Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation A-72-151
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: AIRWORTHINESS DIRECTIVE FORMATS AND PROCEDURES BE REVISED TO INCLUDE INFORMATION AND CONSPICUOUS WARNINGS OF THE POTENTIAL HAZARDS ASSOCIATED WITH THE SUBJECT MATTER OF THE DIRECTIVE. AN ACCEPTABLE ALTERNATIVE WOULD BE THE CONCURRENT RELEASE OF AN OPERATIONAL ALERT NOTICE CONTAINING SIMILAR INFORMATION.
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: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: FAA
To: NTSB
Date: 9/26/1972
Response: AIRWORTHINESS DIRECTIVES (AD'S) DISTRIBUTED TO OWNERS NOW CONTAIN A STATEMENT AS TO THE REASON FOR THEIR ISSUANCE. INSTRUCTIONS REQUIRE THAT EACH FLIGHT OPERATIONS EVALUATION BOARD (FOEB) FORWARD TO THE OPS. DIV., FLIGHT STANDARDS SERVICE, ALL SERVICE BULLETINS AND CREW TRAINING BULLETINS ISSUED BY AIRCRAFT MANUFACTURERS WHICH DEAL WITH OPERATIONAL MATTERS. ADDITIONALLY, THE OPS. DIV. IS A COORDINATOR ONALL A.D.'S CONCERNING OPERATIONAL MATTERS. IF, AFTER REVIEWING A SERVICE BULLETIN OR CREW TRAINING BULLETIN, AND/OR COORDINATING ON A.D., IT APPEARS ON OPS. ALERT OR OPS. BULLETIN IS APPROPRIATE. THAT ACTION IS TAKEN.