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Safety Recommendation Details

Safety Recommendation A-82-065
Details
Synopsis: ON JULY 9, 1982, A PAN AMERICAN BOEING 727 (FLIGHT 759) CRASHED INTO A RESIDENTIAL AREA IN KENNER, LOUISIANA, KILLING 145 PERSONS ON BOARD THE AIRCRAFT AND 8 PERSONS ON THE GROUND. THE SAFETY BOARD'S PRELIMINARY INVESTIGATION INDICATES THAT WIND SHEAR MAY HAVE BEEN A FACTOR. ANALYSIS OF THE AIRCRAFT PERFORMANCE IN THIS ACCIDENT, AS IN ALL OTHER AIR CARRIER ACCIDENTS, DEPENDS HEAVILY ON THE INFORMATION RECEIVED FROM THE FLIGHT DATA RECORDER (FDR). IN THIS CASE, THE OSCILLOGRAPHIC, OR FOIL, FDR CARRIED ON THE ACCIDENT AIRCRAFT LACKS A NUMBER OF BASIC AND IMPORTANT PARAMETERS, ALL OF WHICH ARE NECESSARY TO DETERMINE THE EXTENT TO WHICH WIND SHEAR MAY HAVE AFFECTED AIRCRAFT PERFORMANCE. IN ADDITION, THE RECORDER ITSELF IS TECHNOLOGICALLY OBSOLETE. THE INADEQUACIES OF THE FOIL RECORDER WERE ALSO BROUGHT TO LIGHT IN THE AIR FLORIDA, INC., BOEING 737 ACCIDENT AT WASHINGTON NATIONAL AIRPORT, JANUARY 13, 1982. A SIGNIFICANT TIMING DISPARITY BETWEEN THE CVR AND FDR WAS EVENTUALLY TRACED TO A FAULTY CONTROL SPRING ASSEMBLY AFTER MONTHS OF INVESTIGATIVE WORK BY THE SAFETY BOARD AND THE RECORDER MANUFACTURER. THE LACK OF ENGINE, ATTITUDE, AND ACCELERATION DATA LENGTHENED THE INVESTIGATIVE PROCESS CONSIDERABLY BY NECESSITATING A COSTLY AND LENGTHY SIMULATOR STUDY. RECORDER MANUFACTURERS HAVE RECENTLY INTRODUCED COST-EFFECTIVE DIGITAL RECORDERS TO REPLACE THE FOIL RECORDERS, THUS MAKING PRACTICAL THE INSTALLATION AND USE OF DIGITAL RECORDERS IN ALL AIRCRAFT CURRENTLY REQUIRING A RECORDER.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: At an early date and pending the effective date of the recommended amendment of 14 CFR 121.343 to require installation of digital flight data recorder systems capable of recording more extensive parameters, require that operators of all aircraft equipped with foil flight data recorders be required to replace the foil recorder with a compatible digital recorder. (Superseded by A-87-77 through -89) (Urgent)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Superseded
Mode: Aviation
Location: Kenner, LA, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA82AA028
Accident Reports: Pan American World Airways, Inc., Clipper 759, Boeing 727-235, N4737
Report #: AAR-83-02
Accident Date: 7/9/1982
Issue Date: 7/13/1982
Date Closed: 6/19/1987
Addressee(s) and Addressee Status: FAA (Closed - Superseded)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 5/30/1990
Response: Safety Recommendation A-82-065 was reiterated in the letter issuing Safety Recommendations A-90-070 through A-90-075 sent on 5/30/1990. This letter discusses that additional action is needed in the areas of maintenance requirements and operating standards to further ensure the availability and the reliability of cockpit voice recorders (CVRs), flight data recorders (FDRs), and digital flight data recorders (DFDRs).

From: NTSB
To: FAA
Date: 6/19/1987
Response: This recommendation was classified as closed-superseded per ntsb green sheet a-87- 77 thru -89. With the issuance of Safety Recommendations A-87-77 through -89, the following recommendations have been classified as CLOSED--SUPERSEDED: A-78-28, A-82-64, A-82-65, A-82-66, A-82-67, A-82-106, and A-82-108. The following recommendations have been classified CLOSED—UNACCEPTABLE ACTION/ SUPERSEDED: A-82-107, A-8 2-109, A-82-110, and A-82-111.

From: NTSB
To: FAA
Date: 10/25/1984
Response: We note that the FAA plans to issue a Notice of Proposed Rulemaking (NPRM) by the end of calendar year 1984 and will take into consideration the Safety Board's comments contained in its letter of October 24, 1983. Your staff has not formally discussed with us the contents of the proposed NPRM and its effects on the Board's future accident investigation needs. We believe that such discussion would be beneficial and would appreciate your scheduling a meeting with key FAA representatives regarding this issue at an early date. We will, of course, respond to the NPRM when issued. As you know, the satisfactory resolution of these recommendations is vital to the Safety Board's role in aircraft accident investigation. Upgrading of FDRs has been a subject of concern to us for many years. We appreciate the attention now being given to these recommendations and earnestly seek your continued support. Safety Recommendations A-82-64 through A-82-66 remain classified in an "Open--Acceptable Action" status.

From: FAA
To: NTSB
Date: 9/17/1984
Response: FAA LETTER: AS NOTED IN OUR LETTER TO THE BOARD DATED MAY 27, 1983, THE FAA IS IN THE FORMAL RULEMAKING PROCESS. WE EXPECT THE ISSUANCE OF A NOTICE OF PROPOSED RULEMAKING ACTION BY THE END OF CALENDAR YEAR 1984. WE APPRECIATE THE REVIEW AND COMMENTS IN YOUR LETTER OF OCTOBER 24, 1983, RELATIVE TO OUR MAY 1983 REPORT, "COCKPIT VOICE AND FLIGHT DATA RECORDER EVALUATION." WE WILL TAKE THESE COMMENTS INTO CONSIDERATION IN OUR RULEMAKING ACTION.

From: NTSB
To: FAA
Date: 10/24/1983
Response: The Safety Board is pleased that your are initiating rulemaking to require improved flight recorders in 14 CFR Part 121 operations. Your response stated that existing pre-1969 type certificated aircraft would be required to be retrofitted with a 5- parameter digital flight data recorder (DFDR) within 2 years after the effective date of the rule unless a major internal refurbishment or overhaul ("D" - check) is scheduled within 5 years. You responded further that, in the latter case, an 11- parameter DFDR will be required to be installed at the time of modification or overhaul. The Safety Board believes that the new rulemaking will be a significant step toward improving aviation safety, since we understand that, consistent with Safety Recommendation A-82-65, all foil recorders will be removed from service within 2 years after the effective date of the rule, regardless of whether or not additional parameters are to be installed at a later date. Pending issuance of the new rules, Safety Recommendations A-82-64 and -65 will be held in an "Open--Acceptable Action" status.

From: FAA
To: NTSB
Date: 5/27/1983
Response: FAA LETTER: FOR PART 121 OPERATIONS--EXISTING PRE-1969 TYPE CERTIFICATED AIRCRAFT WOULD BE RETROFITTED WITH A FIVE PARAMETER DIGITAL FDR WITHIN 2 YEARS AFTER THE EFFECTIVE DATE OF THE RULE, UNLESS A MJAOR INTERNAL REFURBISHMENT OR OVERHAUL ("D"-CHECK) IS SCHEDULED WITHIN 5 YEARS. IN THE LATTER CASE, AN 11-PARAMETER DIGITAL FDR WILL BE REQUIRED TO BE INSTALLED AT THE TIME OF MODIFICATION OR OVERHAUL.

From: NTSB
To: FAA
Date: 4/20/1983
Response: As noted in our 2/28/83, letter to you on the same subject, pending suitable amendment of 14 CFR 121.343, Safety Recommendations A-82-64 and -65 will be held in an "Open--Acceptable Action" status. The Safety Board would very much appreciate receiving a copy of the results of the FAA's study of flight data recorders, which was scheduled for completion March 15, 1983.

From: FAA
To: NTSB
Date: 3/4/1983
Response: FAA LETTER: AS NOTED IN OUR RESPONSE OF OCTOBER 29, 1982, THE FAA HAS INITIATED A FLIGHT DATA RECORDER STUDY IN WHICH WE PLAN TO IDENTIFY THE VARIOUS LEVELS OF TECHNOLOGY WHICH ARE FEASIBLE, AS WELL AS THE ASSOCIATED COST AND SAFETY IMPACTS. BOARD RECOMMENDATIONS AND CONCERNS ARE BEING ADDRESSED. THE FINDINGS DERIVED FROM THIS STUDY WILL DETERMINE OUR FURTHER RULEMAKING ACTIONS. OUR STUDY SHOULD BE COMPLETED BY MARCH 15, 1983. WE WILL FURTHER ADVISE THE BOARD OF OUR FINDINGS AND PROPOSED ACTIONS.

From: NTSB
To: FAA
Date: 2/28/1983
Response: The Safety Board is pleased to note that you agree that a retrofit to incorporate a digital recording system capable of recording more extensive parameters is in the public interest. We accept your invitation for our staff to work with the FAA in this analysis. Pending suitable amendment of 14 CFR 121.343, A-82-64 and -65 will be held in an "Open--Acceptable Action" status.

From: NTSB
To: FAA
Date: 1/13/1983
Response: We are happy to note that, in your letter of October 29, 1982, you agreed that a retrofit to incorporate an 11-parameter digital recording system is in the public interest. However, in view of this latest accident, we wish to reiterate and amplify our concern about obsolete-technology foil recorders and to urge you to expedite FAA action on these recommendations.

From: FAA
To: NTSB
Date: 10/29/1982
Response: FAA LETTER: PENDING THE RESULTS OF THE ANALYSIS REFERRED TO IN OUR COMMENT ON A-82-64, THE FAA IS CONSIDERING THIS RECOMMENDATION ALSO. OUR FINAL DETERMINATION WILL DEPEND, IN LARGE PART, ON THE TIME REQUIRED TO IMPLEMENT ANY RETROFIT ACTIONS WHICH MAY BE DEEMED NECESSARY, SINCE A SHORT-TERM RETROFIT, IF ADOPTED, WOULD OBVIATE THE NEED FOR THIS SOLUTION. THE RECOMMENDATION TO REQUIRE ALL FUTURE MANUFACTURED AIRPLANES TO INSTALL A 5 PARAMETER DIGITAL FLIGHT DATA RECORDER WILL ALSO BE EVALUATED IN THE CONTEXT OF THIS ANALYSIS.

From: FAA
To: NTSB
Date: 10/8/1982
Response: FAA LETTER: THE FAA REJECTS THIS RECOMMENDATION TO REPLACE ALL FOIL FLIGHT DATA RECORDERS WITH COMPATIBLE DIGITAL RECORDERS. WE FIND THAT THE COST INVOLVED EXCEEDS THE BENEFITS BY $25.5M (SEE ENCLOSED COST/BENEFIT ANALYSIS). THE RECOMMENDATION TO REQUIRE ALL FUTURE MANUFACTURED AIRPLANES TO INSTALL A 5-PARAMETER DIGITAL FLIGHT DATA RECORDER (DFDR) HAS MERIT. WE INTEND TO FURTHER INVESTIGATE THE FEASIBILITY OF ACTION TO REQUIRE FUTURE AIRPLANES WHOSE ORIGINAL TYPE CERTIFICATE WAS ISSUED BEFORE SEPTEMBER 30, 1969, TO INSTALL A DFDR WITH AT LEAST 5 PARAMETERS. WE WILL KEEP YOU INFORMED OF THE RESULTS OF OUR STUDY OF THIS MATTER.