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Safety Recommendation Details

Safety Recommendation A-16-032
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 US OPERATORS OF MD-80 SERIES AIRPLANES(AMERICAN AIRLINES, DELTA AIRLINES, AND ALLEGIANT AIR): Collaborate with the Federal Aviation Administration and Boeing to (1) conduct a study to examine reverse thrust engine pressure ratio (EPR)-related operational data, procedures, and training and (2) identify industry-wide best practices that have been shown to be effective in reliably preventing EPR exceedances to mitigate the risks associated with rudder blanking.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Aviation
Location: New York, NY, United States
Is Reiterated: No
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: Allegiant Air (Closed - Acceptable Action)
American Airlines, Inc. (Open - Acceptable Response)
Delta Airlines, Inc. (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: American Airlines, Inc.
Date: 2/13/2017
Response: We note that your operating manuals and training curriculum for MD-82/83 aircraft currently include procedures that mitigate the risks of rudder blanking. We also note that you reviewed flight operational quality assurance data, which indicated that your flight crews are complying with the thrust reverser limitations that prevent rudder blanking. In addition, we note that, although you plan to phase out your entire fleet of MD-82/83 aircraft by the end of 2019, you intend to work with the FAA, Boeing, and other MD-80-series operators as recommended. Pending our receipt of periodic updates and completion of the recommended actions, Safety Recommendation A-16-32 is classified OPEN--ACCEPTABLE RESPONSE.

From: American Airlines, Inc.
To: NTSB
Date: 10/21/2016
Response: -From Paul L. Morell, Vice President Safety, Security, Regulatory Compliance and Environmental: Thank you for providing us with the results of the National Transportation Safety Board's (NTSB) investigation of the recent Delta Air Lines MD-88 accident in New York, and for your recommendation that industry collaborate with the Federal Aviation Administration (FAA) and Boeing to identify and share best practices to mitigate the "rudder blanking" phenomenon associated with thrust reverser use on MD-80 series aircraft. American strongly supports your recommendation. As you probably know, American Airlines has extensive experience with the MD-80 series, and we are amidst a phased retirement of this aircraft from our fleet. American currently operates fifty-nine MD-82/83 aircraft, and we expect to retire the last one no later than 20 19. American's Flight Training Department completed a thorough review of the NTSB report, and evaluated the NTSB's safety recommendations in comparison with our current training curriculum and MD-82/83 operating manuals. This review confirmed that American already adheres to the practices NTSB recommends to mitigate the risks of rudder blanking. American's Safety Department also reviewed extensive FOQA data, which confirmed that American MD-82/83 flight crews are complying with thrust reverser limitations designed to prevent the rudder blanking phenomenon. American Airlines is very supportive of safety collaboration, and we look forward to working with the FAA, Boeing and other MD-80 series operators to help ensure everyone has and implements the best safety practices.

From: NTSB
To: Delta Airlines, Inc.
Date: 2/15/2017
Response: We note that you hosted a meeting with American Airlines and Allegiant Airlines MD 80 operational personnel at your headquarters to share operational data and discuss best practices regarding reverse thrust. We further note that, on January 12, 2017, you participated in a meeting in Las Vegas with American Airlines, Allegiant Airlines, Boeing, and the FAA to collaboratively study MD-88 reverse thrust operational data, procedures, and training, and to identify industry-wide best practices to prevent EPR exceedances associated with rudder blanking. Pending completion of actions that satisfy Safety Recommendation A-16-32, it is classified OPEN—ACCEPTABLE RESPONSE.

From: Delta Airlines, Inc.
To: NTSB
Date: 1/4/2017
Response: -From John E. Laughter, Senior Vice President Corporate Safety, Security, and Compliance: We have received your letter to Mr. Ed Bastian, dated October 6, 2016, regarding the NTSB recommendations intended for Delta Air Lines. Delta has performed a rigorous analysis of the final report issued in response to the accident involving the runway excursion of DL1086 at LaGuardia Airport. We have enacted numerous safety measures based on the NTSB Final Report recommendations and findings as well as from our own internal investigation. Delta Air Lines will implement NTSB Recommendation A-16-32. Recognizing the threat of rudder blanking on MD-80 series aircraft and the challenges it imposes on maintaining lateral and longitudinal control when landing on contaminated runways, Delta has proactively completed the following actions in order to fulfill the intent of recommendation A-16-32: • Hosted a preparatory meeting with American Airlines and Allegiant Airlines MD-80 Operational personnel at the Delta Air Lines headquarters to share operational data and discuss best practices with regard to reverse thrust employment. • Committed to participate in a meeting scheduled on 12 January 2017 with American Airlines, Allegiant Airlines, Boeing, and the Federal Aviation Administration to collaboratively study MD-88 reverse thrust operational data, procedures and training, and identify industry wide best practices that will help prevent EPR exceedances in order to mitigate the risk associated with rudder blanking. • Requested operational data from Boeing in preparation for the January meeting. Delta is fully committed to improving the safety margins of the MD-80 series aircraft industry wide by deriving the maximum benefits from lessons learned from the DL1086 accident.

From: NTSB
To: Allegiant Air
Date: 11/2/2018
Response: We note that, on January 12, 2017, you met with the FAA, Boeing, American Airlines, and Delta Airlines to collaborate and share information regarding operational procedures, training, performance calculations, and flight operational quality assurance data illustrating reverse EPR settings and exceedances during landing. We also note that, as a result of this meeting, you and other carriers revised your procedures, callouts during landing, and landing distance performance charts. Specifically, you reported that the following changes have been implemented: 1. 1.3 EPR will be the maximum reverse setting in all conditions. On a dry runway, the pilot may immediately select up to a maximum of 1.3 EPR after nose wheel contact with the runway. On runway conditions other than dry, the pilot must first select idle reverse. Once directional control is verified, the setting may be increased up to a maximum of 1.3 EPR. The same conditions will apply in the event of an aborted takeoff. 2. During the approach briefing, the crew identifies the conditions they are likely to encounter and briefs the reverse EPR setting to be used. The pilot monitoring shall monitor reverse EPR setting and call out the setting achieved and continue to call out any exceedances from the planned value. 3. Landing Performance charts have been modified to reflect changes in reverse thrust usage. Dry runway performance includes a credit for 1.3 EPR reverse setting. Reverse idle is used for all other runway conditions. We believe that these changes, and your plan to remain in contact with the other operators to evaluate their effectiveness, are responsive to this recommendation. We are also pleased to learn that you issued a bulletin to your pilots that outlines the procedural and performance chart changes and explains rudder blanking and rudder effectiveness at various EPR settings. All of these actions satisfy the intent of Safety Recommendation A-16-32, which is classified CLOSED--ACCEPTABLE ACTION.

From: Allegiant Air
To: NTSB
Date: 8/21/2018
Response: -From Jennifer Bartenstein, Director of Safety Management Systems, Allegiant Air: This letter is in response to NTSB Safety Recommendation A-16-32 and outlines the actions and procedural changes Allegiant Air, LLC (Allegiant) has enacted to reduce reverse EPR exceedances on landing as well as to educate the pilot group regarding the effects of rudder blanking. A-16-20 Collaborate with Boeing and US operations of MD-80 series airplanes to (1) conduct a study to examine reverse thrust engine pressure ration (EPR) related operations data, procedures, and training and (2) identify industry-wide best practices that have been shown to be effective in reliable preventing EPR exceedances to mitigate the risks associated with rudder blanking. On January 12, 2017 Allegiant hosted a meeting between the FAA, Boeing, American Airlines and Delta Airlines to collaborate and share information regarding operational procedures, training, performance calculations, and FOQA data illustrating reverse EPR settings and any exceedances during landing. As a result of the meeting, Allegiant along with the other carriers made changes to procedures and callouts during landing as well as landing distance performance charts. The carriers have remained in contact with one another to continue to evaluate the effectiveness of changes. Please see the attached power point presentation used during the meeting. A-16-21 Encourage US operators of MD-80 series airplanes to (1) implement the best practices identified in Safety Recommendation A-16-20 and (2) participate in an industry-wide monitoring program to verify the continued effectiveness of those solutions over time. Changes enacted by Allegiant: (Please see attached excerpts from MD-80 AOM) 1. 1.3 EPR will be the maximum reverse setting in all conditions. On a dry runway, the pilot may immediately select up to a maximum of 1.3 EPR after nose wheel contact with the runway. On runway conditions other than dry, the pilot must first select idle reverse. Once directional control is verified, the setting may be increased up to a maximum of 1.3 EPR. The same conditions will apply in the event of an aborted takeoff. 2. During the approach briefing, the crew identifies the conditions they are likely to encounter and briefs the reverse EPR setting to be used. The PM shall monitor reverse EPR setting and call out the setting achieved and continue to call out any exceedances from the planned value. 3. Landing Performance charts have been modified to reflect changes in reverse thrust usage. Dry runway performance includes a credit for 1.3 EPR reverse setting. Reverse idle is used for all other runway conditions. 4. A bulletin was released to the pilot group outlining all procedural and performance chart changes as well as explain rudder blanking and rudder effectiveness at various EPR settings. A-16-22 Require operators of MD-80 series airplanes to revise operations procedures to include a callout when reverse thrust power exceeds 1.3 engine pressure ratio during landing on a contaminated runway. Allegiant Air requires the PM to call out the EPR setting achieved during the landing roll out or aborted take-off, and continue to assist the PF with EPR setting callouts until the correct setting is achieved. As always, Allegiant looks forward to working with the NTSB on all safety related matters. Please do not hesitate to contact me if you have any questions concerning this matter.

From: NTSB
To: Allegiant Air
Date: 10/6/2016
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. We are providing the following information to urge Allegiant Air to take action on the safety recommendation being issued in this letter. On September 13, 2016, we adopted our report concerning the March 5, 2015, accident in which Delta Air Lines flight 1086, a Boeing MD-88, N909DL, crashed after it departed the left side of runway 13 during landing at LaGuardia Airport, New York, New York.1 Additional information about this accident and the resulting recommendations may be found in the report of the investigation, which can be accessed at our Aviation Information Resources webpage under report number NTSB/AAR-16/02. As a result of this investigation, we issued 14 new recommendations, including 10 to the Federal Aviation Administration; 2 to Boeing; 1 to The Port Authority of New York and New Jersey; and the following recommendation to US operators of MD-80 series airplanes, including Allegiant Air. Chairman HART, Vice Chairman DINH-ZARR, and Members SUMWALT and WEENER concurred in this recommendation. The NTSB is vitally interested in this recommendation because it is designed to prevent accidents and save lives. We would appreciate receiving a response from you within 90 days detailing the actions you have taken or intend to take to implement it. When replying, please refer to the safety recommendation by number.