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General Aviation Safety
On December 20, 2008, about 1818 mountain standard time, Continental Airlines flight 1404, a Boeing 737-500, N18611, departed the left side of runway 34R during takeoff from Denver International Airport (DEN), Denver, Colorado. A postcrash fire ensued. The captain and 5 of the 110 passengers were seriously injured; the first officer, 2 cabin crewmembers, and 38 passengers received minor injuries; and 1 cabin crewmember and 67 passengers (3 of whom were lap-held children) were uninjured. The airplane was substantially damaged. The scheduled, domestic passenger flight, operated under the provisions of 14 Code of Federal Regulations (CFR) Part 121, was departing DEN and was destined for George Bush Intercontinental Airport, Houston, Texas. At the time of the accident, visual meteorological conditions prevailed, with strong and gusty winds out of the west. The flight operated on an instrument flight rules flight plan.
TO THE FEDERAL AVIATION ADMINISTRATION: Modify Federal Aviation Administration Order 7110.65 to require air traffic controllers at airports with multiple sources of wind information to provide pilots with the maximum wind component, including gusts, that the flight could encounter.
Original recommendation transmittal letter:
Closed - Unacceptable Action
Denver, CO, United States
Runway Side Excursion During Attempted Takeoff in Strong and Gusty Crosswind Conditions Continental Airlines Flight 1404, Boeing 737-500, NN18611
Addressee(s) and Addressee Status:
FAA (Closed - Unacceptable Action)
Air Traffic Control,
Safety Recommendation History
In our report about the Denver accident we discussed that the accident controller had, on readily observed displays, the wind speed and direction for the approach end of the runway, the departure end of the runway, and the overall airport wind (AW) indication. The controller gave the accident pilot, as the air traffic control procedures in place directed, only the departure wind conditions. The arrival wind conditions and AW, which were shown on the same display as the departure wind conditions, were significantly higher. We issued this recommendation based on our conclusion that, although the Denver air traffic control tower (DEN ATCT) local controller had followed established practices when he provided the accident pilots with the runway 34R departure end wind information with the accident airplane’s takeoff clearance, the controller did not (nor was he clearly required to) provide information about the most adverse crosswind conditions that were displayed on his ribbon display terminal; therefore, the pilots were not aware of the high winds that they would encounter during the takeoff roll. In your letter, you indicate that providing the recommended maximum wind component, including gusts, is virtually impossible with the current state of technology. We agree with you that it is difficult for a controller to decipher all of the wind information provided from the low level windshear alert system and then mentally to calculate the various wind vectors, but that is not what we recommended. Rather, we are asking that the controller consider all of the information readily displayed to the controller. In your letter, you stated that, if the airport wind conditions had been made available to all pilots on the night of the Denver accident, aircraft with similar cross wind limitations to those of Continental would have been forced to hold and possibly divert, instead of using the runway oriented wind conditions that favored their landing runway. We are concerned that the FAA believes that, had all pilots been given more accurate crosswind information that was available and, as a result, more pilots had complied with their airplane’s limitations, the “unintended” consequence would have been decreased efficiency of airport operations. We ask that you clarify whether the FAA believes that airport operational efficiency is more important than airplanes operating within their limitations for cross-wind conditions. We note that you disagree with the recommended action, believe that the issue has been “effectively addressed” without it, and plan not to act further. Consequently, Safety Recommendation A 10 107 is classified CLOSED--UNACCEPTABLE ACTION. However, because we believe that you may not have fully understood what we were recommending before you concluded that you had effectively addressed our concern and decided that your actions were complete, we believe it would be useful for FAA and NTSB staff to meet and discuss Safety Recommendation A-10-107.
-From Michael P. Huerta, Administrator: Federal Aviation Administration (FAA) Order 107110.65V, Air Traffic Control, effective April 3, 2014, reflects the practice of providing gust information when such information is available from a specific wind source. Most Airport Traffic Control Towers (ATCT) in the National Airspace System that use Low Level Wind Shear Alert System (LLWAS) provide airport wind information, including gusts, to the pilot in accordance with FAA Order JO 7110.65V. The FAA notes this recommendation states to provide "maximum wind component, including gusts, that the flight could encounter," which is virtually impossible to accomplish with the current state of technology. Wind shear and microburst alerts are generated using sophisticated computer algorithms with a constant stream of data from multiple sensors. As early LLWAS systems proved, it is difficult for a pilot or a controller to decipher all of the wind information provided and then mentally calculate the various wind vectors. The recommended practice would create an operation problem with no safety benefit. If the airport wind had been advertised to all pi lots on the night of the accident that resulted in this recommendation, aircraft with similar limitations as Continental would have been forced to hold and possibly divert. instead of using the runway-oriented wind that favored their landing runway. Since the risk of crosswind runway excursions is low, the unintended consequence could decrease efficiency without any safety benefit. The FAA's approach continues to reflect and emphasize the responsibilities of both the pilot [as the final authority with respect to the operation of the aircraft] and the controller to prevent collisions between aircraft. The FAA must balance the demands placed on the controller so his or her primary purpose, to prevent collisions between aircraft, is not compromised. It is virtually impossible for the controller to analyze all of the possible airspace an aircraft could traverse on departure or arrival, analyze the current and past wind, and calculate "the maximum wind component, including gusts that the flight might encounter." This does not take into account variables that are unknown to the controller, including the wind that has yet to arrive at an airport sensor (or is beyond a sensor). Another unknown variable is that the controller does not know which sensor is driving any of the ribbon displays at any given time. Therefore, the FAA will continue with our current practice of providing gust information as part of a wind report. However, at airports using LL WAS, ATCT managers will continue to have discretion to designate either airport wind or runway-oriented wind for operational purposes.
Our last update from the FAA regarding these recommendations was its October 14, 2010, letter. We are concerned that, although close to 3 years have passed since then, we have received no additional information regarding the agency’s efforts to address these recommendations. Pending our timely receipt of such an update and completion of the recommended actions, Safety Recommendations A-10-107 and -109 remain classified OPEN--AWAIT RESPONSE, and Safety Recommendation A-10-115 remains classified “Open?Acceptable Response.”
The NTSB is unable to classify Safety Recommendations A-10-107 through -109 before receiving additional information from the FAA regarding actions either taken or planned to address these recommendations. Accordingly, pending our receipt of such detailed information, Safety Recommendations A-10-107 through -109 remain classified OPEN—AWAIT RESPONSE.
CC#201000393: - From J. Randolph Babbitt, Administrator: The FAA is in the process of gathering information to assess recommendations A-10-107 through A-10-109 to determine the best course of action.
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