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Safety Recommendation Details

Safety Recommendation A-16-026
Details
Synopsis: On March 5, 2015, at 1102 eastern standard time, Delta Air Lines flight 1086, a Boeing MD-88, N909DL, was landing on runway 13 at LaGuardia Airport (LGA), New York, New York, when it departed the left side of the runway, contacted the airport perimeter fence, and came to rest with the airplane’s nose on an embankment next to Flushing Bay. The 2 pilots, 3 flight attendants, and 98 of the 127 passengers were not injured; the other 29 passengers received minor injuries. The airplane was substantially damaged. Flight 1086 was a regularly scheduled passenger flight from Hartsfield-Jackson Atlanta International Airport, Atlanta, Georgia, operating under the provisions of 14 Code of Federal Regulations Part 121. An instrument flight rules flight plan had been filed. Instrument meteorological conditions prevailed at the time of the accident.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Develop best practices related to evacuation communication, coordination, and decision-making during emergencies through the establishment of an industry working group and then issue guidance for 14 Code of Federal Regulations Part 121 air carriers to use to improve flight and cabin crew performance during evacuations.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Aviation
Location: New York, NY, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA15FA085
Accident Reports: Runway Excursion During Landing Delta Air Lines Flight 1086 Boeing MD-88, N909DL, New York, New York March 5, 2015
Report #: AAR-16-02
Accident Date: 3/5/2015
Issue Date: 10/6/2016
Date Closed:
Addressee(s) and Addressee Status: FAA (Open - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/6/2018
Response: Your April 26, 2018, letter regarding the American Airlines flight 383 accident recommendations did not discuss the current status of these recommendations. Please update us on your plans regarding Safety Recommendations A-09-27 and A-16-26, which remain classified OPEN--UNACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 2/6/2018
Response: A-16-026 was reiterated and reclassified as a result of NTSB Aviation Accident Report “Uncontained Engine Failure and Subsequent Fire American Airlines Flight 383 Boeing 767-323, N345AN Chicago, Illinois October 28, 2016.” Report number AAR-18-01. Adopted on January 30, 2018 and published on February 6, 2018. The following is from the report: 1.7.3.2 Communication and Coordination Among Flight and Cabin Crews Safety Recommendation A-16-26 On October 6, 2016, the NTSB issued Safety Recommendation A-16-26 as a result of its investigation of the March 5, 2015, accident involving Delta Air Lines flight 1086, an MD-88 that was landing at LaGuardia Airport in New York, New York, when it departed the left side of the runway, contacted the airport perimeter fence, and came to rest with the airplane’s nose on an embankment next to Flushing Bay. The NTSB’s investigation determined that the captain did not convey a sense of urgency to evacuate the cabin and that the flight attendants were confused about the timing of the evacuation. The investigation also determined that the evacuation began about 12 minutes after the airplane came to a stop and that more than 17 minutes had elapsed between the time that the airplane came to a stop and the time that the passengers were off the airplane (NTSB 2016). As a result of that accident and the lack of FAA action to fully address recurring evacuation communication, coordination, and decision-making problems, the NTSB issued Safety Recommendation A-16-26, which asked the FAA to do the following:67 Develop best practices related to evacuation communication, coordination, and decision-making during emergencies through the establishment of an industry working group and then issue guidance for 14 Code of Federal Regulations Part 121 air carriers to use to improve flight and cabin crew performance during evacuations. On December 27, 2016, the FAA stated that it understood the importance of crewmember communication, coordination, and decision-making related to emergency evacuations and, as such, was considering the establishment of a working group to examine these issues and make recommendations. The FAA indicated that the working group would include representatives from the Air Line Pilots Association, the Association of Flight Attendants, the Association of Professional Flight Attendants, Airlines for America, and the FAA’s Flight Standards Service. On March 27, 2017, the NTSB classified Safety Recommendation A-16-26 “Open—Acceptable Response” pending the establishment of the working group and the development of the recommended best practices. 2.3.2.2 Recurring Evacuation-Related Issues The NTSB’s report on the March 5, 2015, Delta Air Lines flight 1086 accident explained that we have a long history of investigating accidents involving inadequate evacuation-related communication and coordination and issuing safety recommendations to resolve these issues (NTSB 2016).90 The report also noted that FAA efforts to fully address the issues had thus far been insufficient. As a result, the NTSB issued Safety Recommendation A-16-26, which advocated for a multidisciplinary approach to develop best practices to resolve recurring evacuation-related issues by focusing on analyzing data involving airplane evacuations and identifying ways to improve flight and cabin crewmember performance. In response to this recommendation, the FAA stated that it was considering whether to establish a working group comprised of government and industry subject matter experts to examine recurring evacuation-related issues and make recommendations. In March 2017, the NTSB classified Safety Recommendation A-16-26 “Open—Acceptable Response.” The NTSB’s report on the Delta flight 1086 accident also reiterated Safety Recommendation A-09-27, which asked the FAA to update the guidance and training provided to flight and cabin crews regarding communication and coordination during emergency and unusual situations to reflect current industry knowledge based on research and lessons learned. Safety Recommendation A-09-27 is currently classified “Open—Unacceptable Response” because the FAA has still not revised AC 120-48, “Communication and Coordination Between Flight Crewmembers and Flight Attendants,” despite its correspondence indicating that the revised AC was anticipated in 2013. (The AC was last updated in July 1988.) The NTSB is investigating two other accidents with emergency evacuation issues. On September 8, 2015, British Airways flight 2276, a Boeing 777-200 equipped with two GE90-85B engines, experienced an uncontained left engine failure during the takeoff ground roll and caught fire at McCarran International Airport in Las Vegas, Nevada. The fire was extinguished by ARFF personnel. The 157 passengers and 13 crewmembers evacuated on the runway via emergency exit slides. On October 29, 2015, Dynamic International Airways flight 405, a Boeing 767-200ER with 101 occupants aboard, was taxiing for departure at Fort Lauderdale-Hollywood International Airport in Fort Lauderdale, Florida, when fuel began leaking from the left engine, causing a fire.91 Information in the dockets for these accidents indicated that both evacuations began while an engine was still operating, demonstrating that communication and coordination issues between flight and cabin crews continue to exist during airplane evacuations. In its report on the September 2007 accident involving American Airlines flight 1400 in St. Louis, Missouri, the NTSB found that the safety risks posed by inadequate flight and cabin crew communications in emergency situations were not effectively addressed by AC 120-48. When the NTSB issued Safety Recommendation A-09-27 in May 2009, the AC guidance was more than 20 years old. The FAA has not taken any steps to satisfy the recommended action in the more than 8 years since the recommendation was issued. The FAA’s failure to update the almost 30-year-old AC guidance, which does not reflect lessons learned from recent accidents and incidents and address communications challenges resulting from changes in cockpit access for cabin crewmembers after the events of September 11, 2001, is inconsistent with contemporary safety management practices and the FAA’s responsibility for ensuring continual operational safety. Actions to satisfy Safety Recommendations A-09-27 do not require rulemaking or any significant cost to industry or the FAA. The benefit of updating AC 20-148 to incorporate the latest industry knowledge regarding crew communications during emergency situations would be that operators could voluntarily incorporate this information into their training and guidance. More effective communications between flight and cabin crews during emergency situations would improve safety for the traveling public, and updated guidance would help mitigate the recurring evacuation-related safety issues that the NTSB has identified in numerous accident investigations, including four accident investigations within the last 2 years. In addition, the FAA has not updated the NTSB about the status of the working group requested in Safety Recommendation A-16-26, and a notice about the establishment of the working group had not been published in the Federal Register as of November 2017. It is time for the FAA to emphasize the importance of ensuring that flight and cabin crew communications can facilitate safe and effective decision-making and action during situations requiring an evacuation. The NTSB concludes that the FAA’s inadequate actions to improve guidance and training on communication and coordination between flight and cabin crews during emergency situations, including evacuations, could lead to negative consequences for the traveling public if this safety issue continues to be unresolved. Therefore, the NTSB reiterates Safety Recommendations A-09-27 and A-16-26. In addition, because the FAA has not established, or committed to establishing, a working group to address the actions in Safety Recommendation A-16-26 and has not provided another plan to improve flight and cabin crew communication and coordination during evacuations, Safety Recommendation A-16-26 is classified OPEN--UNACCEPTABLE RESPONSE. The AAIB’s investigation of the June 2016 incident at Heathrow Airport also demonstrated evacuation-related communication and coordination problems between flight and cabin crews. The AAIB’s report stated that the flight attendant who initiated the evacuation did not activate the evacuation signal (similar to the flight attendants aboard flight 383). However, another flight attendant went to the flight deck to report that an evacuation was underway, and the captain saw (from a reflection in the terminal building) that an aft emergency slide had been deployed. The captain then made an announcement to stop the evacuation because he thought that he had isolated the source of the smoke and wanted to prevent unnecessary injuries. However, the captain did not discuss the situation in the cabin with the flight attendants before making his announcement, which indicated “a breakdown in communication and co-operation between flight crew and cabin crew members.” The AAIB’s report also indicated that the captain’s announcement caused confusion. One of the flight attendants thought that the captain was not aware of the smoke in the cabin, so she shouted to the passengers to keep moving. Another flight attendant, who saw the captain standing in the flight deck, told the captain that the evacuation should continue because of “thick smoke” in the cabin, and the captain made a subsequent announcement indicating that the evacuation should continue via a jetbridge (which was in place before the evacuation). The AAIB’s report concluded that “prompt and effective communication between the cabin and the flight deck might have avoided an evacuation” and that one reason for the initiation of the evacuation was that the flight attendants “did not receive specific instructions from the flight crew.” The AAIB noted that American Airlines had taken postincident actions in response to the communication and coordination shortcomings found during the investigation but that action was also needed by the regulator because other operators might be susceptible to similar shortcomings. As a result, the AAIB issued Safety Recommendation 2017-029, which asked the FAA to “require that flight and cabin crews participate in joint training to enhance their co-ordination when dealing with emergencies.” The NTSB has made similar recommendations to the FAA, but joint evacuation exercises for flight and cabin crews are still not required.92 The NTSB recognizes the benefits of joint flight and cabin crew evacuation training and notes that the actions requested in Safety Recommendation A-16-26 would also be an effective way to resolve evacuation-related communication and coordination issues.

From: NTSB
To: FAA
Date: 3/27/2017
Response: We note that you plan to establish a working group including representatives from the Air Line Pilots Association, the Association of Flight Attendants, the Association of Professional Flight Attendants, Airlines for America, and your Flight Standards Service to examine the issue and develop the recommended best practices. Pending the establishment of the working group and the development of the recommended best practices, Safety Recommendation A-16-26 is classified OPEN--ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 12/27/2016
Response: -From Michael P. Huerta, Administrator: FAA Order 8900.1. Volume 3. Chapter 30. Section 6. Evaluating Evacuation and Ditching Demonstration. mandates that operators demonstrate communication and coordination capabilities. Specifically, this guidance states that during phase four of the aborted takeoff. emergency evacuation demonstration. or the ditching demonstration the FAA team must evaluate the flightcrew's effectiveness in exercising command responsibilities and the coordination and communication between the flightcrew and flight attendants. Further. FAA Order 8900. 1. Volume 6. Chapter 2. Section 8. Safety Assurance System: Cabin Enroute (Random) Inspections. provides guidance for conducting a cabin enroute inspection to ensure that a certificate holder's cabin safety procedures adhere to 14 CFR and safe operating practices. This guidance also describes what the FAA· s Aviation Safety Inspectors should observe during their inspections. including effective crew coordination for Flightcrcw and cabin crewmember communications, both routine and/or emergency. We understand the importance of crewmember communication. coordination and decision making related to evacuation during emergencies. Accordingly, in response to this safety recommendation. we are considering establishing a working group, including representatives from the Air Line Pilots Association. the Association of Flight Attendants. The Association of Professional Flight Attendants, Airlines For America, and the FAA’s Flight Standards Service, to examine the issue and make recommendations on additional ways of enhancing communication, coordination and decision-making during emergencies.