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Safety Recommendation Details

Safety Recommendation A-81-068
Details
Synopsis: ON JANUARY 21, 1981, A GEORGIA-PACIFIC CORPORATION CESSNA CITATION, N501GP, WITH THE PILOT, THE COPILOT, AND THREE PASSENGERS ABOARD, OVERRAN THE END OF RUNWAY 23 FOLLOWING AN INSTRUMENT LANDING SYSTEM (ILS) APPROACH, CRASHED, AND BURNED AT THE MERCER COUNTY AIRPORT, BLUEFIELD, WEST VIRGINIA. THE AIRCRAFT TOUCHED DOWN BETWEEN 500 AND 2,000 FEET ON THE RUNWAY WHICH WAS COVERED WITH WET SNOW, AND IT DID NOT DECELERATE NORMALLY. ABOUT 1,200 FEET FROM THE DEPARTURE END OF THE RUNWAY, THE PILOT ADDED ENGINE THRUST AND ROTATED THE AIRCRAFT FOR LIFTOFF; HOWEVER, IT DID NOT GET AIRBORNE BECAUSE OF INSUFFICIENT FLYING SPEED. THE AIRCRAFT OVERRAN THE END OF THE RUNWAY AND STRUCK THREE LOCALIZER ANTENNAS AND A 10-FOOT EMBANKMENT BEFORE IT PLUNGED DOWN A STEEP, DENSELY WOODED HILLSIDE. ALL FIVE OCCUPANTS WERE KILLED, AND THE AIRCRAFT WAS DESTROYED BY IMPACT FORCES AND POSTCRASH FIRE.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REVIEW AND REQUIRE REVISIONS AS APPROPRIATE, OF MANUFACTURER'S AIRCRAFT FLIGHT MANUALS TO INCLUDE SUFFICIENT SLIPPERY RUNWAY CONDITION CORRECTION FACTOR INFORMATION OR REQUIRE AN APPROPRIATE WARNING THAT LANDING DISTANCES UNDER SLIPPERY RUNWAY CONDITIONS ARE UNKNOWN.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: Bluefield, WV, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA81AA007
Accident Reports: Georgia Pacific Corporation Cessna 500 Citation, N501GP
Report #: AAR-81-09
Accident Date: 1/21/1981
Issue Date: 6/23/1981
Date Closed: 4/1/1988
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 4/1/1988
Response: All of these recommendations reflected the Safety Board's view that pilots need to be given more quantifiable data about the accelerate-stop and landing distances required for their aircraft on wet, snow covered, or icy runways so that they can make informed decisions before attempting takeoffs or landings on such runways. The Safety Board acknowledges that the ideal solution wherein pilots will be able to accurately correlate aircraft performance data provided by a manufacturer with actual realtime measurements of runway friction may never be technically feasible. Nonetheless, the Safety Board believes that the present contaminated runway operations wherein pilots rely entirely on subjective judgments for making go-no go decisions can be improved. Safety Recommendations A-78-84 and -89 also addressed Safety Board concerns that pilots are not provided sufficient information regarding the effect of a failed tire on the aircraft's acceleration and braking performance nor are they provided guidance about go-no go decisions when a tire fails during takeoff, a frequent cause of rejected take off accidents. The FAA's actions in response to these recommendations has been limited to the preparation of proposed advisory circular (AC) 91-6B which was issued for public comment on August 1, 1986, and the preparation of the Notice of Proposed Rulemaking (NPRM) Number 87-13, Docket Number 25471, which was issued on November 30, 1987. The Safety Board has reviewed both of these documents. Comments on the proposed AC were provided by correspondence dated September 30, 1986, to the FAA's Flight Technical Programs Branch and separate comment on NPRM 87-13 will be provided to the docket. Although both documents provide useful information which can enhance safety Data Source: NTSB Recommendations to FAA and FAA Responses under some conditions, neither adequately address the concerns of the recommendations cited above. The proposed AC, paragraph 7, specifies that wet and contaminated runway takeoff and landing information should be included in the aircraft's approved flight manual or in an operations manual required to be provided by the operator. This guidance is consistent with some of the actions sought by the Safety Board in Safety Recommendations A-78-84, A-78-89, A-81-68, A-82-165, and A- 82-167. However, there has been no action taken to address the acceleration or braking performance degradation caused by a tire failure. Furthermore, adherence to the AC is not required by regulation and the AC specifically excludes the need to present quantified landing distance data for transport category airplane operations where factored performance data is required by 14 CFR 12l.195 or 14 CFR 135.385. The Safety Board also believes that the information contained in an AC or an Air Carrier Operation Bulletin (ACOB) will not reach a significant percentage of air carrier pilots, particularly those who enter the pilot population long after the initial release of the AC or ACOB, unless such information is required to be included in must read documents like the AFM and the Air Carrier Flightcrew Operations Manuals. The Safety Board believes that the FAA should revise draft AC 91-6B to eliminate the exclusion in paragraph 7c(l) which pertains to Part 121 and 135 operations. Further, the Safety Board will continue to urge the FAA to require, through regulation or approval of operation specifications, that air carriers provide crews with the data described in Section 7 of the draft AC. The Safety Board would accept these FAA actions as compliance with Safety Recommendations A-81-68, A-82-165, and A-82-167. Safety Recommendation A-82-161 specifically addressed the need for a review of the adequacy of air carrier training, operating procedures and advisory information provided to flightcrews pertaining to landings on slippery runways. The FAA's last response to this recommendation on April 1, 1983, observed that ACOB 7-76-33 satisfied the intent of the recommendation. The Safety Board believes that proliferation within the air carrier industry as well as the turnover in the FAA's inspection force during the last 10 years warrants new emphasis on the subject. The Safety Board does not accept the 1976 ACOB as compliance with the recommendation. Although the Safety Board urges FAA to reconsider Safety Recommendations A-78-84, A- 78-89, A-81-68, A-82-161, A-82-165, and A-82-167, all of the recommendations are hereby reclassified as "Closed-Unacceptable Action" based upon the limited actions taken by FAA during the past 5 years.

From: FAA
To: NTSB
Date: 12/8/1987
Response: The FAA has drafted a Notice of Proposed Rulemaking (NPRM) to enable manufacturers to furnish performance information for slippery runways in unapproved sections of airplane flight manuals when requested by operators for their optional use. This NPRM is in the process of being coordinated with the Office of the Secretary and the Office of Management and Budget. It is now anticipated that the NPRM will be issued in early 1988. A copy of the NPRM will be provided to the Board as soon as it is issued.

From: NTSB
To: FAA
Date: 8/3/1987
Response: Pending the Board's review of the final action taken with regard to the proposed Notice of Proposed Rulemaking and our review of the amended Advisory Circular 91-6A, Safety Recommendations A-81-68 and A-82-165 have been classified as "Open-- Acceptable Alternate Action."

From: FAA
To: NTSB
Date: 6/19/1987
Response: THE FAA HAS DRAFTED A NPRM PROPOSING CHANGES TO 14 CFR PARTS 25, 121, AND 135. THIS NPRM WILL ENABLE MANUFACTURERS TO FURNISH PERFORMANCE INFORMATION FOR SLIPPERY RUNWAYS IN UN APPROVED SECTIONS OF AIRPLANE FLIGHT MANUALS WHEN REQUESTED BY OPERATORS FOR THEIR OPTIONAL USE. ADDITIONALLY, THE FAA HAS AMENDED AC 91-6A, PERFORMANCE INFORMATION FOR OPERATION WITH WATER, SLUSH, SNOW, ICE ON THE RUNWAY, DATED MAY 24, 1978. THIS AMENDED AC 91-6B IS INTENDED TO BE APPLICABLE IN CONJUNCTION WITH THE NEW CERTIFICATION AND OPERATING RULES. SINCE THESE REGULATORY CHANGES HAVE NOT TAKEN PLACE, IT IS NOT POSSIBLE TO OFFER GUIDANCE IN THE NEW AC. THE REVISED AC WILL BE ISSUED AS SOON AS THE PROPOSED RULES BECOME EFFECTIVE. IT IS ANTICIPATED THAT THE NPRM WILL BE PUBLISHED BY THE FALL OF 1987.

From: NTSB
To: FAA
Date: 11/16/1981
Response: We note that the FAA has planned a conference in November 1981 to discuss and evaluate factors affecting takeoff and accelerate-stop distance criteria. Pending the FAA's further response, A-81-68 is also maintained in an "Open--Acceptable Action" status.

From: FAA
To: NTSB
Date: 9/10/1981
Response: FAA LTR: THE FAA HAS TENTATIVELY SCHEDULED A TECHNICAL CONFERENCE IN NOVEMBER 1981 TO DISCUSS TRANSPORT AIRPLANE TAKEOFF PERFORMANCE REQUIREMENTS. ALL FACTORS AFFECTING TAKEOFF AND ACCELERATE-STOP DISTANCE, INCLUDING WET RUNWAYS, WILL BE DISCUSSED. ALTHOUGH THIS CONFERENCE WILL PRIMARILY CONSIDER TAKEOFF PERFORMANCE, THE FACTORS AFFECTING WET RUNWAY TAKEOFF/ACCELERATE-STOP PERFORMANCE ARE GENERALLY APPLICABLE TO LANDING PERFORMANCE. ACCORDINGLY, IT IS OUR INTENT TO DELAY FURTHER ACTION ON THIS RECOMMENDATION UNTIL FAA EVALUATES THE INFORMATION RESULTING FROM THIS TECHNICAL CONFERENCE. THIS WILL ALLOW FOR THE DEVELOPMENT OF A UNIFORM AIRWORTHINESS STANDARD OR ACCEPTABLE TEST PROCEDURES WHICH MAY SERVE AS A BASIS FOR FULFILLING THE INTENT OF SAFETY RECOMMENDATION A-81-68.