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Safety Recommendation Details

Safety Recommendation A-04-060
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: Amend all relevant regulatory and advisory materials to clarify that operating at or below maneuvering speed does not provide structural protection against multiple full control inputs in one axis or full control inputs in more than one axis at the same time.
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: 8/9/2017
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 8/9/2017
Response: Since this recommendation was issued, you have revised a number of different regulatory and advisory materials, as recommended. In our September 6, 2013, letter to you regarding this recommendation, we said that the remaining actions you needed to take to satisfy it were to revise the Airplane Flying Handbook and the Glider Flying Handbook. We note that page 17 10 of the 2016 revision to the Airplane Flying Handbook contains the recommended clarification. We also note that, on May 11, 2015, you issued an errata sheet for the Glider Flying Handbook containing the recommended clarification. Based on these revisions, Safety Recommendation A-04-60 is classified CLOSED—ACCEPTABLE ACTION.

From: NTSB
To: FAA
Date: 9/6/2013
Response: We are encouraged to learn that, on October 16, 2012, the FAA published advisory circular (AC) 25.1581-1, Change 1, “Airplane Flight Manual.” Pending completion of the remaining actions, which include revisions to the Airplane Flying Handbook and the Glider Flying Handbook, Safety Recommendation A-04-60 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/6/2013
Response: -From Michael P. Huerta, Administrator: In the Federal Aviation Administration's (FAA) August 3, 2012, Jetter, we stated that the "Airplane Flying Handbook" and "Glider Flying Handbook" would be revised and published by December 31 , 2012. However, internal work impacted our ability to complete that comprehensive work, and as a result, we are on track to publish these handbooks at the end of 2013. Conversely, Advisory Circular (AC) 25.1581 -1 , Change 1, "Airplane Flight Manual," was published on October 16, 2012. AC 25.1 851-1 is available here: http://www.faa.gov/documentLibrary/media/ Advisory_ Circular/ AC%2025 .1581-l.pdf I will keep the Board informed of the FAA's progress on this recommendation and provide an update by April 30, 2014.

From: NTSB
To: FAA
Date: 11/8/2012
Response: In our October 3, 2011, letter, we stated that the actions that remained in order to close this recommendation were to revise the Airplane Flying Handbook, the Glider Flying Handbook, and advisory circular (AC) 25.1581-1, “Airplane Flight Manual.” The FAA is revising the AC as part of a larger project to revise AC 25-7, “Flight Test Guide for Certification of Transport Category Airplanes.” We are aware that, earlier this year, the FAA published a notice seeking public comments on proposed revisions to AC 25-7. In its current letter, the FAA stated that it plans to complete all of the actions needed to close this recommendation by the end of 2012. Pending completion of these actions as scheduled, Safety Recommendation A-04-60 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/3/2012
Response: -From Michael P. Huerta, Acting Administrator: The revisions to the remaining documents were delayed from their original schedule due to internal coordination. The "Airplane Flying Handbook" and the "Glider Flying Handbook" are now scheduled to be completed by December 31, 2012. We plan to revise Advisory Circular (AC) 25.1581-1, "Airplane Flight Manual," as part of the larger project that revised AC 25-7A, "Flight Test Guide for Certification of Transport Category Airplanes." We anticipate completing this revision by December 31, 2012, as well. I will keep the Board informed of the FAA’s progress on these recommendations and provide an update by December 31, 2013.

From: NTSB
To: FAA
Date: 10/3/2011
Response: The FAA previously wrote to the NTSB regarding this recommendation on December 13, 2010. At that time, the FAA stated that it had determined the following advisory materials still needed to be revised to clarify that operating at or below the maneuvering speed does not provide structural protection against either multiple full control inputs in one axis or full control inputs in more than one axis at the same time: 1. Advisory Circular (AC) 25.1581-1, Airplane Flight Manual; 2. FAA-H-8083-3A, Airplane Flying Handbook; 3. FAA-H-8083-13, Glider Flying Handbook; and 4. FAA-H-8083-25, Pilot’s Handbook of Aeronautical Knowledge. On March 31, 2011, we replied that completion of those revisions would satisfy this recommendation. In its current letter, the FAA indicated that, on January 21, 2011, it had published an errata sheet for the Pilot’s Handbook of Aeronautical Knowledge to provide the recommended planned to publish the revisions to the Airplane Flying Handbook (item 2) and the Glider Flying Handbook (item 3) by September 30, 2011. For item 1, the FAA plans to revise AC 25.1581-1 as part of a project to revise AC 25-7A, “Flight Test Guide for Certification for Transport Category Airplanes,” with anticipated completion by August 2012. Pending revisions to the Airplane Flying Handbook, the Glider Flying Handbook, and AC 25.1581-1, Safety Recommendation A-04-60 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/17/2011
Response: CC#201100255: - From J. Randolph Babbitt, Administrator: The FAA continues to work with airplane manufacturers to ensure incorporation of this recommendation's statement in the airplane flight manual (AFM) for new transport category airplane designs. As stated in our last letter, the Maneuvering Speed Limitation Statement Final Rule amended the rule language concerning the AFM to ensure incorporation of these requirements into new aircraft. On January 18, 2011, we published Special Airworthiness Information Bulletin, Instruments (enclosure 3), to address this issue for small airplanes, special light-sport category airplanes, experimental light-sport category airplanes, and experimental amateur-built airplanes. We published an errata sheet on January 21 ~ 20 11 ~ for the Pilot's Handbook of Aeronautical Knowledge (enclosure 4) to provide the recommended clarifying information. We plan to publish the revisions to the Airplane Flying Handbook and the Glider Flying Handbook during Fiscal Year 2011. We also plan to revise Advisory Circular (AC) 25.1581-1, Airplane Flight Manual, as part of a project to revise AC 25-7A, Flight Test Guide for Cel1ification for Transport Category airplanes. We anticipate completing this project by August 2012. Because AC 25.1581-1 reiterates what is required by the Maneuvering Speed Limitation Statement Final Rule, we do not consider revising this document to be urgent. I will keep the Board informed of the FAA’s progress on these recommendations, and I will provide an update by June 30, 2012.

From: NTSB
To: FAA
Date: 3/31/2011
Response: To date, the FAA has (1) revised as recommended the airplane flight manuals of all major transport category airplanes used in the United States, (2) published a final rule on August 16, 2010, titled “Maneuvering Speed Limitation Statement,” which amends 14 CFR Part 25.1583(a)(3) to require, for new airplane designs, clarification that operating at or below maneuvering speed does not provide structural protection against multiple full control inputs in one axis or full control inputs in more than one axis at the same time, and (3) completed its review of other relevant regulatory and advisory material and identified the advisory material in need of revision. The FAA provided a list of relevant materials that it is currently revising. Pending completion of those revisions, Safety Recommendation A-04-60 remains classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 12/13/2010
Response: CC# 201100010: - From J. Randolph Babbitt, Administrator: The Airplane Flight Manuals (AFMs) of all major transport category airplanes used in U.S. operations have been revised to clarify that operating at or below maneuvering speed (VA) does not provide structural protection against multiple full control inputs in one axis or full control inputs in more than one axis at the same time. We published a final rule on August 16,2010, Maneuvering Speed Limitation Statement, to amend 14 Code of Federal Regulation (CFR) 25.1583(a)(3) by codifying, for new airplane designs, the clarifications to the statement that must be provided in the AFMs regarding VA (enclosure 3). Additionally, we completed our review of other relevant regulatory and advisory material and have determined the following advisory materials need to be revised to clarify that operating at or below VA does not provide structural protection against multiple full control inputs in one axis or full control inputs in more than one axis at the same time: • Advisory Circular (AC) 61-67C, Stall and Spin Awareness Training; • AC 25.1581-1, Airplane Flight Manual; • FAA-H-8083-3A, Airplane Flying Handbook; • FAA-H-8083-I3, Glider Flying Handbook; and • FAA-H-8083-25, Pilot's Hill1dbook of Aeronautical Knowledge. We completed the revision to the Stall and Spin Awareness Training AC on September 20, 2007. We plan to revise the Airplane Flight Manual AC once the rulemaking for 14 CFR 25.1 583(a)(3) is completed. Finally, we plan to revise the Airplane Flying Handbook by April 2011, the Glider Flying Handbook by this month, and the Pilot's Handbook of Aeronautical Knowledge at the next revision. I will keep the Board informed of the FANs progress on this safety recommendation, and I will provide an update by September 2011.

From: NTSB
To: FAA
Date: 11/2/2009
Response: Notation 7439F: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) notice of proposed rulemaking (NPRM) titled, “Design Maneuvering Speed Limitation Statement,” which was published in 74 Federal Register 45777 on September 4, 2009. The notice proposes to amend the airworthiness standards applicable to transport category airplanes to clarify that flying at or below the design maneuvering speed does not allow a pilot to make multiple large control inputs in one airplane axis or single full-control inputs in more than one airplane axis without endangering the airplane’s structure. Specifically, the proposed rule would require airplane flight manuals to include, in a manner appropriate to the particular airplane model, warnings to that effect. The proposed rule results from the NTSB investigation of the accident involving American Airlines flight 587, an A300-600 airplane, which crashed shortly after takeoff on November 12, 2001. The NTSB determined that the probable cause of that accident was, in part, the in-flight separation of the vertical stabilizer as a result of the loads beyond ultimate design that were created by the first officer’s unnecessary and excessive rudder pedal inputs. The NPRM also indicates that modifications similar to those that would be required by the proposed rule change have already been made to all transport-category airplanes’ airplane flight manuals. As a result of the investigation of the American Airlines flight 587 accident, the NTSB issued Safety Recommendation A-04-60, which asked the FAA to take the following action: Amend all relevant regulatory and advisory materials to clarify that operating at or below maneuvering speed does not provide structural protection against multiple full control inputs in one axis or full control inputs in more than one axis at the same time. The NTSB notes that this proposed rule is consistent with the intent of this recommendation. Therefore, the NTSB fully supports the proposed rule changes. Thank you for the opportunity to comment on this NPRM.

From: NTSB
To: FAA
Date: 8/3/2005
Response: The Safety Board notes that, for existing airplanes, the FAA is taking action to revise the airplane flight manuals (AFM) for all transport-category airplanes to clarify that operating at or below maneuvering speed (VA) does not provide structural protection against multiple full control inputs in one axis or full control inputs in more than one axis at the same time. The FAA has reached an agreement with transport-category airplane manufacturers to add to all AFMs a statement similar to "Avoid rapid and large alternating control inputs, especially in combination with large changes in pitch, roll, or yaw (e.g., large sideslip angles) as they may result in structural failures at any speed, including below VA." For future aircraft designs, the FAA plans to initiate rulemaking to revise 14 CFR 25.1583(a)(3) to address this issue. Until a new rule is adopted, the FAA plans to work with airplane manufacturers to incorporate the statement above for existing aircraft into the AFM for any new transport-category airplane design. The FAA also plans to review all other relevant regulatory and advisory material to determine any other material that needs a similar clarification. When the FAA completes its review (originally expected by March 2005), it will develop and incorporate revised text into the regulatory and advisory material. Pending completion of the revisions to all current transport-category AFMs, completion of revisions to 14 CFR 25.1583 (a)(3), and completion of the review and revision of all regulatory and advisory material, Safety Recommendation A-04-60 is 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 - From Marion C. Blakey, Administrator: The FAA agrees with this safety recommendation and has taken action to revise the airplane flight manuals for all transport-category airplanes to clarify that operating at or below maneuvering speed (VA) does not provide structural protection against multiple full control inputs in one axis or full control inputs in more than one axis at the same time. Currently, 14 CFR 25.1583(a)(3) requires VA to be provided as an operating limitation in the airplane flight manual along with a statement that full application of rudder or aileron controls, as well as maneuvers that involve angles of attack near the stall, should be confined to speeds below the VA. As a result of the AA587 accident, the FAA reached an agreement with transport-category airplane manufacturers to add a statement similar to the following: "Avoid rapid and large alternating control inputs, especially in combination with large changes in pitch, roll, or yaw (e.g., large sideslip angles) as they may result in structural failures at any speed, including below VA." This statement will be added to the airplane flight manuals of nearly all existing transport-category airplane types. (A small number of out-of-production airplane types or airplane types that are otherwise protected against such a structural failure scenario will not have their flight manuals revised.) The FAA plans to initiate a rulemaking action to revise 14 CFR 25.1583(a)(3) to address this issue for future transport-category airplane designs. Airplane manufacturers have requested a fresh look at integrating the new statement with the existing required statement to ensure that it clearly identifies potentially hazardous control inputs without hindering inputs necessary for recovery from abnormal situations. The rulemaking process to be used (e.g., Aviation Rulemaking Advisory Committee, Aviation Rulemaking Committee, public meeting) has not yet been determined. Until a new rule is adopted, the FAA plans to continue working with the airplane manufacturers to have the statement identified above incorporated into the airplane flight manuals for any new transport-category airplane designs. The FAA also plans to review all other relevant regulatory and advisory material to determine which other material needs a similar clarification. The FAA agrees with the Board that AC 61-23C, "Pilot's Handbook of Aeronautical Knowledge," is one example of relevant advisory material needing revision. When this review is completed, which is expected by March 2005, the FAA will identify the process for developing and incorporating revised text into final regulatory and advisory material. I will keep the Board informed of the FAA's progress on this safety recommendation.