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Safety Recommendation Details

Safety Recommendation A-05-015
Details
Synopsis: On December 18, 2003, about 1226 central standard time, Federal Express Corporation (FedEx) flight 647, a Boeing MD-10-10F (MD-10),1 N364FE, crashed while landing at Memphis International Airport (MEM), Memphis, Tennessee. The right main landing gear collapsed after touchdown on runway 36R, and the airplane veered off the right side of the runway. After the gear collapsed, a fire developed on the right side of the airplane. Of the two flight crewmembers and five nonrevenue FedEx pilots2 on board the airplane, the first officer and one nonrevenue pilot received minor injuries during the evacuation. The postcrash fire destroyed the airplane’s right wing and portions of the right side of the fuselage. Flight 647 departed from Metropolitan Oakland International Airport, Oakland, California, about 0832 (0632 Pacific standard time) and was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 on an instrument flight rules flight plan.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Amend the emergency exit training information contained in the flight crew and cabin crew sections in Federal Aviation Administration Order 8400.10, Air Transportation Aviation Inspectors Handbook, to make the emergency exit door/slide training described in the flight crew section as comprehensive as the cabin crew emergency training section of the principal operations inspector handbook.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Memphis, TN, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA04MA011
Accident Reports: Hard Landing, Gear Collapse Federal Express Flight 647, Boeing MD-10-10F, N364FE
Report #: AAR-05-01
Accident Date: 12/18/2003
Issue Date: 5/31/2005
Date Closed: 7/18/2012
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Evacuation, Flightcrew, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/18/2012
Response: The NTSB notes that Notice 8900.149, “Accuracy of Emergency Exit and Escape Devices Training Provided to Flightcrew Members,” published on March 18, 2011, emphasizes to POIs that emergency training programs under section 121.417 should include pulling the manual inflation handle. We believe that the contents of Order 8900.1, volume 3, chapter 19, section 4, and Notice 8900.149 together provide the comprehensive recommended guidance to POIs. Accordingly, Safety Recommendation A-05-15 is classified CLOSED—ACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 5/5/2012
Response: -From Michael P. Huerta, Acting Administrator: As mentioned in our May 26, 2010, letter, Federal Aviation Administration (FAA) Order 8400.10, Air Transportation Aviation Inspectors Handbook, was incorporated into FAA Order 8900.1, Flight Standards Information Management System (FSIMS). Volume 3, chapter 19, section 4 of FAA Order 8900.1 incorporates changes based on this recommendation and best practices for the development of flightcrew emergency training curriculum. We believe these changes helped align the flight and cabin crewmember emergency training sections of FAA Order 8900.1. Title 14, Code of Federal Regulations (14 CFR) section 121.417, Crewmember emergency training, states that each 14 CFR part 121 crewmember training program must provide emergency training that includes specific items. Section 121.4l7(b)(2)(iv) states that these training programs must include training on, "[e]mergency exits in the emergency mode with the evacuation slide/raft pack attached (if applicable), with training emphasis on the operation of the exits under adverse conditions." To ensure the accuracy of training being delivered, we published Notice 8900.149, Accuracy of Emergency Exit and Escape Devices Training Provided to Flightcrew Members, on March 18, 2011. The purpose of this Notice was to direct principal operations inspectors responsible for 14 CFR part 121 air carrier training programs to ensure the accuracy of training being delivered to flightcrew members with respect to emergency exits and escape devices. Further, this Notice emphasizes the importance of harmonization between FAA Order 8900.1 guidance for cabin crewmember and flight crewmember training requirements. In its November 29, 2010, letter, the Board "reiterated that the emergency exit training requirements for both flight and cabin crewmembers should include a requirement to pull the manual inflation handle." Notice 8900.149 clearly states that emergency training programs under section 121.417 should include pulling the manual inflation handle. Additionally, FAA Order 8900.1, volume 3, chapter 19, section 4, paragraph 3-1169 includes the "[O]peration of emergency exits (such as floor level, overwing, and tail cone) in the normal and emergency modes" as a training requirement for flight crewmembers and FAA Order 8900.1, volume 3, chapter 23, section 4, paragraph 3-1801, specifically states that cabin crewmembers must receive training that includes: Actual Opening of Each Type of Door Exit in Emergency Mode: Ability to open exit properly by assuming correct body/protective position; to use door controls correctly; to ensure that door is in open and locked position; to use manual slide inflation system to accomplish or ensure slide or slide raft inflation To help determine if additional training on the operation of emergency exits was necessary, we reviewed the Board's accident and incident data for 14 CFR parts 121 and 135 operators over the last 10 years. We also reviewed the FAA Accident and Incident Data System. The review included causal factors and searches of narrative text and fixed fields. We were unable to find any accidents or incidents, besides the accident that generated this recommendation, in which a flight crewmember's inability to properly open an exit during an emergency was cited in the accident or incident report. We acknowledge that the information in the flight and cabin crewmember emergency exit training sections of FAA Order 8900.1 is not identical. However, we believe that the changes to FAA Order 8900.1 to address this recommendation and the issuance of the Notice, in conceit with the data, represent an appropriate response to this recommendation. I believe the FAA has effectively addressed this safety recommendation, and I consider our actions complete.

From: NTSB
To: FAA
Date: 11/29/2010
Response: In its September 9, 2005, letter, the FAA indicated that it would revise FAA Order 8400.10, Air Transportation Aviation Inspectors Handbook, to reflect guidance to inspectors regarding training in emergency exit doors/slides for flight crewmembers, just as it does for cabin crewmembers. Subsequently, the FAA incorporated 8400.10 into 8900.1; however, after reviewing the guidance contained in volume 3, chapter 19, section 4, of FAA Order 8900.1, which the FAA provided in response to this recommendation, the NTSB still believes that the guidance is inadequate for POls to use to ensure that emergency exit door/slide training for flight crewmembers is as comprehensive as that which cabin crewmembers receive or is as comprehensive as that intended by the recommendation. The NTSB reiterates that the emergency exit training requirements for both flight and cabin crewmembers should include a requirement to pull the manual inflation handle. The FAA's response to Safety Recommendation A-05-015 is unacceptable, and the NTSB is disappointed that it has taken the FAA more than 4 years to provide this information. Accordingly, pending the FAA's timely revisions to Order 8900.1, Safety Recommendation A-05-015 is classified OPEN – UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/16/2010
Response: Letter Mail Controlled 6/16/2010 12:00:13 PM MC# 2100204 - From J. Randolph Babbitt, Administrator: Federal Aviation Administration Order 8400.10, Air Transportation Aviation Inspectors Handbook, was incorporated into FAA Order 8900.1, Flight Standards Information Management System. Volume 3, chapter 19, section 4 of FAA Order 8900.1 (enclosed) incorporates recommendations and best practices for the development of flightcrew member and cabin crew emergency training curriculum. I believe the FAA has effectively addressed this safety recommendation by making the recommended revision to the FAA Order and I consider our actions complete.

From: NTSB
To: FAA
Date: 1/19/2006
Response: The Safety Board notes that the FAA agrees that FAA Order 8400.10, Aviation Safety Inspector's Handbook, should reflect guidance to inspectors regarding training in emergency exit doors/slides for flight crewmembers, just as it does for cabin crewmembers. Accordingly, pending the FAA's revisions to Order 8400.10, which was anticipated to be completed by December 31, 2005, Safety Recommendation A-05-15 is classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/8/2005
Response: Letter Mail Controlled 9/14/2005 3:07:09 PM MC# 2050430 - From Marion C. Blakey, Administrator: 9/8/05 The FAA agrees with the Board that FAA Order 8400.10, Aviation Safety Inspector's Handbook, should reflect comprehensive guidance to inspectors regarding training in emergency exit door/slides for flight crewmembers, just as it does for cabin crewmembers. The FAA will revise FAA Order 8400.10 to incorporate guidance regarding training for flight crewmembers. It is anticipated that the order will be revised by December 31, 2005. I will provide the Board with a copy of the revision to FAA Order 8400.10 as soon as it is issued.