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Safety Recommendation Details

Safety Recommendation A-86-086
Details
Synopsis: 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.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: PERFORM A DIRECTED SAFETY INSPECTION OF FLIGHT ATTENDANT RESTRAINT SYSTEMS ON AIR CARRIER AIRCRAFT TO DETERMINE DESIGN DEFICIENCIES THAT CAUSE DAMAGE TO WEBBING MATERIALS, AND ESTABLISH A PROGRAM AS NEEDED TO REPLACE WORN OR DAMAGED WEBBING AND CORRECT DESIGN DEFICIENCIES.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: DALLAS/FT WORTH, TX, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA85AA031
Accident Reports: Delta Air Lines, Inc., Lockheed L-1011-385-1, N726DA
Report #: AAR-86-05
Accident Date: 8/2/1985
Issue Date: 9/3/1986
Date Closed: 10/26/1987
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 10/26/1987
Response: As stated in our letter of March 19, 1987, the Board believes that the FAA's action does not comply with the intent of this recommendation, which is to "determine design deficiencies that cause damage to webbing materials, and establish a program as needed to replace worn or damaged webbing and correct design deficiencies." The Safety Board further notes that in the FAA's letter of July 16, 1987, in response to Safety Recommendation A-86-83, the FAA had determined that improvements were necessary to Delta Air Lines' maintenance program regarding the inspection and replacement of restraint systems. This action, which occurred after the issuance of Action Notice A8300.11, would indicate that the Notice was not entirely effective. However, as it is apparent that an impasse has been reached on this issue and further correspondence would not yield any fruitful results, Safety Recommendation A-86-86 has been classified as "Closed-Unacceptable Action." Although this recommendation has been closed, the Board still considers this issue to be important to flight safety and will continue to stress our concerns in future accident investigations.

From: FAA
To: NTSB
Date: 9/3/1987
Response: AS STATED IN MY LETTERS DATED 11-18-86 AND 1-30-87, THE FAA BELIEVES THAT ACTION NOTICE A8300.11, WHICH 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, ADDRESSES THE INTENT OF THESE RECOMMENDATIONS (SIC).

From: NTSB
To: FAA
Date: 3/19/1987
Response: The Board believes that the FAA's action does not comply with the intent of this recommendation, which is to "determine design deficiencies that cause damage to webbing materials, and establish a program as needed to replace worn or damaged webbing and correct design deficiencies." Neither of these points was mentioned in your letters or addressed by the action notice. Pending further correspondence, Safety Recommendation A-86-86 has been classified as "Open--Unacceptable Action."

From: FAA
To: NTSB
Date: 1/30/1987
Response: 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.

From: FAA
To: NTSB
Date: 11/18/1986
Response: THE FAA WILL ISSUE AN ACTION NOTICE TO INSTITUTE A PROGRAM OF AIRCRAFT INSPECTION AND MAINTENANCE PRACTICE EVALUATION OF AIR CARRIERS. THE ACTION WILL INSTRUCT PRINCIPAL MAINTENANCE INSPECTORS TO EVALUATE THE MAINTENANCE PROGRAMS TO ASSIGNED CARRIERS REGARDING FLIGHT ATTENDANT RESTRAINT SYSTEMS. IN ADDITION, THE NOTICE WILL EMPHASIZE INSPECTIONS OF FLIGHT ATTENDANT RESTRAINT SYSTEMS DURING NORMAL SURVEILLANCE BY MAINTENANCE INSPECTORS. ON 11-28-86, THE FAA ISSUED AC A8300.11 TO ADDRESS THE RESTRAINT SYSTEMS ISSUES EXPRESSED IN THESE RECOMMENDATIONS.