendation as "Open--Unacceptable Action." The response to Safety Recommendations A-89-44 and 45 in the September 8 letter describes working groups which should result in an organizational structure able to provide the longer term results that Safety Recommendation A-89-45 envisions. Therefore, Safety Recommendation A-89-45 is classified as "Open--Acceptable Action."

From: FAA
To: NTSB
Date: 9/7/1989
Response: (MC-890732, SUMMARIZED) BASED ON ITS REVIEW, THE FAA HAS DETERMINED THAT SAFETY RECOMMENDATIONS A-89-44 THROUGH -49 ISSUED ON JUNE 20, 1989, SUPERSEDED SAFETY RECOMMENDATIONS A-89-22 AND -23. SPECIFICALLY, SAFETY RECOMMENDATIONS A-89-22 AND A-89-45 BOTH PROVIDE GUIDANCE TO OPERATORS ON THE CONDUCT OF INTERNATIONAL OPERATIONS AND INFORMATION THAT COULD AFFECT SAFETY. SAFETY RECOMMENDATIONS A-89-23 AND A-89-46 BOTH ADDRESS THE SAME CONCERN IN REQUESTING THE FAA TO CONDUCT A REVIEW OF THE OPERATING PROCEDURES AND TRAINING PROGRAMS OF AIR CARRIERS ENGAGED IN INTERNATIONAL OPERATIONS TO VERIFY THAT THESE PROCEDURES AND TRAINING PROGRAMS ADDRESS FACTORS THAT COULD AFFECT THE SAFETY OF INTERNATIONAL OPERATIONS. THE FAA BELIEVES THAT, BASED ON THE ACTION IT IS TAKING TO ADDRESS SAFETY RECOMMENDATIONS A-89-44 THROUGH -49, THE SAFETY BOARD SHOULD CLASSIFY A-89-22 AND -23 AS "CLOSED--SUPERSEDED."

From: NTSB
To: FAA
Date: 8/7/1989
Response: Thank you for the FAA's June 29, 1989, response to the National Transportation Safety Board's Safety Recommendations A-89-22 and -23. These safety recommendations concern the issuance of an air carrier operations bulletin regarding the unique conditions of instrument flight at foreign airports, and the need for a requirement for followup by principal operations inspectors. The Safety Board notes that the FAA is in the process of reviewing these safety recommendations. Pending a full response, they will be held in an "Open--Await Response" status.

From: FAA
To: NTSB
Date: 6/29/1989
Response: THE FAA IS IN THE PROCESS OF REVIEWING THESE RECOMMENDATIONS. HOWEVER, ON 6/20/89, THE BOARD ISSUED RECOMMENDATIONS A-89-44 THROUGH -49 WHICH ADDRESS THE SAME ISSUES. SINCE THESE TWO SETS OF RECOMMENDATIONS ARE SO SIMILAR, THE FAA WILL PROVIDE THE BOARD WITH A RESPONSE OT RECOMMENDATIONS A-89-22 & 23 WHEN ITS COMPLETES ITS REVIEW OF RECOMMENDATIONS A-89-44 THROUGH -49.