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Safety Recommendation Details

Safety Recommendation A-91-127
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 A PROCEDURE TO USE THE MAXIMUM ROTATION SPEED DURING TAKEOFF THAT WILL RETAIN THE PRESENTLY REQUIRED END OF RUNWAY AND CLIMB GRADIENT SAFETY MARGINS WHEN OPERATING ON RUNWAYS THAT EXCEED THE MINIMUM TAKEOFF RUNWAY LENGTH REQUIRED; REQUIRE OPERATORS TO PROVIDE MAXIMUM ROTATION SPEED INFORMATION TO DC-9 SERIES 10 FLIGHTCREWS FOR USE IN WINTER OPERATIONS.
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: 12/20/1994
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 12/20/1994
Response: THE BOARD RECOGNIZES THAT THE ADOPTION OF A SPECIAL TAKEOFF ROTATION SPEED (VR) TO BE USED ONLY DURING WINTER ICING CONDITIONS WOULD PRESENT SOME OPERATIONAL CONSIDERATIONS THAT MIGHT NOT BE ACCEPTABLE TO THE FAA OR OPERATORS. THESE OPERATIONAL CONCERNS WERE EXPRESSED IN THE FAA LETTERS OF MAY 27, 1993 (IN RESPONSE TO RECOMMENDATION A-93-22), & 3/1/94 (IN RESPONSE TO RECOMMENDATION A-91-127). BASICALLY THESE CONCERNS WERE THE INCREASE IN RUNWAY DISTANCE REQUIRED OR THE SUBSTANTIAL REDUCTION IN PAYLOAD NEEDED TO MEET EXISTING TAKEOFF SAFETY CRITERIA; THE POSSIBLILITY OF AN OPERATOR OR FLIGHTCREW INTENTIONALLY DISPATCHING AN AIRPLANE WITHOUT DEICING, ASSUMING THAT THE INCREASED ROTATION SPEED WOULD PROVIDE ADEQUATE COMPENSATION & PROTECTION; & THE INABILITY TO CALCULATE THE EFFECT THAT CONCURRENTLY EXISTING RUNWAY SURFACE CONTAMINATION WOULD HAVE ON THE TOTAL TAKEOFF GROUND ROLL. THE FAA CITED OTHER ACTIONS TAKEN ENSURE THAT THE WINGS ARE FREE OF CONTAMINATION AS PRECLUDING THE NEED FOR REVISED OPERATIONAL PROCEDURES. THE ACTIONS CITED WERE THE REQUIREMENTS IMPOSED ON OPERATORS FOR THE GROUND DEICING & ANTI-ICING PROGRAMS &, IN THE CASE OF THE DC-9 SERIES 10, AN AIRWORTHINESS DIRECTIVE TO MODIFY THE WING LEADING EDGE BLEED AIR ANTI-ICE REFORMATION AFTER DEICING. ALTHOUGH NO POSITIVE ACTIONS RESULTED, THE BOARD ACKNOWLEDGES THAT THE FAA UNDERTOOK EFFORTS TO EVALUATE PROCEDURES & STUDY PERFORMANCE IN RESPONSE TO A-91-127 & A-93-22. BASED ON THOSE EFFORTS, THESE RECOMMENDATIONS ARE CLASSIFIED "CLOSED--ACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 3/1/1994
Response: IN RESPONSE TO THE BOARD'S REQUEST FOR RECONSIDERATION, THE FAA STILL DISAGREES WITH THIS RECOMMENDATION. THE FAA ISSUED AIRWORTHINESS DIRECTIVE 93-11-01, EFFECTIVE JULY 22, 1993. WHICH ADDRESSES THE ISSUE AT THE ROOT CAUSE BY PREVENTING ICE FORMATION ON THE WING & BY PRESCRIBING CREW INSPECTION PROCEDURES. THE AD REQUIRES OPERATORS TO MODIFY THE WING LEADING EDGE BLEED AIR ANTI-ICE SYSTEM SO THAT IT CAN OPERATE ON THE GROUND TO PREVENT ICE REFORMATION AFTER DEICING PROCEDURES HAVE BEEN ACCOMPLISHED. ADDITIONALLY THE AD REQUIRES THAT THE AIRPLANE BE OPERATED IN ACCORDANCE WITH 14 CFR 121.629(C), AMENDMENT 121-231, OR THAT THE FLIGHTCREW MUST VERIFY THAT VISUAL CHECK & A PHYSICAL CHECK (HANDS ON) OF THE LEADING EDGE & UPPER WING SURFACE FOR ICE CONTAMINATION HAVE BEEN ACCOMPLISHED. EACH CERTIFICATE HOLDER IS REQUIRED UNDER 14 CFR 121.629(C) TO HAVE AN APPROVED GROUND DEICING/ANTI-ICING PROGRAM IN ITS OPERATIONS SPECIFICATIONS. THE FAA BELIEVES THAT THE WING ANTI-ICE SYSTEM MODIFICATION & THE IMPROVED GROUND DEICING PROCEDURES CONTAINED IN AD 92-11-01 PROVIDE ADEQUATE PROTECTION, & ELIMINATES THE NECESSITY OF ADJUSTING TAKEOFF PERFORMANCE SPEED. THEY PLAN NO FURTHER ACTION ON THIS RECOMMENDATION.

From: NTSB
To: FAA
Date: 6/25/1992
Response: The Safety Board continues to believe that procedural changes that can provide greater safety margins between takeoff speed and aerodynamic stall speed can be implemented without compromising other takeoff safety considerations on those infrequent occasions when snow or ice contamination are possible. We understand that the use of higher rotation speeds must be predicated upon available runway length and proper engine performance as the airplane reaches currently specified rotation speeds. However, the Board believes that pilots can be trained to revert to normal takeoff procedures in the event of an engine failure. Furthermore, the Board believes that the modification of procedures in those instances when wing contamination is possible is analogous to the procedures contained in the Windshear Training Aid approved by the FAA for use when an encounter with a microburst windshear is recognized during takeoff. The Safety Board requests that the FAA reconsider its position on Safety Recommendation A-91- 127, which is classified as "Open--Unacceptable Response."

From: FAA
To: NTSB
Date: 2/27/1992
Response: THE FAA HAS STUDIED VARIOUS PROPOSALS TO INCREASE THE ROTATION SPEED DURING TAKEOFF. THESE PROPOSALS WERE FURTHER EVALUATED AND REJECTED AS OPERATIONALLY UNSATISFACTORY. THEE FAA BELIEVES THAT THE ACTIONS REQUIRED BY AD-92-03-01 MENTIONED IN RESPONSE TO SAFETY RECOMMENDATION A-91-123 AND -124 ARE INTENDED TO PREVENT ICE CONTAMINATION WHICH COULD RESULT IN THE DEGREDATION OF WING LIFT AND STALL AT LOWER THAN NORMAL ANGLES-OF-ATTACK DURING TAKEOFF.