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Safety Recommendation Details

Safety Recommendation A-93-020
Details
Synopsis: ON SUNDAY, MARCH 22, 1992, ABOUT 2135 EASTERN STANDARD TIME, A FOKKER 28-4000 (F-28), N485US, OPERATING AS USAIR FLIGHT 405, CRASHED DURING AN ATTEMPTED TAKEOFF FROM RUNWAY 13 AT LAGUARDIA AIRPORT, FLUSHING, NEW YORK. THE AIRPLANE WAS OPERATING UNDER TITLE 14, CODE OF FEDERAL REGULATIONS (CFR), PART 121, AS A SCHEDULED PASSENGER FLIGHT FROM JACKSONVILLE, FLORIDA, TO CLEVELAND, OHIO, WITH A STOPOVER AT LAGUARDIA AIRPORT. THERE WERE 47 PASSENGERS, 2 FLIGHTCREW MEMBERS AND 2 CABINCREW MEMBERS ON BOARD. THE CAPTAIN, ONE OF THE CABINCREW MEMBERS, AND 25 PASSENGERS RECEIVED FATAL INJURIES. IMPACT FORCES AND THE SUBSEQUENT FIRE DESTROYED THE AIRPLANE.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: WHERE DEICING OPERATIONS ARE CONDUCTED AWAY FROM THE DEPARTURE RUNWAY, REPORT TAXI DELAYS IN CONDITIONS CONDUCIVE TO AIRFRAME ICING IN INCREMENTS THAT ARE LESS THAN 15 MINUTES TO PROVIDE MORE REALISTIC AND USEFUL REPORTS TO DISPATCHERS AND FLIGHTCREWS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Aviation
Location: FLUSHING, NY, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA92MA025
Accident Reports: Takeoff Stall in Icing Conditions USAIR Flight 405, FOKKER F-28, N485US
Report #: AAR-93-02
Accident Date: 3/22/1992
Issue Date: 3/18/1993
Date Closed: 5/25/1995
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s): Dispatch, Icing, Weather

Safety Recommendation History
From: NTSB
To: FAA
Date: 5/25/1995
Response: THE BOARD NOTES THAT THE FAA MAINTAINS THAT THE 15-MINUTE REQUIREMENT IS FOR STATISTICAL ANALYSIS & REPORTING PURPOSES WITHIN THE AIR TRAFFIC & SYSTEM, IS NOT A DETERMINING FACTOR IN THE IMPLEMENTATION & APPLICATION OF AIRPORT DEICING PLANS. NOTWITHSTANDING THIS STATED PURPOSE, THE DELAY REQUIREMENT IS, IN FACT, REFLECTED IN ATC ADVISORIES THAT ARE PROVIDED TO FLIGHTCREWS & AIRLINE DISPATCHERS. THESE INDIVIDUALS USE THIS DELAY INFO IN MAKING REAL-TIME OPERATIONAL DECISIONS RELATED TO HOLDOVER & EXPECTED DEPARTURE TIMES. BUT BECAUSE THESE ADVISORIES DO NOT REPORT A DEPARTURE DELAY UNTIL THERE IS AN ACTUAL DELAY OF 15 MINUTES, THEY CONVEY AN UNDERESTIMATION OF THE DELAYS THAT FLIGHTS ARE LIKELY TO ENCOUNTER. MOREOVER, ESTABLISHING AIRPORT DEPARTURE RATES DOES NOT DIRECTLY MINIMIZE THE LENGTH OF TIME THAT INDIVIDUAL AIRCRAFT SPEND ON THE GROUND AFTER BEING DEICED. THEREFORE, THE BOARD CONTINUES TO BELIEVE THAT THE NEEDS OF THE FLYING COMMUNITY WOULD BE BETTER SERVED BY REPORTING DELAYS IN SMALLER INCREMENTS. THE BOARD AGREES, HOWEVER, WITH THE FAA'S COMMENT IN ITS DECEMBER 22 RESPONSE, THAT THE 15-MINUTE REQUIREMENT IS NOT A DETERMINING FACTOR IN THE IMPLEMENTATION & APPLICATION OF DEICING PLANS & THE BOARD ACKNOWLEDGES THAT FOR THOSE AIRPORTS THAT HAVE DEVELOPED A DEICING PLAN, THE INTENT OF THE RECOMMENDATION HAS BEEN MET. AS A RESULT, FLIGHTCREWS ARE ABLE TO MORE EASILY ASSESS WHETHER A DEPARTURE CAN BE SAFELY MADE WITHIN THE APPROPRIATE HOLD-OVER TIMES. THEREFORE, A-93-20 IS CLASSIFIED "CLOSED--ACCEPTABLE ALTERNATE ACTION."

From: FAA
To: NTSB
Date: 12/22/1994
Response: THE 15-MINUTE REQUIREMENT REFERENCE BY THE BOARD IS FOR STATISTICAL ANALYSIS & REPORTING PURPOSES WITHIN THE AIR TRAFFIC CONTROL SYSTEM. IT IS NOT A DETERMINING FACTOR IN THE IMPLEMENTATION & APPLICATION OF AIRPORT DEICING PLANS. AT LOCATIONS WITH AIRPORT DEICING PLANS, AIR TRAFFIC FACILITIES ESTABLISH DEPARTURE RATES THAT ALLOW STRICT CONTROL OF THE NUMBER OF DEICED AIRCRAFT AWAITING DEPARTURE AT THE RUNWAY--THUS MINIMIZING THE LENGTH OF TIME AN AIRCRAFT SPEND ON THE GROUND AFTER DEICED. DEPARTURE RATES DURING DEICING OPERATIONS ARE CALCULATED BY ASSESSING PRESENT OPERATIONAL CIRCUMSTANCES, THE PREVIOUS EXPERIENCE WITH ICING CONDITIONS, & HISTORICAL DATA. AIRCRAFT ARE ENSURED MINIMUM GROUND TIME AFTER DEICING THROUGH A PROCESS WHERE BY DYNAMIC ADJUSTMENT ARE MADE TO DEPARTURE RATES BASED ON ACTUAL CONDITIONS & EXPERIENCE. THE DEPARTURE RATES ARE NOT ASSOCIATED WITH ANY PREESTABLISHED DELAY REPORTING CRITERIA. FACILITIES COMMUNICATE DEPARTURE RATES & ANY OTHER PERTINENT INFO TO THE AIRPORT USERS & OPERATORS BEFORE, DURING & AFTER DEICING OPERATIONS. THIS INFO IS SUBSEQUENTLY DISSEMINATED TO THE FLIGHTCREWS BY THEIR COMPANY AS SPECIFIED IN THEIR MANDATED AIRLINE-SPECIFIC DEICING/ANTI-ICING PROGRAM. THE BOARD'S RESPONSE TO THE FAA'S MOST RECENT LETTER WAS THAT THE INTENT OF THIS RECOMMENDATION WAS TO PROVIDE FLIGHTCREWS WITH MORE ACCURATE INFO REGARDING TAXI DELAYS. THIS INFO WOULD OPTIMIZE THE TIMING OF DEICING OPERATIONS & ALLOW A CREW TO ASSESS WHETHER IT CAN BE REASONABLY SURE THAT A DEPARTURE CAN BE MADE WITHIN THE APPROPRIATE HOLDOVER TIME LIMITS. I BELIEVE THAT THESE PROCESS THAT I DESCRIBE IN THIS LETTER, WHICH HAS BEEN USED BY AIR TRAFFIC FACILITIES FOR MORE THAN A YEAR, PROVIDES FLIGHTCREWS & AIRPORT OPERATORS WITH ACCURATE, TIMELY INFO TO OPTIMIZE DEICING OPERATION & ENSURES SAFE & EFFICIENT GROUND OPERATIONS DURING ICING CONDITIONS. I BELIEVE THAT THESE PROCEDURES COMPLETELY ADDRESS THIS RECOMMENDATION, & I PLAN NO FURTHER ACTION.

From: NTSB
To: FAA
Date: 3/9/1994
Response: THE BOARD NOTES THAT THE 15-MINUTE REQUIREMENT IS FOR DELAY REPORTING AND IS NOT A DETERMINING FACTOR IN THE IMPLEMENTATION OF AIRPORT DEICING PLANS. FURTHER, AIR TRAFFIC FACILITIES ESTALISH DEPARTURE RATES THAT ALLOW STRICT CONTROL OF THE NUMBER OF DEICED AIRCRAFT AWAITING DEPARTURE AT THE RUNWAY, THUS MINIMIZING THE LENGTH OF TIME AN AIRCRAFT SPENDS ON THE GROUND AFTER BEING DEICED. THE BOARD BELIEVES THAT THE FAA'S RESPONSE TO THIS RECOMMENDATION DOES NOT ADEQUATELY ADDRESS THIS ISSUE, AND THE BOARD REQUESTS THAT YOU RECONSIDER YOUR POSITION ON THIS MATTER. THEREFORE, SAFETY RECOMMENDATION A-93-20 IS CLASSIFIED "OPEN--UNACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 10/26/1993
Response: THE 15-MINUTES REQUIREMENT IS FOR STATISTICAL ANALYSIS AND REPORTING PURPOSES WITHIN THE AIR TRAFFIC CONTROL SYSTEM AND IS NOT A DETERMINING FACTOR IN THE IMPLEMENTATION AND APPLICATION OF AIRPORT DEICING PLANS. AT LOCATIONS WITH AIRPORT DEICING PLANS, AIR TRAFFIC FACILITIES ESTABLISH DEPARTURE RATES THAT ALLOW STRICT CONTROL OF THE NUMBER OF DECIED AIRCRAFT AWAITING DEPARTURE AT THE RUNWAY--THUS MINIMIZING THE LENGTH OF TIME AN AIRCRAFT SPENDS ON THE GROUND AFTER BEING DECIED. DEPARTURE RATES DURING DEICING OPERATTIONS ARE CALCULATED BY ASSESSING PRESENT OPERATIONAL CIRCUMSTANCES (WEATHER CONDITIONS, TRAFFICE DEMAND, RUNWAY/TAXIWAY AVAILABILITY, ETC.), PREVIOUS EXPERIENCE WITH ICING CONDITIONS, AND HISTORICAL DATA. TO ENSURE MINIMUM GROUND TIME AFTER DEICING, DYNAMIC ADJUSTMENTS TO DEPARTURE RATES ARE MADE THAT ARE NOT ASSOCIATED WITH ANY PREESTABLISHED DELAY REPORTING CRITERIA. FACILITIES HAVE BEEN INSTRUCTED TO COMMUNICATE DEPARTURE RATES AND ANY OTHE PERTINENT INFORMATION TO AIRPORT USES AND OPERATORS BEFORE, DURING, AND AFTER DEICING OPERATIONS. THIS INFORMATION IS SUBSEQUENTLY DISSEMINATED TO THE FLIGHTCREWS BY THEIR COMPANY AS SPECIFIED IN THEIR MANDATED AIRLINE-SPECIFIC DEICING/ANTI-ICING PROGRAM.

From: FAA
To: NTSB
Date: 5/27/1993
Response: The Federal Aviation Administration (FAA) does not agree with this safety recommendation. Air traffic facilities establish departure rates which allow strict control of the number of deiced aircraft awaiting departure at the runway, thus minimizing the length of time an aircraft spends on the ground after being deiced. Departure rates during deicing operations are calculated by assessing present operational circumstances such as weather conditions, traffic demand, runway/taxiway availability, previous experience with icing conditions, and historical data. The 15-minute requirement is for delay reporting purposes only and is not a determining factor in the application of airport deicing plans. Facilities have been instructed to communicate with the airport users and operators before, during, and after deicing operations to discuss any necessary adjustments that should be made. I believe that these procedures completely address this safety recommendation, and I plan no further action.