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Safety Recommendation Details

Safety Recommendation A-07-060
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 of thrust reverser-equipped airplanes to incorporate a procedure requiring the non-flying (monitoring) pilot to check and confirm the thrust reverser status immediately after touchdown on all landings.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: Chicago Midway Airport, 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: 4/6/2015
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Flightcrew,

Safety Recommendation History
From: NTSB
To: FAA
Date: 4/6/2015
Response: Since this recommendation was issued 7 years ago, the FAA has consistently maintained that Advisory Circular (AC) 120-71A, “Standard Operating Procedures for Flight Deck Crewmembers,” Appendix 18, “Landing Rollout-Actions and Callouts,” explicitly recommends the action specified in Safety Recommendation A-07-60. The FAA has also consistently indicated that, although compliance with ACs is not mandatory, your principal operations inspectors (POIs) are expected, as part of their routine work, to monitor whether the air carriers assigned to them have incorporated the appropriate elements of ACs into the carriers’ operations manuals. Throughout this time, we have agreed with your agency that AC 120-71A, Appendix 18, recommends the same procedures that we recommended. However, since the AC was issued on February 23, 2003, we have investigated at least two events, including the Southwest Airlines flight 1248 accident that was the basis for our issuing the recommendation, in which we found that not all carriers had implemented procedures consistent with the FAA’s guidance. Flightcrews whose carriers included the thrust reverser status callout in their procedures made the callout; flightcrews whose carriers did not include the procedure did not make the callout. Because the AC did not (and could not) constitute a requirement, we asked that you (1) survey Part 121 and 135 carriers to determine how many include the procedures recommended in Appendix 18 of AC 120-71 and, (2) for those carriers found not to include these procedures, to describe what actions you would take to encourage these carriers to implement the procedures recommended in the AC. You replied that, because POIs are expected to review ACs, surveying Part 121 and 135 operators is unnecessary and, therefore, you did not plan to perform such a survey. We continue to believe that the accidents that we investigated demonstrate that the procedures you recommend in the AC have not been adopted by all airlines, and that relying on POIs to ensure that all operators have incorporated the procedures has not proven to be effective. In your current letter, you state that you continue to believe that AC 120-71A, Appendix 18, together with POIs’ actions to ensure that operators are following the guidance, fully satisfies Safety Recommendation A-07-60. You acknowledge the two specific accidents in which the operator had not followed the guidance and in which the POI’s oversight had not identified, and led to the correction of, this problem. Nevertheless, you believe (1) that new safety management programs you have implemented will ensure that operators comply with the guidance provided in ACs and (2) that, because your POIs use an operator’s data?collected, calculated, and processed by these programs?to confirm that the operator understands and is complying with the guidance, special emphasis items for the POI (such as the survey we suggested that could be the basis for satisfying this recommendation) are no longer necessary or appropriate. We are disappointed that you consider your actions complete in response to Safety Recommendation A-07-60. We do not believe that your data collection systems are capable of detecting, before an accident or serious incident, that an operator’s approved procedures do not incorporate this guidance. Because you have made clear that you will take no further action, Safety Recommendation A-07-60 is classified CLOSED—UNACCEPTABLE ACTION. However, if you can provide further information, through a staff level briefing or documentation, that these systems have been effective in detecting an operator’s procedure that does not comply with AC 120-71A, we may reclassify this recommendation.

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.

From: FAA
To: NTSB
Date: 1/27/2015
Response: -From Michael P. Huerta, Administrator: Based on the Board's previous comments, the Federal Aviation Administration (FAA) reexamined the Takeoff and Landing Performance Assessment (TALPA) Aviation Rulemaking Committee (ARC) recommendations. We determined that the TALPA ARC recommendations do not reference thrust reversers because performance data does not require thrust reverse to stop the aircraft. However, § 121.544 requires that each pilot who is seated at the pilot controls of the aircraft, while not flying the aircraft, must accomplish pilot monitoring duties in accordance with the certificate holder's procedures, which are contained in the manual required by§ 121.133. In addition, part 121 , appendix H requires that line-oriented flight training must provide an opportunity for the pilot to demonstrate workload management and pilot monitoring skills. As stated in our previous letter, the FAA issued Advisory Circular (AC) 120-71A, Standard Operating Procedures (SOP) for Flight Deck Crewmembers. This AC includes landing action and callout provisions for the pilot monitoring to monitor thrust reverser deployment, advise the pilot of thrust reverser status, and advise the pilot if 1.6 Engine Pressure Ratio (EPR) is exceeded on a dry runway or 1.3 EPR is exceeded on a wet or contaminated runway. AC 120-71A is not intended to encourage a dialogue between the principal operations inspector (POI) and the operator; rather AC 120-71 A is used to define whether or not the operator has an appropriate SOP and is or is not following it. The FAA POI's routine work includes monitoring and ensuring that their assigned air carriers have incorporated the appropriate elements of AC 120-71 A into their operations manuals. The FAA acknowledges that two accidents have occurred since the issuance of this recommendation. However, we believe we have addressed this concern through the use of new safety management programs designed to ensure that the certificate holders are in compliance with various forms of guidance. Specifically, the Air Transportation Oversight System, the Safety Management System, and the System Approach for Safety Oversight programs collect, calculate, and process the data from the operator, which the POI will then use to confirm that the operator is in compliance. The data collection systems also capture when the operator is in compliance and verify that the operator is properly using and fully understands the current forms of guidance. The POI is expected to remind noncompliant operators of the AC and reinforce the importance of the SOP and checklist. These programs are designed to remove the need to broadcast emphasis items to the principal inspector. The FAA will continue to rely on these programs to maintain the high safety standards that exist today. I believe the FAA has effectively addressed this recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 7/8/2013
Response: We note that the FAA believes that the recommendations of the Take Off and Landing Performance Assessment Aviation Rulemaking Committee (TALPA ARC) address Safety Recommendation A-07-60; we also note that rulemaking activity related to the TALPA ARC recommendations has been delayed in order for the FAA to allocate resources to other rulemaking projects mandated by Congress. The FAA indicated in its August 23, 2010, letter that the TALPA ARC recommendations addressed the issue of a procedure requiring the monitoring pilot to check and confirm the thrust reverser status immediately after touchdown on all landings. When we replied to that letter, we asked the FAA to document the specific actions taken to address Safety Recommendation A-07-60. We have reviewed the TALPA ARC recommendations and have not found any part of them to include the action specified in Safety Recommendation A-07-60. Accordingly, we ask the FAA to identify where, specifically, one of these recommendations requires operators to incorporate the procedure we recommended for all landings of thrust reverser?equipped airplanes. In its letter, the FAA reiterates an issue discussed in its January 8, 2008, letter. In Advisory Circular (AC) 120-71A, “Standard Operating Procedures for Flight Deck Crewmembers,” Appendix 18, “Landing Rollout-Actions and Callouts,” the FAA explicitly recommends the action specified in Safety Recommendation A-07-60. The FAA indicated that, although compliance with ACs is not mandatory, FAA principal operations inspectors (POIs) are expected, as part of their routine work, to monitor whether the air carriers assigned to them have incorporated the appropriate elements of ACs into their operations manuals. On June 13, 2008, we replied that this AC, issued February 23, 2003, addressed the intent of the recommendation. However, we were then investigating several accidents and incidents involving runway overruns on contaminated runways that occurred several years after the AC had been issued. In the course of these investigations, we found that some carriers had implemented procedures consistent with the guidance provided in Appendix 18, while other carriers had not. When a carrier’s procedures included the thrust reverser status callout, the crew made the callout, but when a carrier did not include the procedure, the crew did not make the callout. Therefore, because the AC did not (and could not) constitute a requirement, we asked the FAA to survey Part 121 and 135 carriers (1) to determine how many include the procedures recommended in Appendix 18 of AC 120-71 and, for those carriers found not to include these procedures, (2) to describe what actions the FAA would take to encourage these carriers to implement the procedures recommended in the AC. In its current letter, the FAA replied that because POIs are expected to review ACs, it believes that surveying Part 121 and 135 operators is unnecessary and, therefore, it does not plan to perform such a survey. We are disappointed and concerned by the FAA’s response concerning the AC. In both the Southwest Airlines flight 1248 accident and in the runway overrun while landing at Traverse City, Michigan, of Pinnacle Airlines flight 4712, a Bombardier/Canadair Regional Jet CL600 2B19, we found that the flightcrew had not taken the action specified both in this recommendation and in Appendix 18 of AC 120-71, nor did the airlines’ procedures require the callout and confirmation. The Southwest flight 1248 accident occurred in December 2005, almost 3 years after the AC had been issued; the Pinnacle flight 4712 accident occurred in April 2007, more than 4 years after the AC had been issued. We believe that these accidents demonstrate that the procedures in the AC have not been adopted by all airlines, and that relying on POIs to ensure that they have been has not proven effective. Accordingly, we believe that the FAA needs to identify and resolve the reasons for the noncompliance with its guidance. Although we are unable to find the recommended requirement in any of the TALPA ARC recommendations, we acknowledge the FAA’s belief that these recommendations satisfy Safety Recommendation A-07-60. Accordingly, pending the FAA’s identifying the specific, relevant language in the TALPA ARC recommendations, and completion of the recommended action, Safety Recommendation A-07-60 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 4/8/2013
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 t, 91. 121, 125. and 135; airport rules in part 139; as well as FAA internal air traffic control procedures and orders. The FAA believes the ARC recommendations address this sarety recommendation. Rulemaking activity related to these recommendations has been delayed to allocate resources to rulemaking projects mandated under the Airline Safety and Federal Aviation Administration Extension Act 0[2010 (Public Law 111-216). Additionally, these changes will be coordinated with the International Civil Aviation Organization. Transport Canada, the European Aviation Safety Agency, and other foreign regulatory authorities. The FAA TALPA roll out team is currently creating a program time line to support implementation of the TALPA ARC recommendations. A specific task of the team is to develop communications with elements of the domestic and international aviation community. In the meantime, the FAA is developing a comprehensive program to support implementation of the TALPA ARC recommendations through appropriate non-regulatory activity. 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. The FAA reminds the Board that we explicitly recommend the checking and confirming actions of the non-flying (monitoring) pilot, as recommended by the Board, in Advisory Circular (AC) 120-71 A. Standard Operating Procedures for Flight Deck Crcw111cmbers. Appendix 18. Landing Rollout - Actions and Cal louts, is devoted entirely to the phase of flight immediately after touchdown, and specifies that the pilot monitoring: • Monitors thrust reverser deployment; and • Advises the pilot flying of thrust reverser status. While compliance with ACs is not mandatory, FAA principal operations inspectors (POIs) are expected, as part of their routine work, to monitor whether the air carriers assigned to them have incorporated the appropriate elements of ACs into their operations manuals. Because POIs are expected to review ACs. we believe surveying part 121 and 135 operators is unnecessary and we have no plans to survey these operators. I will keep the Board informed of the FAA's progress on this safety recommendation and provide an update by February 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: The FAA indicated that Advisory Circular (AC) 120-71, Standard Operating Procedures for Flight Deck Crewmembers, Appendix 18, Landing Rollout Actions and Callouts, explicitly recommends the procedures recommended, stating that immediately after touchdown, the pilot monitoring should monitor thrust reverser deployment and advise the pilot flying of thrust reverser status. The AC, issued February 23, 2003, addresses the intent of this recommendation. However, the Safety Board is investigating several accidents and incidents involving runway overruns on contaminated runways that occurred several years after the AC was issued. In the course of these investigations, the Board found that some carriers have implemented procedures consistent with the guidance in Appendix 18, while other carriers have not. These investigations have found that when a carrier’s procedures included the thrust reverser status callout, the crew made the callout, but when a carrier did not include the procedure, the crew did not make the callout. Therefore, because the AC is not a requirement, the Board asks the FAA to survey Part 121 and 135 carriers to determine how many include the procedures recommended in Appendix 18 of AC 120-71. For those carriers found not to include these procedures, the Board asks the FAA to describe what actions it will take to encourage these carriers to implement the procedures recommended in the document. Pending our review of the results of such a survey, Safety Recommendation A-07-60 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-07-60: The FAA has explicitly recommended the checking and confirming actions of the non-flying (monitoring) pilot, as recommended by the Board, in Advisory Circular (AC) 120-71, Standard Operating Procedures for Flight Deck Crewmembers. Appendix 18, Landing Rollout-Actions and Callouts is devoted entirely to the phase of flight immediately after touchdown, and specifies that the pilot monitoring: ·Monitors thrust reverser deployment; and ·Advises PF [the pilot flying] of thrust reverser status.