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ON AUGUST 2, 1985, AT 1805:52 CENTRAL DAYLIGHT TIME, DELTA AIR LINES (DELTA) FLIGHT 191, A LOCKHEED L-1011-385-1, N726DA, CRASHED WHILE APPROACHING TO LAND ON RUNWAY 17L AT THE DALLAS/FORT WORTH INTERNATIONAL (DFW) AIRPORT, TEXAS. WHILE PASSING THROUGH THE RAIN SHAFT BENEATH A THUNDERSTORM, FLIGHT 191 ENTERED A MICROBURST WHICH THE PILOT WAS UNABLE TO TRAVERSE SUCCESSFULLY. THE AIRPLANE STRUCK THE GROUND ABOUT 6,300 FEET NORTH OF THE APPROACH END OF RUNWAY 17L, HIT A CAR ON A HIGHWAY NORTH OF THE RUNWAY KILLING THE DRIVER, STRUCK TWO WATER TANKS ON THE AIRPORT, AND BROKE APART. EXCEPT FOR A SECTION OF THE AIRPLANE CONTAINING THE AFT FUSELAGE AND EMPENNAGE, THE REMAINDER OF THE AIRPLANE DISINTEGRATED DURING THE IMPACT SEQUENCE, AND A SEVERE FIRE ERUPTED DURING THE IMPACT SEQUENCE. OF THE 163 PERSONS ABOARD, 134 PASSENGERS AND CREWMEMBERS WERE KILLED; 26 PAS SENGERS AND 3 CABIN ATTENDANTS SURVIVED.
THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: ISSUE AN ADVISORY CIRCULAR WITH GUIDANCE ON THE LIMITS OF WEAR AND DAMAGE TO RESTRAINT SYSTEM WEBBING MATERIAL THAT WOULD NECESSITATE THE REPLACEMENT OF WORN OR DAMAGED WEBBING.
Original recommendation transmittal letter:
Closed - Unacceptable Action
DALLAS/FT WORTH, TX, United States
Delta Air Lines, Inc., Lockheed L-1011-385-1, N726DA
Addressee(s) and Addressee Status:
FAA (Closed - Unacceptable Action)
Safety Recommendation History
The Safety Board is disappointed by the results of the FAA's reevaluation of this safety recommendation and does not agree that the development of guidance on what constitutes unacceptable wear of restraint systems is not possible due to "various types of installations and other variables." Irrespective of installation variables, which are relatively few in actual practice, the focal point of this safety recommendation is wear or damage to restraint system webbing materials. The Safety Board remains unconvinced that the combined engineering and maintenance resources of the FAA, the webbing manufacturers, the Society of Automotive Engineers, and the Aerospace Industries Association, as well as foreign certification authorities cannot develop clear and easily understood guidance for FAA and air carrier inspectors to determine what "on condition" wear/damage constitutes a degraded condition of restraint system webbing. As stated clearly in the original safety recommendation letter the Safety Board firmly believes that guidance can be developed for webbing replacement. This would permit determination of whether conditions found by inspectors are superficial and may preclude uneconomic replacement. Conditions such as minor discoloration would require webbing replacement under the present FAA policy of not allowing any damage, regardless of how slight. Since the issuance of this safety recommendation, the Safety Board investigated an accident involving a Horizon Air De Haviland DHC-8-102 at Seattle-Tacoma International Airport which occurred on April 15, 1988. It was found that both pilots' shoulder harness webbings were badly frayed and abraded. The webbing damage was caused by rubbing on pieces of broken plastic installed over the shoulder harness guides on the seat backs. Although the webbing was rated to 4000 pounds tensile strength when manufactured, tests performed by the FAA Civil Aeromedical Institute caused the webbings to fail at 1160 pounds and 1600 pounds, respectively. The webbing for the captain's and first officer's seats were manufactured in March and May 1986, respectively, only 2 years before the accident. The Safety Board is concerned that these shoulder harnesses were allowed to remain in service in spite of the FAA's contention that any evidence of wear is grounds for replacement of webbing. FAA Action Notice A8300.11 issued on November 11, 1986, directed FAA Inspectors to ensure that air carriers implement procedures to replace damaged restraint system components. As the FAA does not agree with the Safety Board's position, Safety Recommendation A- 86-82 has been classified as "Closed--Unacceptable Action."
THE FAA BELIEVES THAT DUE TO THE VARIOUS TYPES OF INSTALLATIONS AND OTHER VARIABLES, ISSUANCE OF AN ADVISORY CIRCULAR IS IMPRACTICAL. ACTION NOTICE A8300.11 WAS ISSUED ON NOVEMBER 28, 1986, REQUIRING THAT FAA INSPECTORS ENSURE THAT AIR CARRIERS ESTABLISH PROCEDURES TO PERIODICALLY INSPECT, REPAIR, AND REPLACE RESTRAINT SYSTEMS "WHEN THERE IS OBVIOUS DAMAGE, WEAR, OR CHAFING WHICH COULD DEGRADE THE INTEGRITY OF THE SYSTEM.
As stated in the FAA's November 18 letter, there currently are no satisfactory quantifiable criteria available to assess the integrity of restraint system webbing material. The intent of this recommendation was for the FAA to develop the necessary guidance and thereafter to promulgate this guidance in an Advisory Circular. Without such guidance the issuance of the proposed action notice mentioned in your letter has little meaning, as the inspectors would not have sufficient information upon which to judge objectively whether an air carriers' inspection, repair, and replacement procedures are adequate. Therefore, the Board requests that the FAA reconsider its response and develop the necessary guidance in an Advisory Circular. Pending further correspondence, Safety Recommendation A-86-82 has been classified as "Open--Unacceptable Action."
On November 28, 1986, the FAA issued Action Notice A8300.11 (copy enclosed) to address the restraint system issues expressed in these recommendations. This action notice requires aviation safety inspectors to ensure that air carriers have established and implemented appropriate procedures to periodically inspect crew and passenger restraint systems and to repair or replace these systems when there is obvious damage, wear, or chafing which could degrade the integrity of the system. The action notice also instructs principal maintenance inspectors to evaluate the maintenance programs of their assigned air carriers regarding crew and passenger restraint systems, and emphasizes inspections of crew and passenger restraint systems during normal surveillance. I believe that this action satisfies the intent of these recommendations, and I consider the FAA's action to be completed.
THE FAA AGREES WITH THE INTENT IF THIS RECOMMENDATION, BUT DOES NOT BELIEVE THAT THE FAA SHOULD ISSUE AN AC TO PROVIDE GUIDANCE ON THE LIMITS OF WEAR AND DAMAGE TO RESTRAINT SYSTEM WEBBING MATERIALS. THE FAA WILL, HOWEVER, ISSUE AN ACTION NOTICE TO FLIGHT STANDARDS FIELD OFFICES TO REQUIRE THAT AVIATION SAFETY INSPECTORS ENSURE THAT AIR CARRIERS HAVE ESTABLISHED AND IMPLEMENTED APPROPRIATE PROCEUDURES TO PERIODICALLY INSPECT CREW AND PASSENGER RESTRAINT SYSTEMS, AND TO REPAIR OR REPLACE THESE SYSTEMS WHEN THERE IS OBVIOUS DAMAGE, WEAR, OR CHAFING WHICH COULD DEGRADE THE INTEGRITY OF THE SYSTEM. ON 11-28-86, THE FAA ISSUED AC A8300.11 TO ADDRESS THE RESTRAINT SYSTEM ISSUES EXPRESSED IN THESE RECOMMENDATIONS.
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