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Safety Recommendation Details

Safety Recommendation A-12-027
Details
Synopsis: On January 27, 2009, about 0437 central standard time, an Avions de Transport Regional (ATR) Aerospatiale Alenia ATR 42-320 (ATR 42), N902FX, operating as Empire Airlines flight 8284, was on an instrument approach when it crashed short of the runway at Lubbock Preston Smith International Airport, Lubbock, Texas. The captain sustained serious injuries, and the first officer sustained minor injuries. The airplane was substantially damaged. The airplane was registered to FedEx Corporation and operated by Empire Airlines, Inc., as a 14 Code of Federal Regulations (CFR) Part 121 supplemental cargo flight. The flight departed from Fort Worth Alliance Airport, Fort Worth, Texas, about 0313. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The National Transportation Safety Board (NTSB) determined that the probable cause of this accident was the flight crew's failure to monitor and maintain a minimum safe airspeed while executing an instrument approach in icing conditions, which resulted in an aerodynamic stall at low altitude. Contributing to the accident were 1) the flight crew's failure to follow published standard operating procedures in response to a flap anomaly, 2) the captain's decision to continue with the unstabilized approach, 3) the flight crew's poor crew resource management, and 4) fatigue due to the time of day in which the accident occurred and a cumulative sleep debt, which likely impaired the captain's performance. Additional review of the stall protection system in the accident airplane and the events leading to the stall in this accident prompted the NTSB to make the following recommendations.
Recommendation: TO THE EUROPEAN AVIATION SAFETY AGENCY: Evaluate all European Aviation Safety Agency-certificated transport-category airplanes equipped with stick pushers to ensure that the stick pusher activates at an angle of attack that will provide adequate stall protection in the presence of airframe ice accretions.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Aviation
Location: Lubbock, TX, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: CEN09MA142
Accident Reports: Crash During Approach to Landing Empire Airlines Flight 8284 Avions de Transport Regional Aerospatiale Alenia ATR 42-320, N902FX
Report #: AAR-11-02
Accident Date: 1/27/2009
Issue Date: 6/26/2012
Date Closed:
Addressee(s) and Addressee Status: European Aviation Safety Agency (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: European Aviation Safety Agency
Date: 3/22/2016
Response: We note that, in response to your request for information from all Large Aeroplane European Type Certificate holders, you determined that the Saab 340 is equipped with a stick pusher that activates at an AoA that is the same for both icing and non-icing conditions. We also note that you are working with Saab to determine the next appropriate step. Pending our review of this information, and your completion of the recommended action, Safety Recommendation A-12-27 remains classified OPEN—ACCEPTABLE ACTION.

From: European Aviation Safety Agency
To: NTSB
Date: 1/7/2016
Response: -From Rachel Daeschler, Head of Safety Intelligence and Performance Department Strategy and Safety Management Directorate: EASA issued a letter to all Large Aeroplane European Type Certificate (TC) holders on 5 July 2013, inquiring which of their EASA certified types and models featured a stick pusher function/device as part of the stall protection, and when it is the case, was this device/function part of the compliance demonstration to Joint Aviation Requirements (JAR)/Certification Specifications (CS) 25 .201 and 25.203 or equivalent requirements. For these models, EASA requested to be provided with data indicating the values of angle of attack triggering the stall warning (stick shaker), the stall protection (stick pusher) and the stall occurrence for both icing and non-icing conditions. The majority of TC holder responses indicated that for their related aircraft types: -either no stick pusher has been installed, - or a stick pusher has been installed and its function was part of the compliance demonstration to JAR/CS 25 .201 and 25.203 or equivalent requirements during the initial type certification process and an appropriate angle of attack (AoA) threshold is kept between stick shaker and stick pusher activation in icing conditions. Only for the SAAB 340 it has been reported that, similar to the ATR 42 model involved in the Lubbock accident, the AoA for activation of stick pusher (stall identification) is not changed between non-icing and icing conditions, even though the AoA activation of stick shaker (stall warning) is lowered in icing conditions. EASA is in consultation with SAAB to determine if further action on the SAAB 340 should be taken.

From: NTSB
To: European Aviation Safety Agency
Date: 12/27/2013
Response: We are encouraged to learn that EASA has requested, from all Large Aeroplane European Type Certificate (TC) holders, information regarding any EASA-certified types and models equipped with a stick pusher that was part of the compliance demonstration to Joint Aviation Requirements/Certification Specifications (CS) 25.201 and 25.203 or equivalent requirements. We note that, for these models, EASA requested information regarding the values of angle of attack triggering the stick shaker, stick pusher, and stall occurrence for both icing and non-icing conditions. Pending our review of this information and completion of the recommended action, Safety Recommendation A-12-27 is classified OPEN—ACCEPTABLE RESPONSE.

From: European Aviation Safety Agency
To: NTSB
Date: 9/27/2013
Response: -From John Vincent, Deputy Director for Strategic Safety, Executive Directorate: EASA issued a letter to all Large Aeroplane European Type Certificate (TC) holders on 5 July 2013, inquiring which of their EASA certified types and models featured a stick pusher function/device as part of the stall protection, and when it is the case, was this device/function part of the compliance demonstration to Joint Aviation Requirements (JAR)/Certification Specifications (CS) 25.201 and 25.203 or equivalent requirements. For these models, EASA requested to be provided with data indicating the values of angle of attack triggering the stall warning (stick shaker), the stall protection (stick pusher) and the stall occurrence for both icing and non-icing conditions.