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Safety Recommendation Details

Safety Recommendation A-07-058
Details
Synopsis: On December 8, 2005, about 1914 central standard time, Southwest Airlines (SWA) flight 1248, a Boeing 737-7H4, N471WN, ran off the departure end of runway 31C after landing at Chicago Midway International Airport (MDW), Chicago, Illinois. The airplane rolled through a blast fence, an airport perimeter fence, and onto an adjacent roadway, where it struck an automobile before coming to a stop. A child in the automobile was killed, one automobile occupant received serious injuries, and three other automobile occupants received minor injuries. Eighteen of the 103 airplane occupants (98 passengers, 3 flight attendants, and 2 pilots) received minor injuries, and the airplane was substantially damaged. The airplane was being operated under the provisions of 14 Code of Federal Regulations (CFR) Part 121 and had departed from Baltimore/Washington International Thurgood Marshall Airport, Baltimore, Maryland, about 1758 eastern standard time. Instrument meteorological conditions prevailed at the time of the accident flight, which operated on an instrument flight rules flight plan.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require all 14 Code of Federal Regulations Part 121 and 135 operators to ensure that all on board electronic computing devices they use automatically and clearly display critical performance calculation assumptions.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Aviation
Location: Chicago, IL, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA06MA009
Accident Reports: Runway Overrun and Collision Southwest Airlines Flight 1248 Boeing 737-74H, N471WN
Report #: AAR-07-06
Accident Date: 12/8/2005
Issue Date: 10/16/2007
Date Closed:
Addressee(s) and Addressee Status: FAA (Open - Acceptable Response)
Keyword(s): Flight Computer

Safety Recommendation History
From: NTSB
To: FAA
Date: 3/4/2015
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) draft Advisory Circulars (AC) 25-X, “Takeoff Performance Data for Operations on Contaminated Runways,” and AC 25-X, “Landing Performance Data for Time-of-Arrival Landing Performance Assessments,” which were posted for comment on the FAA’s website on January 21, 2015. Both of these draft ACs provide guidance and standardized methods that data providers, such as type certificate (TC) holders, supplemental type certificate (STC) holders, applicants, and airplane operators can use when developing performance data for transport category airplanes for operations on contaminated runways. The AC also promotes the use of consistent terminology for runway surface conditions used among data providers and FAA personnel. The NTSB has investigated several accidents within the last 10 years that involve issues addressed by these ACs. As a result of these investigations, the NTSB issued Safety Recommendations A 07 57 through 64, A 08 17, A 08 41 through 43, and A 11 28 and 29. Although the NTSB recommendations concern needed requirements, and ACs are advisory only, the draft ACs address in part most of these recommendations.

From: NTSB
To: FAA
Date: 2/10/2015
Response: We issued this recommendation because, in our investigation of the Southwest Airlines flight 1248 accident, we found that the flightcrew had used an OBC to determine whether the runway at Midway Airport was long enough for the landing, given the conditions at the time, which included an 8-knot tailwind. Because the maximum allowable tailwind for Southwest Airlines was 5 knots, the OBC used the lower number in calculating performance, despite the crew’s having entered 8 knots as the tailwind speed. The OBC did not warn the crew that the tailwind exceeded Southwest’s allowable limits nor that the device was using a different tailwind speed than the value entered in performing its calculations. Using the incorrect data, the computer provided the crew a landing distance that was within the length of the runway. As a result, we issued Safety Recommendation A-07-58 to address the issues of an electronic aid using a different value for performance calculations than the input data entered, and then failing to warn of this change when displaying its results. Over the past 7 years, the FAA has indicated that actions by the Takeoff/Landing Performance Assessment Aviation Rulemaking Committee (TALPA ARC) would address this recommendation. Although the TALPA ARC issued its recommendations to the FAA in mid 2009, we are not aware that the TALPA ARC either considered the issues addressed by Safety Recommendation A-07-58 or made any recommendations regarding them. When we held the teleconference with your staff on December 16, 2014, we discussed the basis for and specifics of this recommendation, and asked whether the TALPA ARC had made any recommendations to the FAA concerning the specific issues related to OBCs. Your staff replied that the TALPA ARC had not, but that, as a result of our teleconference, they better understood the recommendation and would consider whether any related activities that the FAA has pursued since the Southwest Airlines flight 1248 accident, such as issuing regulations and guidance associated with electronic flight bags, adequately address Safety Recommendation A-07-58. They further explained that, if existing regulations and guidance do not adequately address these issues, you would consider what should be done. This recommendation is now 7 years old, and we generally expect action in response to our safety recommendations to be completed within 5 years. In light of our December 16, 2014, teleconference to clarify the action needed, we are keeping the recommendation open, but we urge you act expeditiously to address it. Pending timely action, Safety Recommendation A 07-58 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/28/2014
Response: -From Michael P. Huerta, Administrator: In its December I 6, 2013, letter, the Board recognized that the Federal Aviation Administration (FAA) will be addressing the Takeoff and Landing Performance Assessment (TALPA) Aviation Rulemaking Committee (ARC) recommendations through non-regulatory means as an interim response. Currently, certain aircraft manufacturers offer products that calculate and convey airplane braking ability required and/or available to slow or stop the airplane during the landing roll. For example, Airbus offers the Runway Overrun Prevention System (ROPS) to help prevent runway overruns. Airbus decided not to keep its patented ROPS as a product differentiator and plans to release it to competing aircraft builders. Other manufacturers are developing programs that would report braking action to the air carriers' dispatch centers. One airline utilizes Aviation Safety Technologie's (AST's) SafeLand software system, which monitors and measures aircraft systems in real time to display three dimensional aircraft simulation from landing to ground movements. This information is then sent to home base via the Aircraft Communications Addressing and Reporting System. The AST's algorithm can deliver normalized braking reports as well as runway braking and cornering coefficients. This information will then be shared with aircraft crew members prior to their arrival and can be used to determine real -time braking performance. The FAA encourages the use of such programs and products on a voluntary basis, and we are no longer considering rulemaking related to TALPA or regulating performance data. The FAA does not see a need to conduct a research project on their feasibility because these systems are becoming commercially available. However, as a result of the TALPA ARC recommendations, many document changes will be forth coming, including changes to much of the information currently contained in Safety Alert for Operators (SAFO) 060 12, with an expected target completion elate of October 2016. We plan to incorporate information contained in SAFO 060 12 into the following documents: • Advisory Circulars; • Aeronautical Information Manual; • Notices to Airmen; • Air Traffic Control guidance and manuals; and • Airport guidance and manuals. In addition to the creation of documents and document changes, we are developing the Runway Condition Assessment Matrix (RCAM) tool. The RCAM takes a known assessment criteria provided from the airport and provides the pilot with a downgrade assessment criterion. This downgrade assessment criterion is based on the reported runway conditions, such as the reported runway friction expressed in mu (m) values and reported braking action. This information will provide the pilot with an expected braking ability to slow or stop the airplane during the landing roll. The RCAM is still under final development and the procedures required to use this matrix have not yet been addressed. I will keep the Board informed of the FAA's progress on these safety recommendations and provide an update by January 31, 2016.

From: NTSB
To: FAA
Date: 12/16/2013
Response: We are aware that, in mid-2009, the FAA received the recommendations of its TALPA ARC, but that the agency’s planned rulemaking in response to those recommendations has been delayed because the FAA has been forced to reallocate resources needed to develop the regulations to rulemaking projects that Congress mandated under the Airline Safety and Federal Aviation Administration Extension Act of 2010 (Public Law [PL] 111-216) and the FAA Modernization and Reform Act of 2012 (PL 112-95). Currently, the FAA is developing a program to implement the TALPA ARC recommendations through non-regulatory means. We acknowledge the resource issues created by PL 111-216 and PL 112 95 that impact full implementation of our safety recommendations. Although the details of the FAA’s program for implementing the TALPA ARC recommendations through non-regulatory means are not yet available for our review, these initiatives may constitute effective interim responses until the needed regulatory reforms can be completed. Accordingly, pending the FAA’s completing the actions recommended, Safety Recommendations A-07-58, -59, -63, and A-08-41 remain classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/6/2013
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) received the Takeoff and Landing Performance Assessment (TALPA) Aviation Rulemaking Committee (ARC) recommendations for landing performance assessments in April 2009 and for contaminated runway takeoff performance in July 2009. The TALPA ARC recommended comprehensive changes to aircraft certification rules in parts 23, 25, and 26; operating rules in parts 1, 91, 121, 125, and 135; airport rules in part 139; as well as FAA internal air traffic control procedures and orders. Rulemaking activity related to these ARC recommendations has been delayed to allocate resources to rulemaking projects mandated under the Airline Safety and Federal Aviation Administration Extension Act of2010 (Public Law 111 -216) and the FAA Modernization and Reform Act of2012 (Public Law 112-95). However, the FAA is developing a comprehensive program to support implementation of the TALPA ARC recommendations through appropriate non-regulatory activity. After extensive testing, which continued into the winter season of 20 1 0 and 2011, the FAA is working to review and analyze the data related to the Runway Surface Condition Reporting Matrix that was developed by the ARC for assessing and reporting runway surface conditions. This matrix provides a common language for all users of runway surface condition information and is the cornerstone to most of the TALPA ARC recommendations. The matrix is the first necessary step in development of associated rule and policy changes. Completing this matrix and revising Safety Alert for Operators 06012, Landing Performance Assessments at Time of Arrival (Turbojets), would be part of our comprehensive program. Approval of this program is anticipated in the near future. Specific content of this program is not available because final approval is not yet complete. I will keep the Board informed of the FAA's progress on these safety recommendations and provide an update by June 2014.

From: NTSB
To: FAA
Date: 1/31/2011
Response: The FAA indicated that it is currently evaluating the recommendations n1ade by the Take Off and Landing Performance Assessn1ent (TALPA) Aviation Rulemaking Committee (ARC). The NTSB notes that the FAA is also working with 10 airports and 2 air carriers to validate the accuracy and usability of the Runway Surface Condition Reporting Matrix that was developed by the TALPA ARC for assessing and reporting runway surface conditions. The FAA's efforts to address Safety Recommendations A-07-61, A-07-63, and A-08-41 are responsive; however, the NTSB encourages the FAA to initiate and complete rulemaking in a timely manner in response to the ARC's recon11nendations. In addition, the NTSB requests that the FAA document the specific actions taken to address Safety Recon1mendations A-07-58 through -60 and -64. Pending our receipt and review of this information, and the FAA's prompt action to address these recommendations, Safety Recon1n1endations A-07-58 through -61, -63, -64, and A-08-41 remain classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/23/2010
Response: MC# 201000343: - From J. Randolph Babbitt, Administrator: The Federal Aviation Administration received the Take Off and Landing Performance Assessment (TALPA) Aviation Rulemaking Committee's (ARC) recommendations for landing performance assessment in April 2009 and for contaminated runway takeoff performance in July 2009. The FAA is evaluating the ARC recommendations and intends to initiate rulemaking in 2011. In the interim, the FAA in cooperation with ten airports and two air carriers is in the process of validating the accuracy and usability of the Runway Surface Condition Reporting Matrix that was developed by the ARC for assessing and reporting runway surface conditions. This matrix forms the cornerstone to many of the recommendations put forth by the TALPA. The FAA also continues to encourage operators to incorporate the safety elements contained in Safety Alert for Operators 06012 pending the completion of the rulemaking process. I will keep the Board informed of the FAA's progress on these safety recommendations and provide an updated response by January 2011.

From: NTSB
To: FAA
Date: 6/13/2008
Response: Safety Alert for Operators (SAFO) 06012, issued August 31, 2006, addresses landing distance assessments using a 15-percent safety margin. The SAFO recommends that aircraft dispatchers and flight crews be trained in the assumptions embedded in the landing performance information made available for their use, including on board electronic computing (OBC) devices. The FAA stated that it plans to supersede the SAFO with an amended version that will explicitly recommend revising electronic displays, placarding electronic devices, or including highlighted statements in performance manuals to clearly identify the critical assumptions that pertain to the performance calculations reported to the user. The planned revisions to the SAFO appear to be responsive to the recommendation provided that they recommend that all OBC devices automatically and clearly display critical performance calculation assumptions. However, SAFOs are advisory only, while this recommendation asks that Part 121 and Part 135 carriers be required to incorporate the guidance planned in the SAFO. The Safety Board asks the FAA to describe what actions it will take to ensure that carriers implement the guidance. Pending the answer to that question and issuance of the revised SAFO, Safety Recommendation A-07-58 is classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 1/8/2008
Response: Letter Mail Controlled 1/14/2008 3:39:36 PM MC# 2080007: - From Robert A. Sturgell, Acting Administrator, FAA, 1/8/08 Since the Southwest 1248 accident the Federal Aviation Administration has taken several actions to address the safety issues that are the focus of these recommendations, including the development of proposed Operations Specification C082, and the issuance of Safety Alert for Operators (SAFO) 06012, which address landing distance computation with a 15 percent safety margin. A survey of part 121 operators, the results of which have been briefed to the Board's staff, indicates that 92 percent of U.S. airline passengers are now being carried by air carriers in full or partial compliance with the practices recommended in SAFO 06012. On November 6, 2007, the FAA issued Advisory Circular (AC) 91-79, Runway Overrun Prevention (copy enclosed). This AC provides ways for pilots and operators of turbine-powered airplanes to identify, understand, and mitigate risks associated with runway overruns during the landing phase of flight. It also provides operators with detailed information that may be used to develop company standard operating procedures to mitigate those risks. The broader mandate that the Board is now recommending will require rulemaking. On December 6,2007, the FAA issued a notice announcing the formation of an aviation rulemaking committee (ARC) to review regulations affecting certification and operation of airplanes and airports for airplane takeoff and landing operations on contaminated runways (72 FR 68763) (copy enclosed). The ARC will provide advice and recommendations to: ·Establish airplane certification and operational requirements (including training) for takeoff and landing operations on contaminated runways; ·Establish landing distance assessment requirements, including minimum landing distance safety margins, to be performed at the time of arrival; and ·Establish standards for runway surface condition reporting and minimum surface conditions for continued operations. While this rulemaking effort progresses, we will continue to work with the air carriers and industry to gain the widest possible compliance with the elements of SAFO 06012. In addition to these actions, below is the additional work being done for certain specific recommendations: For A-07-58: SAFO 06012 recommends that aircraft dispatchers and flight crews be trained in the assumptions imbedded in the landing performance information made available for their use. The FAA plans to supersede that SAFO with an amended version that would explicitly recommend revising electronic displays, placarding electronic devices, or including highlighted statements in performance manuals. By whatever method the operator might choose, the information displayed to an aircraft dispatcher or a pilot would clearly identify what critical assumptions pertain to the performance calculations reported to the user. The critical assumptions would be identified by a competent panel comprising managers, the users, and the FAA, for each certificate holder.