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Safety Recommendation Details

Safety Recommendation A-10-119
Details
Synopsis: On November 12, 2001, about 0916 eastern standard time, an Airbus A300-605R,1 N14053, operated as American Airlines flight 587, crashed into a residential area of Belle Harbor, New York, shortly after takeoff from John F. Kennedy International Airport, Jamaica, New York.2 Following an encounter with wake turbulence from a preceding Boeing 747 (747), the first officer made a series of full alternating rudder pedal inputs before the airplane’s vertical stabilizer and rudder separated in flight; both were found in Jamaica Bay about 1 mile north of the main wreckage site.
Recommendation: TO THE EUROPEAN AVIATION SAFETY AGENCY: Modify European Aviation Safety Agency Certification Specifications for Large Aeroplanes CS-25 to ensure safe handling qualities in the yaw axis throughout the flight envelope, including limits for rudder pedal sensitivity.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Belle Harbor, NY, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA02MA001
Accident Reports: In-Flight Separation of Vertical Stabilizer American Airlines Flight 587, Airbus Industrie A300-605R, N14053
Report #: AAR-04-04
Accident Date: 11/12/2001
Issue Date: 8/4/2010
Date Closed: 5/13/2019
Addressee(s) and Addressee Status: European Aviation Safety Agency (Closed - Acceptable Action)
Keyword(s): Rudder

Safety Recommendation History
From: NTSB
To: European Aviation Safety Agency
Date: 5/13/2019
Response: You previously told us that, as an interim solution, you had issued a special condition to ensure that an airplane is designed for loads, considered as ultimate, resulting from the application of two rudder reversal pedal inputs. We note that, in November 2018, you issued Executive Director Decision 2018/010/R, which amended CS-25 (amendment 22) with a new yaw maneuver condition and related acceptable means of compliance (AMC) to ensure that an airplane’s structure is adequately protected from the loads created by rudder control reversals. This amendment clarifies the maneuvering speed limitation statements in the Airplane Flight Manual, and updates the related AMC to ensure that the limitations section recommends that the flight crew avoid large and rapidly alternating control inputs, including those below the maneuvering speed. We believe these actions satisfy the intent of Safety Recommendation A-10-119, which is classified CLOSED--ACCEPTABLE ACTION.

From: European Aviation Safety Agency
To: NTSB
Date: 12/11/2018
Response: -From Erick Ferrandez, Head of Safety Intelligence and Performance Department: The FAA Aviation Rulemaking Advisory Committee (ARAC) established the Flight Controls Harmonization Working Group (FCHWG) to assist in the analysis of the issue of rudder pedal sensitivity and rudder reversals (notice published under Federal register Vol.76, No. 59, dated 28 March 2011). The task of the group was to review the need to revise existing certification specifications for large aeroplanes as well as the need to enforce retroactive measures for the already certificated aircraft. EASA participated in this group which released its "Rudder Pedal Sensitivity/Rudder Reversal Recommendation Report", dated November 7 2013. The report includes recommendations for the amendment of FAR Part 25 and EU CS-25. It is available on the FAA Website at: http://www.faa.gov/regulations_policies/rulemaking/committees/documents/media/taefch_rpsrrtl-32811.pdf As an interim action, based on this report, the Agency issued a Special Condition (SC) to ensure that the aeroplane is designed for loads, considered as ultimate, resulting from the application of two rudder reversal pedal inputs. Rulemaking task RMT.0397 'Unintended or inappropriate rudder usage - rudder reversals' was launched on 30 May 2017 to propose new certification specifications in CS-25 (applicable to new certification projects for large aeroplanes) to mitigate the risk 'of pilots' unintended or Inappropriate rudder pedal usage. This resulted in the publication of Notice of Proposed Amendment (NPA) 2017-18, dated 27/11/17, which proposed new specifications and acceptable means of compliance consistent with the SC. The NPA is available on the EASA Website: https://www.easa.europa.eu/document-library/notices-of-proposedamendment/npa-2017-18 Based on this NPA, the comments received, and in cooperation with the FAA to harmonise as much as possible, EASA issued Executive Director (ED) Decision 2018/010/R, dated 5 November 2018, amending CS-25 (amendment 22): https://www .easa.europa.eu/document-library/agency-decisions/eddecision-2018010r This amendment: - creates a new CS 25.353 yaw manoeuvre condition, consisting of a two-pedal doublet manoeuvre, and the related AMC 25.353. This will ensure that the structure of the aeroplane ls adequately protected from the loads created by rudder control reversals; and - clarifies the existing CS 25.1583(a)(3) regarding manoeuvring speed limitation statements in the Aeroplane Flight Manual (AFM), and amends the related AMC 25.1581. This will ensure that statements are included in the limitations section of AFMs to recommend to the flight crew that they should avoid large and rapid alternating control inputs, including such inputs below the manoeuvring speed.

From: NTSB
To: European Aviation Safety Agency
Date: 9/26/2018
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration's (FAA) notice of proposed rulemaking (NPRM) titled, “Yaw Maneuver Conditions—Rudder Reversals,” which was published at 83 Federal Register 32807 on July 16, 2018. Another incident occurred on January 10, 2008, involving Air Canada flight 190, an Airbus A319 that experienced a sudden in-flight upset after encountering wake turbulence from a Boeing 747 while climbing from flight level (FL) 360 to FL370. With the autopilot on, the airplane initially rolled 28° to the left and then rolled back to 10° to the right. A series of large oscillatory inputs on the lateral and longitudinal side-stick controller and on the rudder pedals followed. During these inputs, the airplane continued to oscillate in roll, achieving roll angle peaks of up to 56° left and 37° right before returning to level flight. Of the 5 crewmembers and 83 passengers on board, 2 crewmembers and 8 passengers sustained minor injuries. As a result of the NTSB’s participation in the Transportation Safety Board of Canada’s investigation of this incident and our findings from the American Airlines flight 587 accident investigation, we issued Safety Recommendation A-10-119 to the European Aviation Safety Agency (EASA). This recommendation asked EASA to take action similar to that in Safety Recommendation A-04-56 for transport-category airplanes designed and certificated in Europe. Pending issuance of appropriate revisions to EASA Certification Specifications for Large Aeroplanes CS-25, Safety Recommendation A-10-119 is currently classified “Open—Acceptable Response.” The NTSB is pleased that the FAA has issued this long-delayed NPRM and urges the FAA to move quickly to complete this rulemaking and issue the revised certification standard.

From: NTSB
To: European Aviation Safety Agency
Date: 7/21/2016
Response: We note that you participated in the Federal Aviation Administration’s (FAA) Aviation Rulemaking Advisory Committee Flight Controls Harmonization Working Group that examined rudder pedal sensitivity and rudder reversals. On March 28, 2011, the FAA tasked this group to examine the issues specified in Safety Recommendation A 04 56, which was issued to the FAA and is substantially similar to Safety Recommendation A-10-119. On November 7, 2013, this group produced a report that included recommendations for the amendment of FAA regulations in Part 25 and EASA regulation CS-25. We further note that, based on the group’s determinations, on November 12, 2015, you issued a draft Special Condition (SC) to ensure that an airplane must be designed for loads, considered as ultimate, resulting from the application of two rudder reversal pedal inputs. This SC will be applied to new airplane type certificates after the publication of the final SC. Finally, we note that you created rulemaking task RMT.0397 to develop a new rule for CS-25 based on the SC, once the final SC is issued. We were pleased to see the SC you issued, allowing for early introduction of this new requirement before the time required for a full revision to CS-25. Pending issuance of appropriate revisions to CS-25 based on the findings of the ARAC report, Safety Recommendation A-10-119 remains classified OPEN—ACCEPTABLE RESPONSE.

From: European Aviation Safety Agency
To: NTSB
Date: 4/27/2016
Response: -From Rachel Daeschler, Deputy Strategy and Safety Management Director and Head of Safety Intelligence and Performance Department: The FAA Aviation Rulemaking Advisory Committee (ARAC) established the Flight Controls Harmonization Working Group (FCHWG) to assist in the analysis of the issue of rudder pedal sensitivity and rudder reversals (notice published under Federal register Vol.76, No. 59, dated 28 March 2011). The task of the group was to review the need to revise existing certification specifications for large aeroplanes as well as the need to enforce retroactive measures for the already certificated aircraft. EASA participated to this Group which released its Rudder Pedal Sensitivity/Rudder Reversal Recommendation Report dated November 7, 2013; the report includes recommendations for the amendment of FAR Part 25 and CS-25. It is available on the FAA Website at: http://www.faa.gov/regulations_policies/rulemaking/committees/documents/media/taefch_rpsrrtl-32811.pdf Based on this report, the Agency issued a Special Condition (SC) to ensure that the aeroplane must be designed for loads, considered as ultimate, resulting from the application of two rudder reversal pedal inputs. The SC was published for consultation on 11/12/2015. The final SC, acceptable means of compliance (AMC), and the responses to comments are available on the EASA Website: https://www.easa.europa.eu/documents/public-consultations/proposedspecial-condition-c-xx This SC will be applied to new Type Certificates for which an application is made after the publication of the final SC. It might also be applied to significant changes to previously certified aeroplanes. A rulemaking task RMT.0397 will follow the SC to introduce a new rule and AMC in CS-25. RMT.0397 is planned to start in the first quarter of 2017.

From: NTSB
To: European Aviation Safety Agency
Date: 8/1/2014
Response: We recently reviewed the November 7, 2013, recommendation report of the Federal Aviation Administration’s (FAA) Aviation Rulemaking Advisory Committee (ARAC) Flight Controls Harmonization Working Group (FCHWG) examining rudder pedal sensitivity and rudder reversal. We are aware that the FAA created this group on March 28, 2011, to examine the issues specified in NTSB Safety Recommendations A-04-56 and -57, which are substantially similar to Safety Recommendations A-10-119 and -120 but were issued to the FAA. You previously told us that you were participating in the ARAC’s work, and we note that the report references your participation. One of the three recommendations made in the report is for the FAA to adopt a new regulation within Part 25 of FAA standards and to issue necessary related technical guidance. The proposed revision would address safe handling qualities in the yaw axis throughout the flight envelope, including limits for rudder pedal sensitivity. We also note that, although the ARAC recommended a revision, it was unable to reach a consensus as to which of the three specific alternatives described in the report (including a proposal to make no changes) should be adopted. We believe that the FAA is currently deciding on what action to take in response to the ARAC’s recommendation and to our Safety Recommendation A-04-56. We recognize that EASA is likely working with the FAA to harmonize whatever revisions are made to the certification standards, so that EASA CS-25 will be similar to FAA Part 25. Your participation in the ARAC group addresses NTSB Safety Recommendation A-0-119. Accordingly, pending issuance of appropriate revisions to CS-25 based on the ARAC report, Safety Recommendation A-10-119 remains classified OPEN—ACCEPTABLE RESPONSE.

From: European Aviation Safety Agency
To: NTSB
Date: 6/4/2014
Response: -From John Vincent, Deputy Director for Strategic Safety, Executive Directorate: EASA participated in the Aviation Rulemaking Advisory Committee (ARAC) Committee Flight Controls Harmonization Working Group (FCHWG) (Reference: Federal Register I Vol. 76, No. 59 I Monday, March 28, 2011 I Notices) tasked to consider whether changes to Part 25 are necessary to address rudder pedal sensitivity and rudder reversals. The report recommends an evolution of the yaw axis certification standards. One of the conclusions was that these new standards should be applicable only to new designs. For existing transport aeroplanes, EASA in accordance with conclusions from FCHWG believe that design reviews and retrofit of modifications should be considered on a case by case basis and that the normal continuing airworthiness of type design process should apply for any potentially unsafe condition that might be identified. It has to be noted that none of the aeroplanes reviewed as part of the FCHWG deliberations were found to have an unsafe condition.

From: NTSB
To: European Aviation Safety Agency
Date: 12/21/2011
Response: These recommendations are very similar to Safety Recommendations A-04-56 and -57, which we issued to the FAA as a result of the AA587 accident investigation. EASA stated that it is supporting the FAA’s study to determine how existing certification standards should be revised. On June 17, 2011, in response to Safety Recommendations A-04-56 and -57, the FAA wrote to us that its Five-Part Rudder Study to better understand the issues associated with rudder usage on transport airplanes is complete, and that it had tasked its Aviation Rulemaking Advisory Committee (ARAC) to develop recommendations for new standards and guidance based on the study. On March 28, 2011, the FAA published a notice in the Federal Register about the formation of an ARAC subcommittee to respond to this task. The FAA indicated that the ARAC will include foreign certification authorities, which we believe includes EASA. The FAA further indicated that the ARAC report, scheduled to be completed by August 2012, will include specific consideration of Safety Recommendations A-04-56 and -57. Pending appropriate revisions being made to the certification standards based on the five-part study, the application of all criteria developed as a result of that study to existing airplane designs, and appropriate actions being taken for airplane designs that do not meet the new standards, Safety Recommendations A-04-56 and -57 were classified “Open—Acceptable Response.” The NTSB is encouraged by EASA’s continued participation in the FAA’s activities to revise and apply to in-service airplanes the certification standards concerning yaw handling characteristics, including rudder pedal sensitivity. Pending EASA’s completing the recommended actions, Safety Recommendations A-10-119 and -120 remain classified OPEN—ACCEPTABLE RESPONSE.

From: European Aviation Safety Agency
To: NTSB
Date: 9/27/2011
Response: From John Vincent, Deputy Director for Strategic Safety, Executive Directorate: The Agency is participating in the Federal Aviation Administration (FAA) Aviation Rulemaking Advisory Committee (ARAC) group created to provide recommendations on this issue (notice published under Federal register Vol.76, No. 59, dated 28 March 2011). The group will review the need to revise existing certification specifications for large aeroplanes as well as the need to enforce retroactive measures for the already certificated aircraft. Based on these recommendations, FAA and the Agency will consider what actions are to be taken.

From: European Aviation Safety Agency
To: NTSB
Date: 7/27/2011
Response: CC#201100306: Patrick Goudou, Executive Director: Thank you for your letter sent on 23 May 2011 and emphasizing the NTSB’s deep interest in the follow-up given on the accident to the Airbus A300-600 registered N14053 operated by American Airlines on November 12th, 2001. The Agency shares also your concern that pilots' training cannot alone be trusted as a sufficient response to the issue of pilots' commanded sequential opposite-rudder inputs (rudder reversals) on large transport-category aeroplanes. It is the reason why the EASA and Airbus reviewed several options for a design change to address that concern. As a consequence, the purpose of the design change to be implemented on Airbus A300-600 and Airbus A310 is to provide increased protection from potentially hazardous rudder pedal inputs at high airspeeds as requested in recommendation UNST-2004-063 (A-04- 63). Following the initial study of reduced pedal travel limiter unit for the A300-600 and A310, the Agency informed you in our letter dated January 14, 2011, that the development of a Stop Rudder Input Warning (SRIW) system was also alternatively evaluated. The SRIW system monitors rudder inputs and triggers flight deck deterring aural instructions, voiced by the message 'STOP RUDDER INPUTS', combined with Visual warnings (by means of red lights in the glare shield just above the Primary Flight Displays) as soon as one dangerous rudder doublet Is detected, thus preventing: a further increase of the aerodynamic loads on the fin. A thorough evaluation of this SRIW system is currently taking place and, as usual in the frame of a certification process and in line with the EU-US validation process, the FAA responsible authority in that matter, is fully involved; thus ensuring that the proposed change satisfies both parties. In addition to the certification exercise, an FAA evaluation of the crew training aspects has been retained prior introduction of the proposed modification into US-registered aeroplanes. In accordance with the framework on cooperation in the regulation of civil aviation safety, technical data is shared with the FAA who is also part of the tests validating the benefit as well as the non-regression. With regards to recommendations UNST-2010-119 (A-10-119) and UNST-2010-120 (A10-120), EASA is supporting the FAA study in order to determine whether and how existing certification standards could be revised. In parallel, following the A320 ACA190 wake vortex encounter at high speed, Airbus has completed an aircraft level evaluation of the single aisle design in terms of sustainable loads. Airbus is working with EASA on the definition of a design change that would provide increased protection from potentially hazardous rudder pedal inputs. Several design options are currently under feasibility study (warning, reduced rudder travel limitation unit, pedal travel limitation unit).

From: NTSB
To: European Aviation Safety Agency
Date: 5/23/2011
Response: As EASA indicated in its letter, these recommendations are very similar to Safety Recommendations A-04-56 and -57, which were issued to the United States Federal Aviation Administration (FAA) on November 10, 2004. Since the issuance of these recommendations, the FAA has been evaluating its certification standards for the yaw handling characteristics of transport category airplanes. The FAA has both briefed NTSB staff and written to us to describe its activities in response to Safety Recommendations A-04-56 and -57. The FAA is currently completing a five-part study of the associated issues and has indicated that, based on the results of the study, it plans to make appropriate revisions to FAA certification standards. In addition, after these standards have been revised, the FAA will implement Safety Recommendation A-04-57, applying the revised standards to in-service aircraft and requiring modifications to existing airplanes where appropriate. In its current letter, EASA acknowledges that the FAA study is appropriate and indicates that EASA will work with the FAA to determine whether and how existing certification standards should be revised, based on the FAA’s analysis. Although the NTSB has not yet had the opportunity to perform a detailed review of the FAA’s five-part study, based on the information and results that we have reviewed, it appears to be responsive to Safety Recommendation A-04-56. However, we recently cautioned the FAA that the ACA190 event demonstrates that, because of the similarity of the rudder control system designs of the A320 series and A300-600/A310 aircraft, the A320 family is also susceptible to potentially hazardous rudder pedal inputs. The five-part study may not constitute an acceptable response to Safety Recommendation A-04-56 unless the study recognizes what we believe to be similarities and addresses the potential for hazardous rudder pedal inputs on the A320 series of aircraft. In its January 14, 2011, letter, EASA acknowledges that both the AA587 accident and the ACA190 event were triggered by a wake vortex encounter at high airspeed, but EASA believes that crew reactions were very different in the two events. EASA stated that, in the ACA190 event, the crew inputs combined side-stick and pedals and were not aggressive, whereas, in the AA587 accident, the crew reaction reflected the negative training from American Airline’s advanced aircraft maneuvering program. EASA concluded that, if a crew is caught unaware in a wake vortex, they may react by making control inputs, but they would not necessarily make the type of repetitive aggressive input in the AA587 accident. The NTSB requests that EASA reconsider the relevance of the ACA190 event. As described in the letter that transmitted Safety Recommendations A-10-119 and -120 to EASA, the flight data recorder in the ACA190 event showed that, in response to the wake vortex encounter, the flight crew had made three to four alternating rudder pedal inputs over 15 seconds, and Airbus’s analysis indicated that these pilot reactions to the wake vortex encounter were responsible for exceeding the limit load on the vertical stabilizer by 29 percent. Regardless of whether pilot reactions are characterized as aggressive, the yaw handling characteristics of the A319 aircraft in the ACA190 event were such that the pilots seriously overloaded the airframe. The NTSB notes that, despite the widespread publicity that had occurred and the training revisions that had been implemented after the AA587 accident, the ACA190 pilots still made alternating rudder inputs while at high airspeed. Accordingly, pending (1) completion by the FAA of the five-part study and (2) EASA’s making appropriate revisions to its certification standards based on the findings of the study and on the AA587 and ACA190 accident investigations, Safety Recommendation A-10-119 is classified OPEN – ACCEPTABLE RESPONSE. Pending application of all criteria developed in response to Safety Recommendation A-10-119 to existing airplane designs and EASA’s taking appropriate actions for airplane designs that do not meet the new standards, Safety Recommendation A-10-120 is classified “Open—Acceptable Response.”

From: European Aviation Safety Agency
To: NTSB
Date: 1/14/2011
Response: CC# 201100047: - From Patrick Goudou, Executive Director: Thank you for your letter of 3rd August 2010 in response to EASA letters dated 19th March 2010 and 6th April 2010, in which EASA provided its position with respect to NTSB recommendation UNST 2004-063, addressing NTSB concerns about Potential Effects Following Inappropriate Pilot Rudder Pedal Inputs resulting from their investigation of the accident of Airbus A300-605R, registration N14053 on 12/11/2001 at New York. The NTSB reiterates Safety Recommendation A-04-63 and asks for further details about the PTLU. The NTSB has also raised in this letter 2 new Safety Recommendations to EASA (A-10-119 and A 10-120), which repeat recommendations previously made by NTSB to the FAA reference A-04-56 and 57. EASA notes the FAA initial response to A-04-56 and -57 in which the FAA indicated that the current standards in FAR Part 25 may need to be redefined and that it was evaluating these and conducting a study to identify critical rudder control system parameters and human interaction with those controls. EASA acknowledges that such a study is appropriate and we would be willing to work with the FAA to develop the research already conducted in order to determine whether and how existing certification standards could be revised. When the study concludes that Certification Standards need to be revised, a new task will be introduced in the EASA rulemaking programme and it will be developed following the usual rulemaking procedure, which includes a regulatory impact assessment to set the priority and schedule, and the best harmonisation with the FAA. At this stage it is worth noting that our general objective, when amending existing or developing new certification standards, is to identify clearly the safety objective to be met by the applicant and wherever possible to avoid making the standards too prescriptive. With this in mind, our general approach to this particular subject would be to consider the pilot, flight control and aircraft interactions, including the structural capability of the airframe to withstand an abuse case, rather than to focus too closely on specific parameters within an individual control circuit design. Regarding progress on the development of the reduced pedal travel limiter unit for the A300-600 and A310, EASA has received an overall engineering certification and embodiment programme from Airbus, which shows that such a solution will take several years to develop, certify and embody. Airbus has in parallel proposed a new alternative design which is aimed at de-coupling the pilot input. Airbus has included in its proposal a development, certification and embodiment plan which is considerably shorter than for the R-PTLU. The new design monitors rudder input parameters and triggers flight deck visual and aural warnings, which would reqUire the pilot to release the pedals, thus preventing an escalation of the coupling. EASA is carefully evaluating the new concept and has started the certification process of the associated design change, in coordination with the FAA. In respect of the A320 family, which is mentioned in the NTSB letter, EASA has previously acknowledged that there are some similarities between the Air Canada flight 190 event and the American Airlines flight 587 accident; both were triggered by a wake vortex encounter at high airspeed. It is however important to restate that the crew reactions were very different. In the AC 190 event the crew inputs combined side-stick and pedals were not aggressive whereas in the AA587 accident the crew reaction reflected the negative training from the AAMP. This difference indicates to us that if a crew is caught unaware in a wake vortex encounter there is a possibility that they would react by making control inputs, but they would not necessarily make repetitive aggressive inputs. Consistent with our approach to the rulemaking review, we have tasked Airbus with conducting an aircraft level evaluation of the A320 design to ensure that the design as a whole is robust enough to withstand such a low probability event.