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Safety Recommendation Details

Safety Recommendation A-10-109
Details
Synopsis: 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.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require air traffic control towers to locally develop and implement written runway selection programs that proactively consider current and developing wind conditions and include clearly defined crosswind components, including wind gusts, when considering operational advantage with respect to runway selection.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Aviation
Location: Denver, CO, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA09MA021
Accident Reports: Runway Side Excursion During Attempted Takeoff in Strong and Gusty Crosswind Conditions Continental Airlines Flight 1404, Boeing 737-500, NN18611
Report #: AAR-10-04
Accident Date: 12/20/2008
Issue Date: 7/29/2010
Date Closed:
Addressee(s) and Addressee Status: FAA (Open - Unacceptable Response)
Keyword(s): Air Traffic Control

Safety Recommendation History
From: NTSB
To: FAA
Date: 11/8/2019
Response: We note that you still plan to develop a maximum tailwind and crosswind component, based on conditions, which will be universally applied at towered airports, and that air traffic facilities will work with local users to establish criteria for runway selection at local airports. Although we continue to consider your plan responsive to this recommendation, we are concerned that you have made little progress in the almost 4 years since you last wrote to us regarding Safety Recommendation A-10-109. This recommendation is almost 10 years old, and we note that you do not expect to have a defined runway selection plan for all towered airports for another couple of years. Please expedite actions to address Safety Recommendation A-10-109. Pending the development of wind criteria for changing runways and the recommended written runway selection program, Safety Recommendation A-10-109 remains classified OPEN--UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/25/2019
Response: -From Daniel K. Elwell, Acting Administrator: The Board's letter dated April 14, 2016, noted the Federal Aviation Administration (FAA) did not address that the DEN Air Traffic Control Tower was in compliance with FAA Order JO 7110.65, Chapter 3, Section 5, paragraph 3-5-1. This paragraph states that it is best to use the runway most aligned with the wind, except in cases where a runway use program is in effect. If an operation can be safely conducted, the controllers may designate another runway for use when the selection provides the controllers and pilots with operational advantages. The pilot is obligated to determine whether he or she can safely operate on the runway offered by the controller, and he or she is always free to reject a runway assignment. While the Board urges the FAA to create a formal runway use policy for DEN, the runway use program highlighted in the Board's April 14, 2016, letter referencing FAA Order JO 7110.65 specifically addresses exceptions in the guidance for noise abatement purposes. This program contains a provision that noise will no longer be a factor in runway selection if the crosswind exceeds a certain value. On the night of the accident that provoked this recommendation, noise would not have been a factor in runway selection. A formal noise abatement program, designed to reduce noise over residential areas, would not provide an exception to the guidance to use the runway most closely aligned with the wind. As stated in our December 9, 2015, letter we will improve weather dissemination to users, continue defining crosswind performance characteristics of transport category aircraft, encourage additional pilot training and awareness of mountain wave hazards, and encourage additional pilot training in the proper response to abnormal events on the runway. We are evaluating several changes to FAA Orders to improve noise abatement programs and give additional guidance to air traffic facilities on runway selection based on wind speed and direction. These changes will take into account the circumstances of the accident, as well as the Board's concerns regarding Safety Recommendation A-10-109. We plan to establish safety standards for air traffic facilities to consider when selecting runways, including crosswind and tailwind limits for each specific towered airport. Air traffic facilities will work with local users to establish criteria with maximums for runway selection at respective local airports. We anticipate this program will be established by the end of2019. We recognize the Board's note that the crosswind information was not provided to the accident pilots. However, the pilot in command will have the final authority as to which runway can be accepted for takeoff and landing. We will establish a defined runway selection plan for all towered airports no later than the end of 2021. We also worked with the Commercial Aviation Safety Team (CAST) to complete actions outlined in the CAST safety enhancement 219, Runway Excursion Policies, Procedures, and Training to Prevent Runway Excursions. We determined that safety enhancement 219 addresses safety issues similar to Safety Recommendation A-10-109. The FAA's Air Traffic Organization established training for air traffic controllers regarding the contribution of adverse winds, runway surface conditions, and unstable approaches on the risk of runway excursion. The FAA and CAST completed this safety enhancement in December 2017. I will keep the Board informed of the FAA' s progress on Safety Recommendation A-10-109 and anticipate providing an update by January 2020.

From: NTSB
To: FAA
Date: 4/14/2016
Response: To satisfy this recommendation, the DEN ATCT specifically and the air traffic control system in general need to develop a runway selection program as directed in FAA Order 7110.65, “Air Traffic Control,” Chapter 3, “Terminal,” Section 5, “Runway Selection,” paragraph 3-5-1, “Selection,” which states that “except where a runway use program is in effect,” air traffic control personnel should use the runway most nearly aligned with the wind unless use of another runway “will be operationally advantageous, or is requested by the pilot.” As we discussed in the letter in which we issued this recommendation, in our investigation of the Denver accident, we found that the DEN ATCT did not have a formal runway-use program; however, according to DEN ATCT management personnel, they had an unofficial runway-selection policy, which was to use the runway configuration that provided the greatest operational advantage for the airport at crosswind speeds up to 20 knots. This unofficial policy also indicated that DEN ATCT personnel were to consider using a different runway when requested by a pilot or when crosswind speeds exceeded 25 knots. Requests for alternate departure runways were rare at the Denver airport and mostly occurred when crosswinds exceeded 30 knots. On the night of the accident, the DEN ATCT was operating in a runway configuration that used three runways for departures, all of which were under the control of the same local controller. Although all three of the departure runways were available for the accident flight’s departure, the DEN ATCT assigned the accident pilots runway 34R for departure, primarily because of operational considerations. The DEN ATCT local controller, who cleared the accident pilots for takeoff on runway 34R with departure winds from 270° at 27 knots, was likely not attending to the AW shown on his ribbon display terminal, which indicated westerly winds at 35 knots with gusts to 40 knots. As a result, the controller likely believed runway 34R to be an appropriate departure runway. However, if the local controller had noted (and subsequently provided the pilot with) the available AW information, which more accurately reflected the existence and ongoing development of mountain wave?related, very localized, strong and gusty winds, he may have offered, or the pilot may have requested, a runway more aligned with the wind. Further, if the DEN ATCT had a runway selection policy that explicitly detailed runway assignment procedures for operations in strong crosswinds, the local controller or the DEN ATCT management would likely have selected a runway more aligned with the wind. We issued Safety Recommendation A 10 109 because we had concluded that the DEN ATCT runway selection policy did not clearly account for crosswind components when selecting a runway configuration. In your current letter, you do not address the key issue, which is that the DEN ATCT in particular and air traffic control system in general should comply with FAA Order 7110.65, Chapter 3, Section 5, paragraph 3-5-1 and create a formal runway use policy for Denver. Instead, your letter states that the air traffic control system needs to balance safety and operational efficiency considerations, and that it is the pilot’s responsibility to ask for another runway if the pilot is uneasy with the crosswinds. We note that the crosswind information from the AW display was not provided to the accident pilots. We do not agree that you have effectively addressed this recommendation. However, you also indicated that you are working with industry to establish wind criteria for changing runways based upon user needs, and that you plan to develop and include a maximum tailwind and crosswind component based upon conditions that will be universally applied at towered airports. Although you said you consider your action complete, we believe it is premature to close this recommendation until your efforts with industry to establish wind criteria for changing runways are completed. Accordingly, pending completion of that work and development of the recommended written runway selection program, Safety Recommendation A-10-109 is classified OPEN--UNACCEPTABLE RESPONSE. We point out that this is the first substantive reply that you have provided to us regarding either of these recommendations in the 5 1/2 years since they were issued, despite our formally requesting an update on your activities 2 years ago. Actions to satisfy recommendations such as these are usually completed within 3 to 5 years. Accordingly, we ask that you expedite actions to address Safety Recommendation A-10-109.

From: FAA
To: NTSB
Date: 12/9/2015
Response: -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.

From: NTSB
To: FAA
Date: 9/6/2013
Response: 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.”

From: NTSB
To: FAA
Date: 12/16/2011
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.

From: FAA
To: NTSB
Date: 10/14/2010
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.