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Safety Recommendation Details

Safety Recommendation A-91-006
Details
Synopsis: ON DECEMBER 3, 1990, AT 1354 EST, NORTHWEST AIRLINES FLIGHT 299, A BOEING B-727, AND NORTHWEST FLIGHT 1482, A MCDONNELL DOUGLAS DC-9, COLLIDED NEAR THE INTERSECTION OF RUNWAY 03C/ 21C AND 09/27 AT DETROIT METROPOLITAN/ WAYNE COUNTY AIRPORT, ROMULUS, MICHIGAN. THE B-727 WAS TAKING OFF FROM RUNWAY 03C, AND THE DC-9 HAD TAXIED ONTO THAT RUNWAY JUST PRIOR TO THE ACCIDENT. VISIBILITY WAS REPORTED TO HAVE BEEN 1/4 MILE IN FOG AT THE TIME. ONE FLIGHT ATTENDANT AND SEVEN PASSENGERS ONBOARD THE DC-9 WERE KILLED; THERE WERE NO INJURIES TO THE PERSONS ONBOARD THE B-727.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION IMMEDIATELY REQUIRE OPERATORS OF DC-9/MD-80 SERIES AIRPLANES TO INCLUDE IN THEIR FLIGHTCREW AND FLIGHT ATTENDANT TRAINING PROGRAMS THE SAFETY BOARD'S FINDINGS REGARDING THE TAILCONE MANUAL RELEASE SYSTEM AND TAILCONE FAMILIARIZATION TOURS AND HANDS-ON TRAINING ON THE OPERATION OF THE RELEASE HANDLE IN DC-9/MD-80 AIRPLANES USING ACTUAL AIRPLANES OR FAA-APPROVED SIMULATORS. (URGENT)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: ROMULUS, MI, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA91MA010AB
Accident Reports: NW Airlines, Inc., Flights 1482 and 299 Runway Incursion and Collision
Report #: AAR-91-05
Accident Date: 12/3/1990
Issue Date: 1/8/1991
Date Closed: 1/6/1993
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Flightcrew,Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 1/6/1993
Response: THE SAFETY BOARD NOTES THAT THE FAA REVISED AIR CARRIER OPERATIONS BULLETIN (ACOB) 8-76-6, DC-9 TAILCONE TRAINING DEVICE APPROVALS ON JULY 13, 1992. ALTHOUGH THE REVISION TO ACOB 8-76-6 INCLUDES SEVERAL POSITIVE CHANGES, THE BOARD NOTES THAT CHAPTER 9, PARAGRAPH 907(C)(1) STATES THAT, IF AIR CARRIERS ELECT TO TRAIN THEIR AIRCREWS ON AIRCRAFT WHERE THE OPERATION OF THE TAILCONE RELEASE HANDLE RELEASE THE TAILCONE, THEN EITHER THE INSTRUCTOR OR A TRAINEE SHOULD OPERATE THE TAILCONE RELEASE HANDLE WHILE THE OTHER TRAINEES OBSERVE. THE INTENT OF SAFETY RECOMMENDATION A-91-6 IS TO ENSURE THAT EACH FLIGHTCREW AND FLIGHT ATTENDANT TRAINEE IS FAMILIAR WITH THE FORCES AND OTHER TACTILE ASPECTS OF FREEING THE HANDLE FROM ITS STOWAGE CLIPS AND PULLING THE HANDLE FAR ENOUGH TO UNLOCK THE TAILCONE. THE SAFETY BOARD CONTINUES TO BELIEVE THAT THIS INTENT WILL BE MET ONLY WHEN FLIGHTCREW AND FLIGHT ATTENDANTS RECEIVE HANDS-ON EXPERIENCE WITH EXITS THAT THEY MAY BE REQUIRED TO OPERATE DURING AN EMERGENCY EVACUATION. THEREFORE, THE SAFETY BOARD CLASSIFIES SAFETY RECOMMENDATION A-91-6 "CLOSED--UNACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 8/17/1992
Response: THE FAA HAS COMPLETED ITS ALTERNATE ACTION TO ADDRESS THIS SAFETY RECOMMENDATION. ON JULY 13, 1992, THE FAA REVISED AIR CARRIER OPERATIONS BULLETIN (ACOB) 8-76-6, DC-9 TAILCONE TRAINING DEVICE APPROVAL. THE REVISED ACOB IS ENTITLED GUIDELINES FOR CREWMEMBER TRAINING ON AIRCRAFT TAILCONES AND APPROVAL OF TAILCONE TRAINING DEVICES AND PROVIDES AN ACCEPTABLE MEANS FOR CONDUCTING ALTERNATE TRAINING THROUGH TOURS OF AIRCRAFT HAVING TAILCONES. THIS ACOB DIRECTS PRINCIPAL OPERATIONS INSPECTORS TO ENSURE THAT THEIR ASSIGNED CARRIERS INCLUDE IN THEIR AIRCRAFT TRAINING PROGRAMS THE REQUIREMENT TO TEST THE ACCURACY OF THE OPERATING FORCES OF MANUAL RELEASE HANDLES ON TAILCONE AND VENTRAL DOOR TRAINING DEVICES.

From: NTSB
To: FAA
Date: 8/2/1991
Response: The Safety Board notes that the FAA plans to issue an Air Carrier Operations Bulletin (ACOB) to ensure that adequate training guidance is available to principal operations inspectors and operators of DC-9/MD-80 series aircraft. Pending further information, Safety Recommendation A-91-6 is classified as "Open--Accetpable Response."

From: FAA
To: NTSB
Date: 3/18/1991
Response: THE FAA PLANS TO ISSUE AN AIR CARRIER OPERATIONS BULLETIN (ACOB) TO ENSURE THAT ADEQUATE TRAINING GUIDANCE IS AVAILABLE TO PRINCIPAL OPERATIONS INSPECTORS AND OPERATORS OF DC-9/MD-80 SERIES AIRCRAFT.