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Safety Recommendation Details

Safety Recommendation A-72-155
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 AND THE NATIONAL AIR TRANSPORTATION CONFERENCES STUDY THE DESIRABILITY OF ESTABLISHING FLIGHT SAFETY OFFICES IN EACH MEMBER ORGANIZATION, AND MAKE THIS A SUBJECT OF DISCUSSION WITH THE ASSOCIATION'S MEMBERSHIP AT THE EARLIEST OPPORTUNITY.
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Addressee(s) and Addressee Status: Air Transport Association of America, Inc. (Closed--No Longer Applicable)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: LETTER FROM THE VICE-PRESIDENT NATC TO THE DIRECTOR, BUREAU OF AVIATION SAFETY TO SAY THAT THEY WOULD LIKE A MEETING TO DISCUSS HOW THEY COULD BEST IMPLEMENT THE TWO RECOMMENDATIONS RELATING TO "STRUCTURAL INTEGRITY OF AIRCRAFT COMPONENTS" AND THE "ESTABLISHMENT OF FLIGHT SAFETY OFFICERS." IT WAS POINTED OUT THAT MANY OF THE GROUPS UNDER NATC WERE TOO SMALL AND DIVERSIFIED TO ORGANIZE FOR SAFETY AND WOULD THEREFORE NEED ASSISTANCE.11/29/73 BAC ALERT SERVICE BULLETINS NOW INCORPORATE SUCH A WARNING. ATA SPEC. 100 IS BEING REVISED TO INCORPORATE THIS RECOMMENDATION (PER BAC). GAMA IS PRESENTLY REEVALUATING SERVICE BULLETINS. NATC DISCUSSED THE NEEDED CHANGE DURING THEIR ANNUAL CONFERENCE IN FEBRUARY1973. GRADY GATLIN, ATA, STATED THAT THE ATA REVIEW BOARDASSURES THAT THE WORDING OF THE SERVICE BULLETINS WILL ASSURE THAT DEFINITIVE INFORMATION ON THE PROBLEM ASSOCIATED WITH THE ISSUANCE OF THE BULLETIN WILL BE INCORPORATED. REVIEW OF BAC SB'S INDICATE COMPLIANCE.