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Safety Recommendation A-90-078
Details
Synopsis: ON JULY 19, 1989, A MCDONNELL DOUGLAS DC-10-10, OPERATED BY UNITED AIRLINES AS FLIGHT 232, EN ROUTE FROM DENVER, COLORADO, TO CHICAGO, ILLINOIS, EXPERIENCED AN IN-FLIGHT EMERGENCY FOLLOWING THE FRAGMENTATION AND SEPARATION OF THE NO. 2 ENGINE FAN DISK. THE AIRPLANE CRASHED DURING AN ATTEMPTED EMERGENCY LANDING ON RUNWAY 22 AT SIOUX GATEWAY AIRPORT, SIOUX CITY, IOWA. DURING THE GROUND IMPACT SEQUENCE, THE AIRPLANE SEPARATED INTO SECTIONS AND PORTIONS BURNED. THE CENTER SECTION OF THE AIRPLANE, WHICH CONTAINED MOST OF THE PASSENGERS, CAME TO REST INVERTED IN A CORNFIELD ADJACENT TO RUNWAY 17 AND 3,700 FEET FROM THE INITIAL IMPACT ON RUNWAY 22. OF THE 296 PERSON ON BOARD THE AIRPLANE, 110 PASSENGERS AND 1 FLIGHT ATTENDANT WERE FATALLY INJURED. AUTOPSIES REVEALED THAT 35 PASSENGERS DIED OF SMOKE INHALATION, INCLUDING 24 WITHOUT TRAUMATIC BLUNT FORCE INJURIES. THE OTHERS WHO WERE FATALLY INJURED DIED OF MULTIPLE INJURIES FROM BLUNT FORCE IMPACT. OF THE REMAIN ING 185 PERSONS ON BOARD, 47 SUSTAINED SERIOUS INJURIES, 125 SUSTAINED MINOR INJURIES, AND 13 WERE NOT INJURED.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Revise 14 CFR 91, 121 and 135 to require that all occupants be restrained during takeoff, landing, and turbulent conditions, and that all infants and small children below the weight of 40 pounds and under the height of 40 inches be restrained in an approved child restraint system appropriate to their height and weight. (superseded by A-95-50 and A-95-51)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action/Superseded
Mode: Aviation
Location: SIOUX CITY, IA, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA89MA063
Accident Reports: United Airlines Flight 232 McDonnell Douglas DC-10-10​
Report #: AAR-90-06
Accident Date: 7/19/1989
Issue Date: 5/30/1990
Date Closed: 5/15/1995
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action/Superseded)
Keyword(s): Child Restraint Systems

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/23/2014
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) notice of proposed rulemaking (NPRM), titled “Disclosure of Seat Dimensions to Facilitate Use of Child Safety Seats on Airplanes During Passenger-Carrying Operations,” which was published in 79 Federal Register 18213 on April 1, 2014. The FAA initiated this rulemaking in response to a requirement in section 412 of the FAA Modernization and Reform Act of 2012. The NPRM proposes that air carriers conducting domestic, flag, and supplemental operations be required to provide information on their websites to assist passengers in determining which child safety seats can be used on aircraft in these operations. Although the statutory provision specified that air carriers post on their websites the maximum dimensions of child restraint systems (CRS) that could be used on each of their airplanes, the FAA alternatively proposes to require air carriers to provide the width of the widest passenger seat in each class of service for each make, model, and series of airplane used in passenger-carrying operations. The NPRM states that this rule would provide greater information to caregivers to help them determine whether a particular CRS will fit in an airplane seat. The NPRM does not affect existing regulations regarding the use of CRSs onboard airplanes or a passenger younger than 2 years traveling onboard aircraft with or without the use of a CRS. The NTSB generally supports this NPRM, as its intent is to help facilitate the increased voluntary use of CRSs on airplanes. The NTSB has long advocated that infants and children under 2 years of age should be properly restrained aboard aircraft and has issued several related safety recommendations to the FAA. In 2010, the NTSB also held a forum, titled “Child Passenger Safety in the Air and in Automobiles,” with the primary purpose to improve passenger safety through education and advocacy. If implemented, the proposed rule will provide passengers with greater knowledge concerning the fit of CRSs on airplanes, which will help achieve this goal. Furthermore, our 2014 Most Wanted List focuses on strengthening occupant protection in transportation, and the NTSB believes that infants and young children should be afforded the same level of protection as other passengers who must be properly restrained in their own seats during flight. Although the proposed rule does not address the NTSB’s previous safety recommendations on proper restraint for children under 2 years, we anticipate that if the rule is implemented, the voluntary use of CRSs in Part 121 air carrier operations should increase. Most recently, the NTSB issued Safety Recommendation A-10-123 on this issue, which asked the FAA to “amend 14 Code of Federal Regulations [CFR] Part 121 and 135 to require each person who is less than 2 years of age to be restrained in a separate seat position by an appropriate child restraint system during takeoff, landing, and turbulence.” This recommendation was classified “Closed- Unacceptable Action.” In addition, Safety Recommendation A-90-78 asked the FAA to “revise 14 CFR 91, 121 and 135 to require that all occupants be restrained during takeoff, landing, and turbulent conditions, and that all infants and small children below the weight of 40 pounds and under the height of 40 inches be restrained in an approved child restraint system appropriate to their height and weight.” This recommendation was classified CLOSED--UNACCEPTABLE ACTION.

From: NTSB
To: FAA
Date: 8/4/1998
Response: Notation 7019: The National Transportation Safety Board has reviewed your Advance Notice of Proposed Rulemaking (ANPRM), "Child Restraint Systems," which was published in 63 FR 8323 on February 18, 1998. The ANPRM requests comments on crash performance and ease-of-use information about existing and new automotive child restraint systems (CRS), when used in aircraft, as well as the development of any other new or improved CRS designed exclusively for aircraft use. The ANPRM also seeks information about the technical practicality and cost feasibility of requiring small children and infants to be restrained in CRS in aircraft. The ANPRM is in response to the February 12, 1997, report to President Clinton by the White House Commission on Aviation Safety and Security. The report stated, "The [Federal Aviation Administration] FAA should revise its regulations to require that all occupants be restrained during takeoff: landing, and turbulent conditions, and that all infants and small children below the weight of40 pounds and under the height of 40 inches be restrained in an appropriate child restraint system, such as child safety seats, appropriate to their height and weight." In 1979, the Safety Board issued its first safety recommendation regarding CRS aboard aircraft. At that time, the Board recommended that the FAA expedite research with a view toward early rulemaking on a means to most effectively restrain infants and small children during in-flight upsets and survivable crash landings (A-79-63). Since then the Safety Board has issued five additional recommendations on this subject. In 1983, the Safety Board recommended that the FAA accept CRS approved by the National Highway Traffic Safety Administration (NHTSA) until the FAA and the NHTSA developed CRS standards acceptable for both automotive and aircraft use (A-83-1). In 1990, the Safety Board recommended that the FAA require that all aircraft occupants be restrained (A-90-78) and that the FAA conduct research to determine at what age/size children can be properly restrained by aircraft lap belts (A-90-79). Safety Recommendation A-90-78 was classified "Closed-Unacceptable/Superseded" on May 26, 1995, and A-90-79 was classified "Closed-Acceptable Action" on May 15, 1995. In its April 4, 1995, accident report on the crash of a DC-9 in Charlotte, North Carolina, the Safety Board noted its disappointment with the FAA's actions regarding the required use of CRS on air carrier flights. The report noted the probable introduction of ISOFIX (standard CRS attachments that will be incorporated into the design of automobiles) and expressed Safety Board concerns about possible future problems for parents who might not have the appropriate CRS for aircraft use. Accordingly, the Safety Board issued a recommendation asking the FAA to develop standards for forward-facing, integrated CRS for use in aircraft (A-95-50). Safety Recommendation A-95-50 was classified "Open-Acceptable Response" on July 26, 1996. The Safety Board continues to believe that all occupants, including young children should be restrained. Not requiring restraint use for infants and children Jess than 2 years old is inconsistent with recent policy by several airlines that seated occupants should be restrained at all times during a flight to ensure their safety. The Safety Board also continues to believe that the FAA should develop standards for integrated CRS for aircraft. The Safety Board is aware that the NHTSA has issued a proposed revision to Federal Motor Vehicle Safety Standard 213 to consider a method of securing CRS in automobiles. This change would require motor vehicles to have a dedicated anchorage system for CRS separate from the seatbelt system. These changes would make it impossible to use a CRS with an airline Jap belt and further reinforce the need to develop standards for integrated CRS for aircraft. The Safety Board appreciates the opportunity to comment on this ANPRM.

From: NTSB
To: FAA
Date: 5/15/1995
Response: (CLOSED IN GREENSHEET) THE BOARD IS SATISFIED WITH THE FAA'S ACTION REGARDING THE STUDY OF CHILD RESTRAINT SYSTEMS; THUS, A-90-79 IS CLASSIFIED "CLOSED--ACCEPTABLE ACTION." ALSO, BECAUSE CAMI FOUND THAT NORMAL LAP BELTS CAN PROVIDE ACCEPTABLE RESTRAINTS FOR 3-YEAR-OLD CHILDREN, THE BOARD FINDS THAT THE 40 POUNDS, 40 INCHES STANDARD USED IN A-90-78 HAS BEEN SUPERSEDED BY THE FINDINGS OF THE CAMI REPORT. SINCE THE FAA HAS NOT TAKEN STEPS TO REQUIRE THAT ALL OCCUPANTS BE RESTRAINED DURING TAKEOFF, THE BOARD NOW CLASSIFIES A-90-78 AS "CLOSED--UNACCEPTABLE ACTION/SUPERSEDED" BY A-95-50 & A-95-51.

From: NTSB
To: FAA
Date: 8/31/1993
Response: Safety Recommendation A-90-078 was reiterated in the letter issuing Safety Recommendations A-93-106 through A-93-109 sent on 8/31/1993. This letter discusses that on September 6, 1992, about 1802 central daylight time, a Piper PA-30, N7065Y, operating under the provisions of 14 CFR Part 91, entered an uncontrolled descent and crashed at Broussard, Louisiana.

From: NTSB
To: FAA
Date: 3/15/1993
Response: THE BOARD NOTES THAT THE FAA DOES NOT AGREE WITH THIS RECOMMENDATION, & HAS, INSTEAD, ISSUED A FINAL RULE THAT ONLY REQUIRES OPERATORS TO ACCEPT ALL APPROVED CHILD RESTRAINT SYSTEMS. THIS RULE IS UNACCEPTABLE, BECAUSE IT DOES NOT REQUIRE THE USE OF APPROVED CHILD RESTRAINTS; IT MERELY PROHIBITS OPERATORS FROM DENYING THEIR USE. ON JANUARY 5, 1993, TWO INFANTS ON BOARD AMERICAN AIRLINES FLIGHT 1539 WERE TOSSED ABOUT THE CABIN WHEN THE PLANE ENCOUNTERED TURBULENCE OVER SOUTH FLORIDA, CAUSING ONE CHILD TO SUFFER A BRUISE ON HER HEAD WHEN SHE LANDED IN THE ROW BEHIND HER FAMILY & THE OTHER TO BE THROWN BACK TWO ROWS WHERE HE ENDED UP SAFELY IN THE ARMS OF A PASSENGER. IN LIGHT OF THIS INCIDENT, ALONG WITH THE LACK OF ANY REASON TO BELIEVE THAT SUCH INCIDENTS & WORSE WILL NOT HAPPEN AGAIN, THE BOARD REQUESTS THE FAA TO RECONSIDER ITS POSITION CONCERNING RECOMMENDATION A-90-78 & CLASSIFIES IT "OPEN--UNACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 11/5/1992
Response: THE FAA DOES NOT AGREE WITH THIS SAFETY RECOMMENDATION TO REQUIRE THAT ALL INFANTS AND SMALL CHILDREN BELOW THE WEIGHT OF 40 POUNDS AND UNDER THE HEIGHT OF 40 INCHES BE RESTRAINED IN APPROVED CHILD RESTRAINT SYSTEM APPROPRIATE TO THEIR HEIGHT AND WEIGHT. ON SEPTEMBER 8, 1992, THE FAA ISSUED A FINAL RULE (DOCKET NO. 26142; AMENDMENT NOS. 91-231, 121-230, 125-17, AND 135-44) ENTITLED MISCELLANEOUS OPERATIONAL AMENDMENTS. THIS FINAL RULE AMENDS 14 CFR PARTS 91.107, 121.311, 125.211, AND 135.128 TO REQUIRE THAT OPERATORS ACCEPT ALL APPROVED CHILD RESTRAINT SYSTEMS. A COPY OF THE FINAL RULE IS AVAILABLE FOR THE BOARD'S INFORMATION.

From: NTSB
To: FAA
Date: 1/28/1991
Response: Safety Recommendation A-90-78 states that the FAA should require all occupants to be restrained during takeoff, landing, and turbulent conditions, and that all infants and small children below the weight of 40 pounds and under the height of 40 inches be restrained in an approved child restraint system appropriate to their height and weight. As discussed in the Safety Board letter of May 30, 1990, the Safety Board has been aware of the notice of proposed rulemaking (NPRM) 90-6, Miscellaneous Operational Amendments, published on February 22, 1990, and of the petition for rulemaking proposed by the Air Transport Association of America (ATA). The Safety Board found the NPRM unacceptable because it did not require the use of an approved child restraint that parents (or guardians) are to supply, but would only prohibit operators from denying their use. The ATA petition solicited public comment but did not lead to positive action by the FAA. Although the Safety Board is aware that a final rule has not been promulgated, the FAA has taken no positive action on the ATA petition or on Safety Recommendation A-90-78. Therefore, Safety Recommendation A- 90-78 is classified "Open--Unacceptable Response."

From: NTSB
To: FAA
Date: 11/1/1990
Response: From the accident report of United Airlines flight 232 McDonnell Douglas DC-10-10 at the Sioux Gateway Airport in Sioux City, Iowa on July 19, 1989. The Board adopted this report on 11/1/1990. These, A-90-78 and -79, recommendations were classified as “Closed—Superseded” by other recommendations issued on June 18, 1990: A-90-78 and A-90-79.

From: FAA
To: NTSB
Date: 8/6/1990
Response: THE FAA PUBLISHED NPRM 90-6, MISCELLANEOUS OPERATIONAL AMENDMENTS TO REQUIRE AIR CARRIERS ACCEPT AN APPROVED CHILD RESTRAINT IF REQUESTED AND PROVIDED BY THE PARENT OR GUARDIAN. COMMENTS RECEIVED ARE BEING ANALYZED. THE FAA ALSO RECEIVED A PETITION FOR RULEMAKING FROM THE AIR TRANSPORT ASSOCIATION SEEKING RESTRAINTS FOR CHILDREN NOT HAVING REACHED AGE 2. THE FAA PUBLISHED THE PETITION AND WILL REVIEW COMMENTS. I WILL APPRISE THE BOARD…