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Safety Recommendation Details

Safety Recommendation A-91-124
Details
Synopsis: ABOUT 0019, SUNDAY FEBRUARY 17, 1991, RYAN INTERNATIONAL AIRLINES FLIGHT 590 (RYAN 590), A DC-9-15, CRASHED WHILE TAKING OFF FROM CLEVELAND-HOPKINS INTERNATIONAL AIRPORT (CLE). THE FLIGHTCREW CONSISTED OF TWO PILOTS. THERE WERE NO OTHER CREWMEMBERS OR PASSENGERS ON THE FLIGHT, WHICH WAS CONTRACTED TO CARRY MAIL FOR THE U.S. POSTAL SERVICE. BOTH PILOTS WERE FATALLY INJURED, AND THE AIRPLANE WAS DESTROYED AS A RESULT OF THE ACCIDENT. BETWEEN 1968 AND 1987, THERE WERE FOUR ACCIDENTS INVOLVING DC-9 SERIES 10 AIRPLANES IN WHICH THERE WAS A LOSS OF CONTROL SHORTLY AFTER TAKEOFF. IN ALL CASES, THE INVESTIGATION SHOWED THAT THE AIRPLANES ACCELERATED NORMALLY AND REACHED AIRSPEEDS AT WHICH THEY SHOULD HAVE BEEN CAPABLE OF ESTABLISHING AND SUSTAINING A SAFE CLIMB. INSTEAD, ALL WERE OBSERVED TO ENTER STEEP ROLL ATTITUDES AND DESCEND TO THE GROUND. ALSO, IN ALL OF THESE ACCIDENTS, WITNESSES REPORTED, AND THE SOUNDS ON THE COCKPIT VOICE RECORDERS (CVRS) CONFIRMED, THAT ENGINE COMPRESSOR SURGES OCCURRED AS THE AIRPLANES DESCENDED.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REQUIRE IN AIR CARRIER OPERATIONS MANUALS AND APPROPRIATE AIRPLANE FLIGHT MANUALS THAT FLIGHTCREWS OF DC-9 SERIES 10 AIRPLANES PERFORM A VISUAL AND TACTILE INSPECTION OF THE WING LEADING EDGE AND UPPER SURFACE USING NECESSARY EQUIPMENT PRIOR TO DEPARTURE WHENEVER TEMPERATURES BELOW 5 DEGREES C AND VISIBLE MOISTURE EXIST OR WHENEVER THE AIRPLANE RECENTLY ENCOUNTERED ICING CONDITIONS. (Supersedes Safety Recommendation A-88-136)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: CLEVELAND, OH, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA91MA021
Accident Reports: Ryan intl Airlines DC-9-15, N565PC Loss of Control on Takeoff
Report #: AAR-91-09
Accident Date: 2/17/1991
Issue Date: 12/11/1991
Date Closed: 6/25/1992
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Icing,Weather

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/25/1992
Response: The Safety Board notes that AD 92-03-01 requires a revision to the airplane flight manual specifying that a visual and hands-on-check must be accomplished before takeoff. The AD fulfills the intent of this safety recommendation, which is now classified as "Closed--Acceptable Action."

From: FAA
To: NTSB
Date: 2/27/1992
Response: THE FAA ISSUED AP-92-03-01 APPLICABLE TO DC-9-10 SERIES AIRPLANES. THIS AD REQUIRES A REVISION TO THE AFM LIMITATIONS SECTION WHICH SPECIFIES THAT TAKEOFF MAY NOT BE INITIATED UNLESS THE FLIGHTCREW VERIFIES THAT VISUAL AND PHYSICAL CHECKS OF THE LEADING EDGE AND UPPER WING SURFACES HAVE BEEN ACCOMPLISHED WHEN THE OUTSIDE AIR TEMPERATURE IS BELOW 6 DEGREES C AND THE DIFFERENCE BETWEEN THE DEW POINT TEMPERATURE AND OUTSIDE AIR TEMPERATURE IS LESS THAN 3 DEGREES C OR VISIBLE MOISTURE IS PRESENT.