Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation A-72-149
Details
Synopsis: FLIGHT 366, A BOEING 720B, ON A PROFICIENCY CHECK FLIGHT, YAWED AND ROLLED OUT OF CONTROL, AND CRASHED WHILE IN THE PROCESS OF EXECUTINGA 3-ENGINE MISSED-APPROACH FROM A SIMULATED ENGINE-OUT ILS INSTRUMENT APPROACH. THE FIVE CREW-MEMBERS AND ONLY OCCUPANTS DIED IN THE CRASH. THE WEATHER CONDITIONS AT ONTARIO WERE 600 FEET OVERCAST, WITH 3/4-MILE VISIBILITY IN FOG, HAZE, AND SMOKE. THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINES THAT THE PROBABLE CAUSE OF THIS ACCIDENT WAS THE FAILURE OF THE AIRCRAFT RUDDER HYDRAULIC ACTUATOR SUPPORT FITTING. THE FAILURE OF THE FITTING RESULTED IN THE INAPPARENT LOSS OF LEFT RUDDER CONTROL WHICH, UNDER THE CONDITIONS OF THIS FLIGHT, PRECLUDED THE PILOT'S ABILITY TO MAINTAIN DIRECTIONAL CONTROL DURING A SIMULATED ENGINE-OUT MISSED- APPROACH. THE EXISTING WEATHER CONDITIONS DEGRADED EXTERNAL VISUAL CUES, THEREBY HAMPERING RAPID ASSESSMENT OF AIRCRAFT PERFORMANCE BY THE FLIGHT CHECK CAPTAIN.
Recommendation: THE AIR TRANSPORT ASSOCIATION, NATIONAL AIR TRANSPORTATION CONFERENCES, THE AEROSPACE INDUSTRIES ASSOCIATION, THE GENERAL AVIATION MANUFACTURERS ASSOCIATION, AND THE FEDERAL AVIATION ADMINISTRATION REEMPHASIZE THE NEED FOR CONTINUOUS VIGILANCE IN MAINTAINING THE STRUCTURAL INTEGRITY OF EXISTING AIRCRAFT COMPONENTS THAT ARE MADE OF MATERIALS KNOWN TO BE, OR SUSPECTED OF BEING, SUSCEPTIVE TO STRESS-CORROSION CRACKING.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Ontario, Canada
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA71AZ009
Accident Reports: Western Air Lines, Inc., Boeing 720- 047B, N3166
Report #: AAR-72-18
Accident Date: 3/31/1971
Issue Date: 6/7/1972
Date Closed: 11/16/1972
Addressee(s) and Addressee Status: Aerospace Industries Association (Closed--No Longer Applicable)
FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Aerospace Industries Association
Date:
Response: We are in the process of completing our investigation into the Eagle Otome accident of this past January. As you may be aware, one of the two pilots onboard was diagnosed with obstructive sleep apnea (OSA), and had recently changed his medication regimen for another diagnosed condition before the accident. We dealt with the issues of OSA and Coast Guard requirements vis a vis reported changes in medical condition/medication use in four recommendations that the NTSB issued to the Coast Guard. At present the status of this recommendation is OPEN -- ACCEPTABLE RESPONSE. A public meeting on this accident is tentatively planned for early next year. We anticipate that the Board members will discuss those recommendations, evaluate the Coast Guard response to them, and possibly change the classification based on the Coast Guard's response to the recommendations in light of the Eagle Otome accident. At the Board meeting NTSB staff will be expected to accurately convey the Coast Guard position, discuss the issues from staff's perspective, and answer the Board's questions. We are now finishing up our draft report of the accident, which will include discussions of those recommendations. In order to provide the best information for the Board's consideration, we would like to meet with you and/or your representative(s), including people working on those recommendations, so that the Coast Guard and NTSB staff have a good mutual understanding of each other's positions and concerns, and the status of your work on the recommendations. It is short notice, but we would like to meet next week to start the dialog, recognizing that subsequent meetings may be in order.

From: FAA
To: NTSB
Date: 9/26/1972
Response: FAA HAS ISSUED A MAINTENANCE BULLETIN "CORROSION CONTROL" HANDBOOK 8430.1 AND ADVISORY CIRCULAR 70-26, "MAINTENANCE INSPECTION NOTES FOR BOEING B-707/720 SERIES AIRCRAFT. A PROPOSED ADVISORY CIRCULAR ENTITLED "CORROSION CONTROL FOR AIRCRAFT" IS EXPECTED TO BE ISSUED IN JANUARY 1973.