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Safety Recommendation Details

Safety Recommendation A-82-066
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: Amend 14 CFR 121.343 so that, after a specified date, all aircraft manufactured after that date, regardless of the date of original type certificate, be equipped with one or more approved flight recorders that record data from which the information listed in table I [see greensheet] can be determined as a function of time. For newly type-certificated aircraft, any dedicated parameter which may be necessary because of unique features of the specific aircraft configuration and the type design should also be required. (Superseded by A-87-77 through -89)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Superseded
Mode: Aviation
Location: Kenner, LA, United States
Is Reiterated: No
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: 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: Your response to the Safety Recommendation indicated that you are initiating rulemaking concerning 14 CFR Part 121 operations so that all aircraft manufactured after a to-be-specified date would be required to have a 16-parameter DFDR installed. The Safety Board assumes the 16 parameters referred to are the parameters in 14 CFR Part 121, Appendix B, which currently requires 16 parameters as a function of time. Another parameter, radio transmitter keying, is not contained in this list but is required by 14 CFR 121.343(g). We trust that you intend to continue to require this 17th parameter as well. We believe that your final rule should retain as a minimum the parameter list of 14 CFR Part 121, Appendix B, but we urge you to make the following refinements in respect to the parameters: 1. Time should be recorded explicitly from a GMT clock instead of being based on elapsed time derived from tape motion. Currently DFDR elapsed time measurements are extremely unreliable during periods of lost recorder synchronization. 2. The thrust of each engine and the position of each thrust reverser should be recorded once every second instead of once every 4 seconds. Individual engine problems cannot be documented properly if the activity of each engine is recorded only once every 4 seconds. 3. Longitudinal acceleration should be substituted for lateral acceleration if only two acceleration parameters are required. Longitudinal acceleration is more valuable than lateral acceleration because it gives a measure of takeoff and stopping accelerations. However, for proper performance calculations, all three accelerations should be recorded. Since most modern airplanes have accelerometers to measure the acceleration in all three axes, requiring the recording of three instead of two axes will not require that another accelerometer be installed in the aircraft. 4. The accuracy specifications of pilot control inputs, control surface positions, and pitch trim position should contain the caveat "unless higher accuracy uniquely required." Again, we are pleased that you are initiating rulemaking to require that all aircraft manufactured after a to-be-specified date have a 17-parameter DFDR. Safety Recommendation A-82-66 urged that data be recorded from which the information listed in Table I (attached) could be determined as a function of time. We are concerned, therefore, that your proposed rulemaking for new airplanes will not include all those parameters necessary to monitor airplane performance and the status of flight-essential functions. Perhaps the 17 parameters are sufficient for most present-day airplanes, but not for today's state-of-the-art airplanes, nor for future airplanes. Airplanes with solid-state control systems components, computer- driven instruments and autopilots, and cathode-ray-tube displays will require new approaches to aircraft accident and incident investigations. We will be more dependent on the data stored in the digital FDR than ever before. Physical evidence regarding a number of essential factors needed to be determined in the investigation of an accident will not be retained after a crash if only a 17-parameter DFDR is available. New airplanes are employing digital data busses which connect every system with information lines. Extensive data are on the busses, and new sensors do not have to be installed in order to capture the data. We believe that those data which are already sensed and in digital form should be recorded, particularly since DFDRs already have the extra capacity to record additional parameters.* Your cost-benefit Data Source: NTSB Recommendations to FAA and FAA Responses analysis would appear to have overlooked these facts. Further, we believe that crucial digital data should be identified for storage in the flight recorder system early in the airplane design as a part of the type certification process. Your May 1983 report, "Cockpit Voice and Flight Data Recorder Evaluation," page 30, says, "About three fatal accidents would have to be prevented [in a 15-year period] to offset costs if the NTSB's recommended alternative is implemented." These cost figures do not take into account the availability of the multiple parameter information on the digital data busses already discussed. In addition, The Journal of Commerce on June 2, 1983, reported that the recent annual general meeting of the International Union of Aviation Insurers was told to expect three wide-bodied aircraft losses per year (emphasis added). Moreover, wide-bodied aircraft constitute only a portion of all aircraft used in air carrier service. Thus, the potential losses are even higher. Therefore, the Safety Board believes that your cost-benefit analysis understates the potential benefits and believes further that there is a high positive benefit-to-cost ratio in implementing the Safety Board's recommendations. In April 1983, the Safety Board held a government/industry meeting at Springfield, Virginia, wherein participants formed several groups and made formal recommendations to the Safety Board. The Major Accident Investigations Group supported the Safety Board's position with the following formal recommendation. It was the recommendation of the group that the Board review present [cockpit voice recorder] CVR, [flight data recorder] FDR/Digital Flight Data Recorder requirements as they interface with the new electronic instruments and components, considering that information previously retrievable after the fact may no longer be available, and new expanded coverage may be required for a DFDR. The Human Performance/Factors Group at the same meeting made the following formal recommendation in support of the intent of Safety Recommendation A-82-66: It is recommended that for aircraft having digital flight control systems, the digital flight data recorder must record control modes, control input, including automatic inputs and responses to aid in accident investigation. Also of interest is the fact that the International Civil Aviation Organization (ICAO) sent a letter to its member states on March 4, 1983, with a set of proposals to improve flight recorder systems. The proposals very much parallel all of the Safety Board recommendations cited in this letter. In light of the fact that digital data are available to be recorded in state-of-the- art airplanes and that recording such data has wide support, the Safety Board strongly encourages you to expand the rulemaking to include extra parameters from digital data busses in new airplanes so equipped. We recommend again the parameters listed in Table I of our Safety Recommendation letter to you of July 13, 1982. Pending issuance of the new rule, Safety Recommendation A-82-66 will be held in an "Open--Unacceptable Action" status.

From: FAA
To: NTSB
Date: 5/27/1983
Response: FAA LETTER: FOR PART 121 OPERATIONS--ALL AIRCRAFT MANU FACTURED AFTER A TO-BE-SPECIFIED DATE WOULD BE REQUIRED TO HAVE A 16-PARAMETER DIGITAL FDR INSTALLED.

From: NTSB
To: FAA
Date: 2/28/1983
Response: The Safety Board is pleased to note that you agree that this recommendation may be in the public interest. Certainly, our staff will be available to work with FAA regarding this matter. Pending suitable amendment of 14 CFR 121.343, A-82-66 will be held in an "Open--Acceptable Action" status.

From: FAA
To: NTSB
Date: 10/29/1982
Response: FAA LETTER: THE FAA IS RECONSIDERING THIS RECOMMENDATION TO INSTALL FLIGHT DATA RECORDERS CAPABLE OF RECORDING DATA FROM WHICH THE INFORMATION LISTED IN TABLE I (OF THE RECOMMENDATIONS) CAN BE DETERMINED FOR AIRCRAFT MANUFACTURED AFTER A SPECIFIC DATE REGARDLESS OF THE DATE OF THE ORIGINAL TYPE CERTIFICATION. INCLUDED IN OUR ANALYSIS DISCUSSED IN OUR COMMENT ON A-82-64 WILL BE THIS SPECIFIC RECOMMENDED ACTION. IT APPEARS THAT THIS RECOMMENDATION, OR ADOPTION OF A COURSE OF ACTION VERY CLOSE TO THAT RECOMMENDED, MAY BE IN THE PUBLIC INTEREST. AS NOTED EARLIER, THE FAA WELCOMES PARTICIPATION OF THE BOARD IN THIS ANALYSIS, AND I WILL KEEP YOU INFORMED ON OUR PROGRESS.

From: FAA
To: NTSB
Date: 10/8/1982
Response: FAA LETTER: THE FAA REJECTS THIS RECOMMENDATION TO INSTALL FLIGHT DATA RECORDERS CAPABLE OF RECORDING DATA FROM WHICH THE INFORMATION LISTED IN TABLE I CAN BE DETERMINED FOR AIRCRAFT MANUFACTURED AFTER A SPECIFIC DATE REGARDLESS OF THE DATE OF THE ORIGINAL TYPE CERTIFICATION. WE FIND THAT THE COSTS INVOLVED EXCEED THE BENEFITS BY $35.6 MILLION (SEE ENCLOSED COST/BENEFIT ANALYSIS).