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Safety Recommendation Details

Safety Recommendation A-91-126
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: EVALUATE THE NEED FOR ACTIONS AS DESCRIBED IN SAFETY RECOMMENDATIONS A-91-123 THROUGH A-91-125 FOR OTHER TRANSPORT CATEGORY TURBOJET AIRPLANES THAT DO NOT HAVE LEADING EDGE DEVICES AND ARE PARTICULARLY SUSCEPTIBLE TO FLIGHT CONTROL PROBLEMS ARISING FROM SMALL AMOUNTS OF FROST, ICE OR SNOW ON THE WINGS.
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: 8/1/1995
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Icing, Weather

Safety Recommendation History
From: NTSB
To: FAA
Date: 8/1/1995
Response: THE BOARD NOTES THAT THE FAA ADDRESSED THE WING ICING CHARACTERISTICS OF TWO AIRPLANES, THE MCDONNELL DOUGLAS DC-8 & FOKKER F-28. THE FAA'S LETTER PROVIDED THAT, "THE DC-8 WAS NOT PUT IN THE SAME CATEGORY AS THE DC-9-10 BECAUSE IT HAS SLOTS IN THE CRITICAL AREAS OF THE WING LEADING EDGE WHICH PERFORM AN AERODYNAMIC FUNCTION SIMILAR TO CONVENTIONAL LEADING EDGE SLATS." THE BOARD AGREES THAT THE DRAWING ON PAGE 73 OF THE 5/22/1991, "DC-8, DC-9-10 FLIGHT SAFETY WORKSHOP" BROCHURE IS MISLEADING BECAUSE, AS THE FAA'S LETTER STATES, 'DC-8 SLOT OPENINGS ARE NOT DEPICTED IN THE TAKEOFF/LANDING DRAWING." REGARDING THE FOKKER F-28, THE BOARD NOTES THAT ON 11/30/94, THE FAA ISSUED AIRWORTHINESES DIRECTIVE (AD) 94-25-03, APPLICABLE TO FOKKER F-28 SERIES AIRPLANES. THIS AD, WHICH BECAME EFFECTIVE ON 12/21/94, REQUIRES A REVISION TO THE AIRPLANE FLIGHT MANUAL TO PROHIBIT TAKEOFF IN CERTAIN ICING CONDITIONS UNLESS EITHER A TACTILE INSPECTION IS PERFORMED OR SPECIFIC TAKEOFF PROCEDURES ARE FOLLOWED. THE BOARD IS PLEASED THAT THE FAA WILL CONTINUE TO MONITOR PROGRESS IN TECHNOLOGY THAT HAS THE POTENTIAL FOR REDUCING THE LIKELIHOOD OF GROUND DEICING-RELATED ACCIDENTS. THEREFORE, THE SAFETY BOARD CLASSIFIES, A-91-126 "CLOSED--ACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 3/20/1995
Response: THE BOARD ASKED THE FAA TO EXPLAIN THE BASIS FOR WHICH THE MCDONNELL DOUGLS DC-8 WAS EVALUATED. THE DC-8 WAS NOT PUT IN THE SAME CATEGORY AS THE DC-9-10 BECAUSE IT HAS SLOTS IN THE CRITICAL AREAS OF THE WING LEADING EDGE WHICH PERFORM AN AERODYNAMIC FUNCTION SIMILAR TO CONVENTIONAL LEADING EDGE SLATS. I BELIEVE THAT THE CONCERN EXPRESSED BY THE BOARD WAS BASED ON THE INFO CONTAINED IN THE MCDONNELL DOUGLAS "DC-8, DC-9-10 FLIGHT SAFETY WORKSHOP" BROCHURE DATED 5/22/91.

From: NTSB
To: FAA
Date: 6/25/1992
Response: From your response, we assume that you intended to refer to airplanes that do not have leading edge devices. In that case, we would like to know the basis upon which the Douglas DC-8 was evaluated since some of the manufacturer's own literature cites that airplane's susceptibility to control problems with minimal wing contamination. On March 22, 1992, a Fokker F-28 crashed during takeoff at La Guardia Airport in weather conditions conducive to the accumulation of snow or ice on the airplane. While the investigation is not complete, the Safety Board is examining the possibility of degraded aerodynamic performance resulting from wing contamination. Because the Safety Board believes that the FAA should take more positive action to ensure that the operators of airplanes, other than the DC-9 series 10, adequately address the problems of winter operations in flight manuals and training programs, Safety Recommendation A-91-126 is classified as "Open--Unacceptable Response."

From: FAA
To: NTSB
Date: 2/27/1992
Response: THE FAA CONDUCTED A SURVEY OF BOEING, DOUGLAS, AND LOCKHEED AIRPLANES HAVING LEADING EDGE DEVICES, OTHER THAN THE DC-9-10 SERIES AIRPLANE, AND FOUND THAT THESE AIRPLANES ARE NOT CONSIDERED PARTICULARLY SUSCEPTIBLE TO FLIGHT CONTROL PROBLEMS ARISING FROM A SMALL AMOUNTS OF FROST, ICE, OR SNOW ON THE WINGS. THE FAA IS CONTINUING ITS EFFORT TO IDENTIFY OTHER TRANSPORT CATEGORY TURBOJET AIRPLANES WHICH DO NOT HAVE LEADING EDGE DEICE OR ANTI-ICE DEVICES.