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Safety Recommendation Details

Safety Recommendation A-00-094
Details
Synopsis: .In this letter, the national transportation safety board recommends that the Federal Aviation Administration (FAA) take action to address the following safety issues: air carrier pilot training in landing techniques and bounced landing recovery, training tools and policies that promote proactive decision-making to go around if an approach is unstabilized, the use of on board computers to determine the required runway length for landing, md-11 handling characteristics and structural integrity requirements, and hard landing inspection requirements. The safety board identified these issues in its investigation of the 1997 accident involving Federal Express flight 14 in Newark, NJ. This letter summarizes the Board's rationale for issuing these recommendations
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Convene a joint government-industry task force composed, at a minimum, of representatives of manufacturers, operators, pilot labor organizations, and the FAA to develop, within 1 year, a pilot training tool to do the following: promote an orientation toward a proactive go-around.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Newark, NJ, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA97MA055
Accident Reports: Crash During Landing Federal Express, Inc., McDonnell Douglas MD-11, N611FE
Report #: AAR-00-02
Accident Date: 7/31/1997
Issue Date: 8/25/2000
Date Closed: 10/22/2002
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Flightcrew, Go Around, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 10/22/2002
Response: As recommended, the FAA convened a joint government industry task force under the auspices of CAST, and implemented the recommended actions. Accordingly, Safety Recommendations A-00-93 and -94 are classified "Closed--Acceptable Action."

From: FAA
To: NTSB
Date: 5/15/2002
Response: Letter Mail Controlled 06/10/2002 9:25:16 AM MC# 2020574 As part of the effort in response to Safety Recommendation A-00-92, -93, and -94, a joint government-industry task force composed of representatives from manufacturers, operators, pilot labor organizations, and the FAA has been convened under the auspices of the CAST. The CAST has decided not to develop airplane type-specific safety interventions, but will develop and implement generic safety interventions, including generic training interventions. The task force has produced the following significant training materials that address the intent of Safety Recommendations A-00-93 and -94: · Issued Advisory Circular (AC) 120-71, Standard Operating Procedures for Flight Deck Crewmembers, Appendix 2, Stabilized Approach: Concepts and Terms, in August 2000. · Issued Flight Standards Information Bulletin for Air Transportation (FSAT) 00-08, Standard Operating Procedures for Flightdeck Crewmembers AC 120-71), Including Stabilized Approach, in August 2000. · Published Approach and landing accident reduction (ALAR) Training Guide, in July 2001. The Air Transport Association (ATA) led an initiative to produce a training guide specifically targeting ALAR. The guide is included as an appendix to FSAT 01-12, Approach and Landing Accident Reduction (ALAR) : Recommended Flightcrew Training, issued October 31, 2001. The guide is also posted on the FAA web site (www.faa.gov/avr/afs/fsat/fsatl.htm) for voluntary implementation. The CAST member organizations have endorsed the use of the training guide in developing and evaluating ALAR training. Safety Recommendation A-00-93 is partly satisfied by the three training materials listed above. These tools address training in ALAR to the conclusion of a stabilized approach, which is defined in AC 120-71 as ending at a point where the landing maneuver (including flare) begins. Specific topics addressed include maintaining a stabilized approach and identification of an unstable approach. The performance of airplanes during landings varies with each aircraft type. Performance characteristics specifically mentioned in Safety Recommendation A-00-93 that would vary with aircraft type include flare, recovery techniques for high sink rate during flare, over-control, and premature derotation during a bounced landing. It is unlikely that a task force as recommended by the Board would be any more effective in developing type-specific training than the certification team convened during airplane certification. Training requirements for landings are always considered during airplane certification and are explicitly stated as necessary in the FAA Flight Standardization Report and/or in the FAA-approved Airplane Flight Manual. Additional guidance is commonly generated by the manufacturer and included in the flightcrew operating manual, or equivalent, as an added safety service to a manufacturer's customers. Even in those cases where explicit training requirements for flare, over-control, and bounced landings may not be established during certification or recommended by the manufacturer, airlines have usually developed their own effective training as a practical matter. No airline can afford a preventable landing accident; therefore, ground training, flight training, proficiency checks, supervised operating experience, and annual pilot-in-command line checks continually stress each airline's standard operating procedures regarding landings. The standard operating procedures, in turn, are continually subject to revision in response to new guidance material generated by the manufacturer, like the guidance material developed by Boeing in response to Safety Recommendation A-00-99. Also, standard operating procedures are often revised in response to a certificate holder's operating experience and in response to guidance generated by competent working groups like that recently chaired by the Flight Safety Foundation (FSF). The FSF has begun a wide distribution of its ALAR Toolkit. The Toolkit was released in February 2001, and is the end product of a collaboration of industry and government representatives and chaired by the FSF. The Toolkit consolidates a broad selection of reports and other training materials targeting ALAR. Like the other training references mentioned above, the Toolkit does not include airplane type-specific guidance regarding landings. However, it does contain generic guidance regarding stabilized approach and bounced landings and bounce-landing recovery. The FSF has distributed the copyrighted Toolkit to every FSF member, with a strong recommendation from the CAST that it be used in connection with other training materials. The FSF has also distributed the Toolkit to all major airplane manufacturers and other manufacturers. The FSF has clearly expressed its explicit permission that the manufacturer may distribute the Toolkit to each of its customers for implementation in the customer's flightcrew training programs. The Toolkit is also available to the public for sale. Concurrently, the International Civil Aviation Organization has begun a distribution of the Toolkit to its member states, including the United States. On October 31, 2001, the FAA issued FSAT 01-12, Approach and Landing Accident Reduction (ALAR): Recommended Flightcrew Training. The bulletin informs certificate holders and FAA inspectors of the training guidance now available that targets ALAR and recommends its use. The bulletin reiterates the importance of prompt revisions to standard operating procedures when a manufacturer issues recommendations for change or when other valuable guidance becomes available. The bulletin specifically mentions the flightcrew operating manual changes Boeing issued relating to DC-l0, MD-l0, and MD-11 landings, and the more general training materials developed by the ATA and FSF like the ALAR Training Guide and ALAR Toolkit. I have enclosed a copy of the bulletin for the Board's information. I believe that the intent of Safety Recommendation A-00-93 has been exceeded by the measures taken by the FAA and industry, and I consider the FAA's action to be completed. With respect to Safety Recommendation A-00-94, the CAST recently endorsed the ALAR Training Guide developed by a task force headed by the ATA. The guide specifically targets ALAR. CAST member organizations have endorsed the use of the guide in developing and evaluating ALAR training. The guide is included as an appendix to FSAT 01-12, Approach and Landing Accident Reduction (ALAR) : Recommended Flightcrew Training, issued October 31, 2001. The guide is also posted on the FAA web site (www.faa.gov/avr/afs/fsatjfsatl.htm) for voluntary implementation. The bulletin issued in response to Safety Recommendation A-00-93 also responds to this safety recommendation--the ALAR Training Guide and the FAA bulletin explicitly promote an orientation to a proactive go-around. The bulletin further encourages operators to use the guide and directs FAA inspectors to ensure that air carrier certificate holders under their oversight are aware of the ALAR Training Guide and encourage its use in flightcrew training for ALAR. I believe that the FAA has addressed the full intent of this safety recommendation and I consider the FAA's action to be completed.

From: NTSB
To: FAA
Date: 6/13/2001
Response: Pending completion and implementation of the JSAT recommendations, Safety Recommendations A-00-92, -93, and -94 are classified "Open-Acceptable Response."

From: FAA
To: NTSB
Date: 11/13/2000
Response: Letter Mail Controlled 11/15/2000 3:27:59 PM MC# 2001695 The FAA agrees with the intent of these safety recommendations. The Approach and Landing and Loss of Control Joint Safety Analysis Teams (JSAT) that were convened under the FAA's Safer Skies Safety Initiative have already addressed the issues outlined in these safety recommendations. The JSAT's have analyzed data from global fatal accidents, including the Federal Express MD-11 accident, and developed specific interventions to address simulator training for stabilized approaches and recovery from unstabilized approaches, including emphasis on proactive go-around philosophy. The interventions are as follows: to reduce the likelihood of hard landings, airlines/operators should develop training syllabi with improved coverage of landings, including identification of and recovery from unstabilized flares, high sink rates, and bounced landings; and airlines/operators should implement a true no-fault go-around policy. The interventions were provided to the Commercial Aviation Safety Team to determine the best method of implementation. The FAA will provide any additional information regarding the factors that can contribute to structural failures involving the landing gear, wings, and fuselage and structural loading consequences of bottoming landing gear struts and tires to the safety team as requested. It is anticipated that this effort will be completed by June 2001. I will keep the Board informed of the FAA's progress on these safety recommendations.