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Safety Recommendation Details

Safety Recommendation A-91-028
Details
Synopsis: ON JANUARY 18, 1990, AT 1904 EASTERN STANDARD TIME, EASTERN AIRLINES FLIGHT 111 (EA 111), N8867E, A BOEING 727-225A, COLLIDED WITH N44UE, AN EPPS AIR SERVICE BEECHCRAFT KING AIR A100, WHILE EA 111 WAS LANDING ON RUNWAY 26 RIGHT AT THE WILLIAM B. HARTSFIELD INTERNATIONAL AIRPORT, ATLANTA, GEORGIA, AND AS THE KING AIR A100 WAS PREPARING TO TURN OFF THE RUNWAY AFTER HAVING LANDED AHEAD OF EA 111. BOTH AIRPLANES WERE IN RADIO COMMUNICATION WITH THE HARTSFIELD AIR TRAFFIC CONTROL (ATC) TOWER LOCAL CONTROLLER AT THE TIME OF THE ACCIDENT. AS A RESULT OF THE COLLISION, THE KING AIR A100 WAS DESTROYED AND THE B-727 RECEIVED SUBSTANTIAL DAMAGE. THE PILOT OF THE KING AIR WAS FATALLY INJURED, AND THE COPILOT WAS SERIOUSLY INJURED. THERE WERE NO PASSENGERS ONBOARD THE KING AIR AND THERE WERE NO REPORTED INJURIES ON THE B-727.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: AMEND THE AIR TRAFFIC CONTROL HANDBOOK, 711.65F, PARAGRAPH 3-127, TO PRECLUDE THE ISSUANCE OF MULTIPLE LANDING CLEARANCES TO AIRCRAFT OUTSIDE OF THE FINAL APPROACH FIX. ALSO, ESTABLISH A NUMERICAL LIMIT SO THAT NO MORE THAN TWO LANDING CLEARANCE MAY BE ISSUED TO SUCCESSIVE ARRIVALS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: ATLANTA, GA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA90MA017AB
Accident Reports: Runway Collision of Eastern Airlines Boeing 727, Flight 111 and EPPS Air Service
Report #: AAR-91-03
Accident Date: 1/18/1990
Issue Date: 6/12/1991
Date Closed: 3/6/1995
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 3/6/1995
Response: THE BOARD NOTES THAT THE FAA ISSUED A NATIONAL CHANGE PROPOSAL TO AMEND ORDER 7110.65. THE BOARD FURTHER NOTES THAT THE FAA BELIEVES THAT THE PRESENT AIR TRAFFIC PROCEDURES FOR MULTIPLE LANDING CLEARANCES ARE EFFECTIVE & CORRECT, & THAT THE FAA PLANS NO FURTHER ACTION. THE BOARD DOES NOT AGREE THAT THE PRESENT PROCEDURES FOR MULTIPLE LANDING CLEARANCES IN ORDER 7110.65 ARE "EFFECTIVE AND CORRECT." THE EXISTING PROCEDURES APPEAR TO REQUIRE A LEVEL OF HUMAN PERFORMANCE THAT MAKES NO ALLOWANCE FOR ANY ERROR OF OMISSION OR LAPS OF ATTENTION. ON THE CONTRARY, THE BOARD BELIEVES THAT THE FATAL ACCIDENT THAT PRECIPITATED THIS RECOMMENDATION ILLUSTRATES THAT THE AIR TRAFFIC PROCEDURES FOR MULTIPLE LANDING CLEARANCES DO NOT ADEQUATELY TAKE INTO CONSIDERATION THE CONTINGENT HUMAN PERFORMANCE FACTORS OF DISTRACTION & INADVERTENT INATTENTION THAT CAN ORIGINATE FROM ANY SORT OF DISRUPTIVE EVENT. THE BOARD RECOGNIZES THAT CONTROLLERS ARE REQUIRED TO ENSURE THAT SEPARATION EXISTS AT ALL TIMES THROUGHOUT THE APPROACH AS WELL AS WHEN THE AIRCRAFT CROSSES THE LANDING THRESHOLD. THE BOARD BELIEVES THAT PRECLUDING THE ISSUANCE OF MULTIPLE LANDING CLEARANCES TO AIRCRAFT OUTSIDE THE FINAL APPROACH FIX & LIMITING THE NUMBER OF LANDING CLEARANCES TO NO MORE THAN TWO SUCCESSIVE ARRIVALS (AS WAS DONE BEFORE MARCH 1978), CAN PROVIDE THE CONTROLLER WITH ADDITIONAL TIME TO ENSURE THE CONTINUING SEPARATION OF THE AIRPLANES WITHIN THE CONTROLLERS'S SPAN OF RESPONSIBILITY. THEREFORE BOARD CLASSIFIES A-91-28 "CLOSED --UNACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 9/16/1994
Response: THE FAA FIRST ACTION IN RESPONSE TO A-91-28 WAS TO ISSUE A NATIONAL CHANGE PROPOSAL TO AMEND ORDER 7110.65 AS REQUESTED BY THE BOARD. AS STATED IN THE FAA'S RESPONSE OF 8/3/93, THE COMMENTS RECEIVED IN RESPONSE TO THE NATIONAL CHANGE PROPOSAL WERE THAT SUCH A CHANGE WOULD INCREASE WORKLOAD, WOULD REMOVE FLEXIBILITY FROM THE CONTROLLER, & WOULD NOT ENHANCE SAFETY. THE FAA HAS AGAIN REVIEWED ITS POSITION ON THIS RECOMMENDATION IN CONJUCTION WITH THE CURRENT PROCEDURES WHICH ADDRESS MULTIPLE LANDING CLEARANCES. THE FAA BELIEVES THAT THE PRESENT PROCEDURES IN ORDER 7110.65 ARE EFFECTIVE & CORRECT. IN FACT, THE FAILURE TO MAINTAIN THE PROPER SEPARATION UP TO THE RUNWAY THRESHOLD WAS A PRIMARY ISSUED IN THE SUBJECT ACCIDENT--NOT THE NUMBER OF LANDING CLEARANCES ISSUED & THE POINT AT WHICH THE CLEARANCES WERE ISSUED.

From: NTSB
To: FAA
Date: 11/19/1993
Response: THE BOARD BELIEVES THAT THE ACCIDENT THAT PRECIPITATED RECOMMENDATION A-91-28 POINTS OUT THE NEED TO LIMIT THE NUMBER OF MULTIPLE LANDING CLEARANCES ISSUED TO AIRCRAFT OUTSIDE OF THE FINAL APPRACH FIX. CURRENT PROVISIONS IN ATC PROCEDURES PERMIT A CONTROLLER TO ISSUE LANDING CLEARANCES TO SEVERAL AIRCRAFT IN SUCCESSION WITHOUT ASSURANCE THAT ADEQUATE SEPARATION WILL BE MAINTAINED BETWEEN AIRPLANES APPROACHING THE LANDING THRESHOLD. BASED ON THIS INFORMATION, THE BOARD CLASSIFIES RECOMMENDATION A-91-28 "OPEN--UNACCEPTABLE RESPONSE" AND REQUESTS THAT THE FAA RECONSIDER ITS POSITION.

From: FAA
To: NTSB
Date: 8/3/1993
Response: THE FAA CIRCULATED A NATIONAL CHANGE PROPOSAL TO AMEND ORDER 7110.65F, AIR TRAFFIC CONTROL, TO PRECLUDE THE ISSUANCE OF MORE THAN TWO LANDING CLEARANCES TO SUCCESSIVE ARRIVALS. THE COMMENTS RECEIVED FROM THE AIR TRAFFIC REGIONAL OFFICES AND FACILITIES INDICATE THAT THIS CHANGE WOULD INCREASE WORKLOAD, REMOVE FLEXIBILITY FROM THE CONTROLLER AT A VERY CRITICAL POINT, AND MAY COMPROMISE RATHER THAN INCREASE SAFETY CONSEQUENTLY, THE FAA DOES NOT SUPPORT IMPLEMENTING THIS CHANGE.

From: NTSB
To: FAA
Date: 11/15/1991
Response: Safety Recommendation A-91-28 recommends that the FAA amend the Air Traffic Control Handbook, 7110.65F, paragraph 3-127, to preclude the issuance of multiple landing clearances to aircraft outside of the final approach fix. Also, establish a numerical limit so that no more than two landing clearances may be issued to successive arrivals. Because the FAA plans to circulate a national change proposal to amend Order 7110.65F, Safety Recommendation A-91-28 is classified as "Open-- Acceptable Response."

From: FAA
To: NTSB
Date: 8/12/1991
Response: THE FAA WILL CIRCULATE A NATIONAL CHANGE PROPOSAL TO AMEND ORDER 7110.65F TO PRECLUDE THE ISSUANCE OF MULTIPLE CLEARANCES TO AIRCRAFT OUTSIDE THE FINAL APPROACH FIX. THE NATIONAL CHANGE PROPOSAL WILL ALSO ESTABLISH A NUMERICAL LIMIT SO THAT NO MORE THAN TWO LANDING CLEARANCES MAY BE ISSUED TO SUCESSIVE ARRIVALS.