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Safety Recommendation Details

Safety Recommendation A-91-125
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 PRINCIPAL OPERATIONS INSPECTORS TO REVIEW CERTIFICATE HOLDERS OPERATING DC-9 SERIES 10 AIRPLANES TO DETERMINE THE ADEQUACY OF FLIGHTCREW TRAINING PROGRAMS RELATED TO AIRFRAME ICING CONDITIONS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate 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: 7/17/1992
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s): Flightcrew, Icing, Training and Education, Weather

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/17/1992
Response: THE SAFETY BOARD NOTES THAT THE FAA ISSUED AIR CARRIER OPERATIONS BULLETIN (ACOB) 3-92-1, AIRFRAME ICING TRAINING FOR AIRCREWS OPERATING DC-9-10 SERIES AIRPLANES, DC-9-80 SERIES AIRPLANES, AND MODEL MD-88 AIRPLANES. THIS BULLETIN DIRECTS POIS TO ENSURE THAT THEIR RESPECTIVE OPERATORS ARE AWARE OF AIRFRAME ICING PROBLEMS AND THAT THE FLIGHTCREW TRAINING PROGRAMS AND OPERATIONS MANUALS CONTAIN GUIDANCE AND PROCEDURES FOR CONDUCTING VISUAL AND PHYSICAL (HANDS ON) INSPECTIONS OF THESE AIRCRAFT WHEN ICING CONDITIONS EXIST.

From: NTSB
To: FAA
Date: 6/25/1992
Response: The Safety Board notes that the FAA agrees with the intent of this safety recommendation and intnets to issue an Air Carrier Operations Bulletin (ACOB) on this subject. Accordingly, Safety Recommendation A-91-125 is classified as "Open-- Acceptable Alternate Response."

From: FAA
To: NTSB
Date: 5/21/1992
Response: ON APRIL 17, 1992, THE FAA ISSUED AIR CARRIER OPERATIONS BULLETIN (ACOB) 3-92-1, AIRFRAME ICING TRAINING FOR AIRCREWS OPERATING DC-9-10 SERIES AIRPLANES, DC-9-80 SERIES AIRPLANES, AND MODEL MD-88 AIRPLANES. THIS BULLETIN DIRECTS PRINCIPAL OPERATIONS INSPECTORS (POI) TO ENSURE THAT THEIR RESPECTIVE OPERATORS ARE AWARE OF AIRFRAME ICING PROBLEMS AND THAT THE FLIGHTCREW TRAINING PROGRAMS AND OPERATIONS MANUALS CONTAIN GUIDANCE AND PROCEDURES FOR CONDUCTING VISUAL AND PHYSICAL (HANDS ON) INSPECTIONS OF THESE AIRCRAFT WHEN ICING CONDITIONS EXIST. THIS BULLETIN ALSO DIRECTS POI'S TO GIVE SPECIAL ATTENTION TO THE ADEQUACY OF TRAINING OBJECTIVES, METHODS, MEDIA, AND EVALUATION TECHNIQUES WHICH INVOLVE INSTRUCTION RELATED TO AIRFRAME ICING CONDITIONS.

From: FAA
To: NTSB
Date: 2/27/1992
Response: THE FAA AGREES WITH THE INTENT OF THIS SAFETY RECOMMENDATION AND PLANS TO ISSUE AN AIR CARRIER OPERATIONS BULLETIN (ACOB) DIRECTING PRINCIPAL OPERATIONS INSPECTORS (POI) TO REVIEW FLIGHTCREW TRAINING PROGRAMS OF CERTIFICATE HOLDERS THAT OPERATE DC-9-10 SERIES AIRPLANES. THIS ACOB WILL DIRECT POI'S ENSURE THAT SPECIFIC ATTENTION IS DIRECTED TOWARD THE ADEQUACY OF TRAINING OBJECTIVES, METHODS, MEDIA, AND EVALUATION TECHNIQUES WHICH INVOLVE INSTRUCTION RELATED TO AIRFRAME ICING CONDITIONS.