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General Aviation Safety
ON JANUARY 23, 1982, WORLD AIRWAYS, INC., FLIGHT 30H, A MCDONNELL DOUGLAS DC-10-30, WAS A REGULARLY SCHEDULED PASSENGER FLIGHT FROM OAKLAND, CALIFORNIA, TO BOSTON, MASSACHUSETTS, WITH AN EN ROUTE STOP AT NEWARK, NEW JERSEY. FOLLOWING A NONPRECISION INSTRUMENT APPROACH TO RUNWAY 15R AT BOSTON-LOGAN INTERNATIONAL AIRPORT, THE AIRPLANE TOUCHED DOWN ABOUT 2,500 FEET BEYOND THE DISPLACED THRESHOLD OF THE RUNWAY, LEAVING 6,691 FEET REMAINING ON WHICH TO STOP. ABOUT 1936:40, THE AIRPLANE VEERED TO AVOID THE APPROACH LIGHT PIER AT THE DEPARTURE END OF THE RUNWAY AND SLID INTO THE SHALLOW WATER OF BOSTON HARBOR. THE NOSE SECTION SEPARATED FROM THE FORWARD FUSELAGE AFTER THE AIRPLANE DROPPED ONTO THE SHORE EMBANKMENT. OF THE 212 PERSONS ON BOARD, 2 ARE MISSING AND PRESUMED DEAD. THE OTHERS EVACUATED THE AIRPLANE SAFELY, BUT WITH SOME INJURIES. THE REPORTED WEATHER WAS A MEASURED 800-FOOT OVERCAST, 2 1/2 MILE VISIBILITY, LIGHT RAIN AND FOG, TEMPERATURE 35 DEGREES, AND WIND 165 DEGREES AT 3 KNS. THE WET RUNWAY WAS COVERED WITH HARD-PACKED SNOW AND A COATING OF RAIN AND/OR GLAZED ICE.
THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REQUIRE THAT AIR CARRIER PRINCIPAL OPERATIONS INSPECTORS REVIEW THE OPERATING PROCEDURES AND ADVISORY INFORMATION PROVIDED TO FLIGHTCREWS FOR LANDING ON SLIPPERY RUNWAYS TO VERIFY THAT THE PROCEDURES AND INFORMATION ARE CONSISTENT WITH PROVIDING MINIMUM AIRPLANE STOPPING DISTANCE. (Supersedes Safety Recommendations A-74-119 through -121 and A-76-136 and -137)
Original recommendation transmittal letter:
Closed - Unacceptable Action
BOSTON, MA, United States
World Airways, Inc., Flight 30H, McDonnell Douglas DC-10-30CF, N113WA
Addressee(s) and Addressee Status:
FAA (Closed - Unacceptable Action)
Safety Recommendation History
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 Data Source: NTSB Recommendations to FAA and FAA Responses 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 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 121.195 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.
Your April 1, response included a copy of Air Carrier Operations Bulletin 7-76-33 and inferred that the ACOB fully satisfied the intent of Safety Recommendation A-82-161. We agree that the ACOB contains pertinent and valuable information regarding operating procedures on slippery runways. We also concur that the content should be reviewed to assure that the procedures cited are still valid. However, in addition to the FAA's review of these procedures, we believe that positive action should be taken to require Air Carrier Principal Operations Inspectors to ascertain that the pertinent information is contained in operations manuals and training documents of their assigned air carriers. We will classify Safety Recommendation A-82-161 as "Open--Acceptable Action" awaiting further response regarding the ACOB review and actions to assure air carrier distribution of the essential information.
FAA LETTER: AIR CARRIER OPERATIONS BULLETIN 7-76-33, SUGGESTED PROCEDURES WHEN LANDING ON SLIPPERY RUNWAYS, ADDRESSES THIS RECOMMENDATION. HOWEVER, THE SUGGESTED PROCEDURES CONTAINED IN THE BULLETIN WERE BASED ON INFORMATION DEVELOPED PRIOR TO 1974. WE INTEND TO EVALUATE THE SUGGESTED PROCEDURES TO DETERMINE IF THEY REMAIN VALID IN VIEW OF CURRENT INFORMATION AND IF THERE ARE ANY ADDITIONAL PROCEDURES THAT NEED EMPHASIS.
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