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Safety Recommendation Details

Safety Recommendation A-04-059
Details
Synopsis: On November 12, 2001, about 0916:15 eastern standard time, American Airlines flight 587, an Airbus Industrie A300-605R, N14053, crashed into a residential area of Belle Harbor, New York, shortly after takeoff from John F. Kennedy International Airport, Jamaica, New York. Flight 587 was a regularly scheduled passenger flight to Las Americas International Airport, Santo Domingo, Dominican Republic, with 2 flight crewmembers, 7 flight attendants, and 251 passengers aboard the airplane. The airplane’s vertical stabilizer and rudder separated in flight and were found in Jamaica Bay, about 1 mile north of the main wreckage site. The airplane’s engines subsequently separated in flight and were found several blocks north and east of the main wreckage site. All 260 people aboard the airplane and 5 people on the ground were killed, and the airplane was destroyed by impact forces and a postcrash fire. Flight 587 was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Develop and disseminate guidance to transport-category pilots that emphasizes that multiple full deflection, alternating flight control inputs should not be necessary to control a transport-category airplane and that such inputs might be indicative of an adverse aircraft-pilot coupling event and thus should be avoided.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Belle Harbor, NY, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA02MA001
Accident Reports: In-Flight Separation of Vertical Stabilizer American Airlines Flight 587, Airbus Industrie A300-605R, N14053
Report #: AAR-04-04
Accident Date: 11/12/2001
Issue Date: 11/10/2004
Date Closed: 6/9/2006
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 5/12/2014
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) draft Advisory Circular (AC) 120-UPRT, “Upset Prevention and Recovery Training,” which was posted for comment on the FAA’s website on March 12, 2014. Draft AC 120-UPRT describes the philosophy and recommended training for airplane upset prevention and recovery. The purpose of the AC is to provide recommended practices and guidance regarding academic and flight simulation device training for pilots to prevent the development of airplane upset conditions and ensure correct and consistent recovery responses to upsets. The AC was created from recommended practices developed by major airplane manufacturers, labor organizations, air carriers, training organizations, simulator manufacturers, and industry representative organizations. Although this AC is directed to air carriers in implementing 14 Code of Federal Regulations (CFR) Part 121 regulations, the FAA encourages all airplane operators, pilot schools, and training centers to implement upset prevention and recovery training and to use the guidance contained in the AC, as applicable to the type of airplane in which training is conducted. We generally support the draft AC (with specific suggestions below). On November 12, 2013, the FAA published a final rule titled “Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers.” Draft AC 120 UPRT and draft revised AC 120-109A provide the guidance necessary for operators and FAA inspectors to implement the requirements in the final rule. In addition, we are pleased to note that draft AC 120-UPRT contains several prominent warnings against the use of excessive rudder inputs and recommends the use of the Airplane Upset Recovery Training Aid in developing upset recovery training programs. Safety Recommendations A-02-1 and -2 and A-04-59 and -61, which are all classified as “Closed?Acceptable Action,” addressed these issues.

From: NTSB
To: FAA
Date: 6/9/2006
Response: On November 10, 2004, the FAA advised the Safety Board that in August 2004, a revised "Airplane Upset Recovery Training Aid" had been issued and distributed to over 900 operators throughout the world. The FAA also indicated that it planned to issue an AC endorsing the use of this aid, announcing its availability to the public at no cost, emphasizing that multiple full deflection, alternating flight control inputs should not be necessary to control a transport-category airplane, and stressing that such inputs might be indicative of an adverse aircraft-pilot coupling event and should be avoided. The Safety Board reviewed a copy of the aid, found it to be responsive to these recommendations, and on August 3, 2005, Safety Recommendations A-04-59 and -61 were classified "Open-Acceptable Response," pending issuance of the AC. In its current letter, the FAA indicates that it has implemented a new system to release critical safety information to operators quickly through safety alerts for operators (SAFO). On October 25, 2005, the FAA issued SAFO 05002, "Multiple full deflection, alternating flight control inputs." This SAFO urges directors of safety, directors of operations, fractional ownership program managers, and pilots of transport-category airplanes to familiarize themselves with the location, availability, and content of "The Airplane Upset Recovery Training Aid," and to pay particular attention to the cautions against control reversals and pilot-induced oscillations that are repeated throughout the training aid. The Safety Board reviewed SAFO 05002 and determined that it should achieve the same results as the AC discussed in the FAA's November 10, 2004, letter. The Board has noted that the FAA has at times been slow to issue ACs with critical safety information and applauds the FAA's efforts to address this problem through the development of SAFOs. The Board urges the FAA to ensure that operators and FAA principal operations inspectors (POI) follow the guidance provided in the SAFO. Specifically in the case of SAFO 05002, the FAA should ensure that the training aid is actually used by operators to develop their upset recovery programs and by POIs to evaluate and accept these programs. As issuance of the SAFO meets the intent of Safety Recommendations A-04-59 and -61, these recommendations are classified "Closed-Acceptable Action."

From: FAA
To: NTSB
Date: 1/9/2006
Response: Letter Mail Controlled 1/18/2006 7:50:31 AM MC# 2060040 Marion C. Blakey, Administrator, FAA, 1/9/06 In response to Safety Recommendations A-04-59 and A-04-61, the Federal Aviation Administration has announced the availability of a revised "Airplane Upset Recovery Training Aid." This training aid was revised in August 2004 and distributed to over 900 operators worldwide, including U.S. certificate holders operating under 14 CFR Part 121. This training aid contains industry best practices and is designed to avoid inaccurate or negative training processes. While this training aid represents the latest upset recovery information, recommended practices, and training procedures, this training aid advises operators that full deflection, alternating flight control inputs should not be necessary to control a transport-category airplane. The training aid also states that such inputs might be indicative of an adverse aircraft-pilot coupling event and should be avoided. The FAA previously agreed to announce the availability of the Airplane Upset Recovery Training Aid through the issuance of an Advisory Circular. However, the FAA has recognized the need to implement an alternative method to release important critical safety information to operators quickly. To disseminate critical safety information rapidly, the FAA has developed a new program for notifying operators of critically important safety alert information for operators (SAFO). On August 29, 2005, the FAA issued Order 8000.87, Safety Alerts for Operators, which permits the FAA's Air Transportation Division to convey important safety information directly to operators in a timely manner. I have enclosed the alert that introduces the SAFO program. This new SAFO program is responsive to safety- related information, such as Board recommendations and other critical safety information. The FAA has established a public Web site for SAFO information and began placing safety information on this Web site on October 25, 2005. I have also enclosed a copy of SAFO 05002, Multiple full deflection, alternating flight control inputs, for the Board's information. This SAFO urges directors of safety, directors of operations, fractional ownership program managers, and pilots of transport-category airplanes to be familiar with the location, availability, and content of "The Airplane Upset Recovery Training Aid," and to pay particular attention to the cautions against control reversals and pilot-induced oscillations that are repeated throughout the training aid. I believe that the FAA has satisfactorily responded to these safety recommendations, and I look forward to your response.

From: NTSB
To: FAA
Date: 8/3/2005
Response: The Safety Board notes that "The Airplane Upset Recovery Training Aid" was revised in August 2004 and distributed to over 900 operators worldwide. This aid contains best practices developed by the industry and is designed to avoid inaccurate or negative training. The FAA believes that the aid addresses the issues in these recommendations, including adverse APC. The FAA plans to issue an AC endorsing the use of this aid, (1) announcing its availability to the public at no cost, (2) emphasizing that multiple full deflection, alternating flight control inputs should not be necessary to control a transport-category airplane and that such inputs might be indicative of an adverse aircraft-pilot coupling event and should be avoided, and (3) calling attention to examples of inaccurate or negative training that should be avoided in implementing flight crew training. The Safety Board reviewed a copy of the aid and found it to be responsive to these recommendations. Pending issuance of the AC, Safety Recommendations A-04-59 and -61 are classified "Open--Acceptable Response."

From: FAA
To: NTSB
Date: 3/1/2005
Response: Letter Mail Controlled 3/17/2005 12:28:54 PM MC# 2050112 "The Airplane Upset Recovery Training Aid" is the acknowledged guide for pilots flying transport-category turbojet airplanes with swept wings, like the A300-605R accident airplane. This aid is the product of a broad range of aviation experts, including Airbus, Boeing, and the FAA. This aid was originally issued in 1997, and then revised in August 2004 to address the issues that the Board has expressed, including adverse aircraft-pilot coupling, also known as pilot-induced oscillation. The aid has been prominently displayed on an FAA public web site for 6 or 7 years. The Board can view the aid by logging onto the web site at http://www.faa.gov/avr/afs/afs200/afs210/index.cfm. The FAA will issue an advisory circular (AC) endorsing the use of the aid, announcing its availability to the public at no cost, and emphasizing that multiple full deflection, alternating flight control inputs should not be necessary to control a transport-category airplane and that such inputs might be indicative of an adverse aircraft-pilot coupling event and should be avoided. The AC will be developed and ready for internal FAA coordination by March 1, 2005 I will provide the Board with a copy of the AC as soon as it is issued.