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Safety Recommendation Details

Safety Recommendation A-72-150
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, THE GENERAL AVIATION MANUFACTURERS ASSOCIATION, OPERATORS, AND MANUFACTURERS OF AIRCRAFT, AIR FRAMES, ACCESSORIES AND COMPONENTS, REVISE PRESENT SERVICE BULLETIN (PARTICULARLY ALERT SERVICE BULLETIN) FORMATS AND PROCEDURES TO INSURE THAT DEFINITIVE INFORMATION ON THE PROBLEM IS PROVIDED THEREIN, INCLUDING A CONSPICUOUS WARNING OF THE POTENTIAL OPERATIONAL HAZARDS INVOLVED.
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: 11/29/1973
Addressee(s) and Addressee Status: Air Transport Association of America, Inc. (Closed--No Longer Applicable)
Keyword(s):

Safety Recommendation History
From: Air Transport Association of America, Inc.
To: NTSB
Date: 9/26/1972
Response: A LETTER WAS SENT TO NATC TO TRY TO HELP THEM SOLVE THEIR PROBLEM. THE FLIGHT SAFETY GROUP OF THE ATA, UNDER THE DIRECTION OF GRADY GATLIN STUDIED THIS PROPOSAL, DISCUSSED IT WITH MEMBERS OF THE ASSOCIATION, AND TO DATE, IT APPEARS THAT ALL MEMBERS HAVE SAFETY OFFICERS - SOME OF THE SAFETY OFFICERS ARE USED IN DUAL ROLES DUE TO THE SIZE OF THE OPERATIONAL GROUPS AND THE LIMIT OF THE AIR CARRIER'S OPERATION. NATC DISCUSSED THIS PROPOSAL AT THEIR ANNUAL CONFERENCE INFEBRUARY 1973 WITH THEIR MEMBERS. SO FAR THE RESPONSE HAS BEEN FAVORABLE. REF. NATC BOOKLET "ORGANIZING FOR SAFETY".