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Safety Recommendation Details

Safety Recommendation A-91-057
Details
Synopsis: ON DECEMBER 3, 1990, AT 1354 EASTERN STANDARD TIME, NORTHWEST AIRLINES (NWA) FLIGHT 1482, A MCDONNELL DOUGLAS DC-9, AND NORTHWEST AIRLINES FLIGHT 299, A BOEING 727 (B-727), COLLIDED NEAR THE INTERSECTION OF RUNWAYS 09/27 AND 03C-21C AT DETROIT METROPOLITAN/WAYNE COUNTY AIRPORT (DTW), DETROIT MICHIGAN. THE DC-9 WAS TO BE A REGULARLY SCHEDULED PASSENGER FLIGHT TO PITTSBURGH, PENNSYLVANIA, AND THE B-727 WAS TO BE A REGULARLY SCHEDULED PASSENGER FLIGHT TO MEMPHIS, TENNESSEE. BOTH AIRPLANES WERE OPERATING UNDER FEDERAL AVIATION REGULATIONS (FAR) PART 121 AND INSTRUMENT METEOROLOGICAL CONDITIONS PREVAILED AT THE TIME AT DTW. THE B-727 WAS ON ITS TAKEOFF ROLL ON RUNWAY 3C AT THE TIME OF THE COLLISION, AND THE DC-9 HAD TAXIED ONTO THE RUNWAY JUST PRIOR TO THE ACCIDENT. THE B-727 WAS SUBSTANTIALLY DAMAGED, AND THE DC-9 WAS DESTROYED DURING THE COLLISION AND SUBSEQUENT FIRE. OF THE 40 PASSENGERS AND 4 CREWMEMBERS ABOARD THE DC-9, 7 PASSENGERS AND 1 FLIGHT ATTENDANT RECEIVED FATAL INJURIES. NONE OF THE 146 PASSENGERS AND 8 CREWMEMBERS ON THE B-727 WERE INJURED.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REQUIRE THAT CFR 139 CERTIFICATED AIRPORTS INSTALL SEMIFLUSH RUNWAY EDGE LIGHTS IN ACCORDANCE WITH ADVISORY CIRCULAR 150/5340-24.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate 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: 7/23/1991
Date Closed: 2/16/1995
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 2/16/1995
Response: THE BOARD NOTES THAT THE FAA, DURING THE ANNUAL FISCAL YEAR 1993 INSPECTIONS OF 14 CFR PART 139 AIRPORTS, IDENTIFIED 424 INSTANCES WHERE SEMIFLUSH LIGHTS SHOULD BE INSTALLED ON RUNWAY SURFACES. IT IS FURTHER NOTED THAT ADDITIONAL SEMIFLUSH LIGHTS WILL BE INSTALLED ON VIRTUALLY ALL RUNWAYS WHERE TWO OR MORE CONSECUTIVE LIGHTS ARE MISSING. THE BOARD BELIEVES THAT THESE ACTIONS HAVE SATISFIED THE INTENT OF A-91-57, & THEREFORE CLASSIFIES IT "CLOSED--ACCEPTABLE ALTERNATE ACTION."

From: FAA
To: NTSB
Date: 10/7/1994
Response: ON 4/29/94, THE FAA RESPONDED IN DETAIL TO NTSB RECOMMENDATION A-91-57 & ITS ACTIONS WERE CLASSIFIED AS OPEN ACCEPTABLE BY THE BOARD ON 6/7/94. BASED ON THIS INPUT, THE BOARD LISTED A-91-57 IN AN OPEN ACCEPTABLE STATUS WHEN THE "MOST WANTED" LIST WAS ADOPTED IN MAY 1994.

From: NTSB
To: FAA
Date: 8/31/1994
Response: THE BOARD NOTES THAT, AS PART OF THE CURRENT FAA AIRPORT CERTIFICATION INSPECTIONS, AIRPORT SAFETY INSPECTORS ARE IDENTIFYING MISSING LIGHTS & DETERMINING WHETHER THE MISSING LIGHTS COMPROMISE SAFETY. IF NO SAFETY PROBLEM EXITS, THE INSPECTORS HAVE BEEN TOLD NOT TO REQUIRE THE INSTALLATION OF THESE LIGHTS. THE BOARD BELIEVES THE FAA SHOULD REQUIRE CERTIFICATED AIRPORTS TO BE IN COMPLIANCE WITH FAA ADVISORY CIRCULAR 150/5340-24. THEREFORE, THE BOARD CLASSIFIES A-91-57 "OPEN--UNACCEPTABLE RESPONSE" & ASKS THE FAA TO RECONSIDER ITS POSITION.

From: NTSB
To: FAA
Date: 6/7/1994
Response: THE BOARD NOTES THAT THE FAA, DURING THE ANNUAL FISCAL YEAR 1993 14 CFR PART 139 AIRPORTS INSPECTION, IDENTIFIED 424 INSTANCES WHERE SEMIFLUSH LIGHTS SHOULD BE INSTALLED ON RUNWAY SURFACES. IT IS FURTHER NOTED THAT VIRTUALLY ALL OF THE INSTANCES WHERE TWO OR MORE CONSECUTIVE LIGHTS ARE MISSING ON A RUNWAY WILL RESULT IN THE INSTALLATION OF ADDITIONAL SEMIFLUSH LIGHTS. THE BOARD BELIEVES THAT THESE INSTALLATIONS, WHEN ACCOMPLISHED, WILL CONSTITUTE AN EFFECTIVE RESPONSE TO A-91-57. THEREFORE, THE BOARD CLASSIFIES THE RECOMMENDATION "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 4/29/1994
Response: ON 12/9/92, THE FAA TOLD THE BOARD THAT WHILE THE PRESENT RUNWAY EDGE LIGHTING STANDARDS CONTAINED IN ADVISORY CIRCULAR 150/5340-24, RUNWAY & TAXIWAY EDGE LIGHTING SYSTEM, MAINTAIN THE CONTINUITY OF THE VISUAL CUE FOR PILOTS TO ALIGN AIRCRAFT PROPERLY ON THE RUNWAY, IT MAY BE DEVIATED FROM IF SAFETY WILL NOT BE COMPROMISED. THE FAA STATED THAT IT WOULD REVIEW SITUATIONS WHERE EDGE LIGHTS HAVE NOT BEEN INSTALLED & APPRISE THE BOARD OF THE RESULTS. THE FAA HAS COMPLETED ITS REVIEW & OFFERS THE FOLLOWING IN RESPONSE TO THIS SAFETY ISSUE.

From: FAA
To: NTSB
Date: 1/31/1994
Response: AS PART OF THE CURRENT CERTIFICATION INSPECTIONS, AIRPORT SAFETY INSPECTIONS ARE IDENTIFYING MISSING LIGHTS & MAKING DETERMINATIONS ON WHETHER OR NOT THE MISSING LIGHTS COMPROMISE SAFETY. IF THE INSPECTORS BELIEVE THAT THERE IS A SAFETY PROBLEM, THEY ARE REQUIRING AIRPORT OWNERS TO INSTALL THE MISSING LIGHTS. IF NO SAFETY PROBLEM EXISTS, THE INSPECTORS HAVE BEEN TOLD NOT TO REQUIRE THE INSTALLATION SINCE THERE COULD BE MORE SERIOUS PROBLEMS CAUSED BY SAW-CUTTING THE PAVEMENT AS WELL AS BY SNOW-REMOVAL PLOWS HITTING THE SEMI-FLUSH LIGHTS. I WILL KEEP THE BOARD APPRISED OF THE FAA'S PROGRESS ON THIS RECOMMENDATION.

From: NTSB
To: FAA
Date: 3/15/1993
Response: THE BOARD NOTES THAT THE FAA ISSUED A CERTALERT TO ITS AIRPORT CERTIFICATION INSPECTORS TO BRING THE BOARD'S CONCERNS TO THEIR ATTENTION. FURTHERMORE, DURING AIRPORT CERTIFICATION INSPECTIONS, THE FAA REQUESTED THAT THESE INSPECTORS FOCUS THEIR ATTENTION ON THE REQUIREMENTS OF AC 150/5340-24 TO DETERMINE IF SAFETY HAS BEEN COMPROMISED. PENDING FURTHER INFORMATION, THE BOARD CLASSIFIES RECOMMENDATION A-91-57 "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 12/9/1992
Response: THE FAA BELIEVES THAT THE RUNWAY EDGE LIGHTING STANDARDS FOR AC 150/5340-24, RUNWAY AND TAXIWAY EDGE LIGHTING SYSTEM, PROVIDE THE PROPER VISUAL CUE FOR PILOTS TO ALIGN AIRCRAFT ON THE RUNWAY. THE AC STATES THAT WHEN A RUNWAY IS INTERSECTED BY OTHER RUNWAYS OR TAXIWAYS, SEMI-FLUSH LIGHTS SHOULD BE INSTALLED TO MAINTAIN 200 FOOT UNIFORM SPACING FOR HIGH INTENSITY RUNWAY LIGHTING SYSTEMS. HOWEVER, THE AIRPORT OPERATOR IS ALLOWED TO DEVIATE FROM THESE STANDARDS AS LONG AS SAFETY WILL NOT BE COMPROMISED. ON NOVEMBER 23, 1992, THE FAA ISSUED A CERTALERT TO ITS AIRPORT CERTIFICATION INSPECTORS TO BRING THE BOARD'S CONCERNS TO THEIR ATTENTION AND TO REQUEST THAT, DURING AIRPORT CERTIFICATION INSPECTIONS, THEY FOCUS THEIR ATTENTION ON THE ABSENCE OF SEMI-FLUSH LIGHTS AT RUNWAY-RUNWAY AND RUNWAY-TAXIWAY INTERSECTIONS TO DETERMINE IF SAFETY HAS BEEN COMPROMISED.

From: NTSB
To: FAA
Date: 3/27/1992
Response: The Safety Board notes that the FAA is taking action in response to Safety Recommendations A-91-54 through -63 and A-91-65 through -66 and will keep us advised of progress. Pending our further evaluation of these safety recommendations, they are classified as "Open--Acceptable Response."

From: FAA
To: NTSB
Date: 10/3/1991
Response: THE FAA BELIEVES THAT THE PRESENT RUNWAY EDGE LIGHTING STANDARDS MAINTAIN THE CONTINUITY OF THIS VISUAL CUE FOR PILOTS TO ALIGN AIRCRAFT ON THE RUNWAY PROPERLY. AC 150/5340-24, RUNWAY AND TAXIWAY EDGE LIGHTING SYSTEM, STATES THAT WHEN A RUNWAY IS INTERSECTED BY OTHER RUNWAYS OR TAXIWAYS, SEMI-FLUSH LIGHTS SHOULD BE INSTALLED TO MAINTAIN THE UNIFORM SPACING FOR HIGH INTENSITY RUNWAY LIGHTING SYSTEMS AT 200 FEET. THE FAA IS PREPARING A CERTALERT TO ITS AIRPORT CERTIFICATION INSPECTORS TO REQUEST THAT DURING THE AIRPORT CERTIFICATION INSPECTIONS THEY FOCUS THEIR ATTENTION ON THE PRESENCE OF SEMI-FLUSH LIGHTS IN ACCORDANCE WITH THE AC 150/5340-24.

From: NTSB
To: FAA
Date:
Response: At the 1990 Board meeting addressing the NTSB’s Most Wanted List of Transportation Safety Improvements (MWL), the Board voted to place Safety Recommendations A-86-33, A-86-40 and A-86-42 on the Federal MWL under the issue category “Runway Incursions/ Ground Collisions of Aircraft.” On November 8, 2007 at the Board meeting addressing the Federal Most Wanted List of Transportation Safety Improvements the category’s name was changed to “Improve Runway Safety.” Since 1990, the Board has voted to include Safety Recommendations A-91-29, A-91-30, A-91-54 through A-91-58, A-91-110 through A-91-115, A-95-86, A-95-92, A-95-93, A-95-97, A-00-66, A-0067, A-00-68, and A-07-57 is this category as well.