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Safety Recommendation Details

Safety Recommendation A-93-030
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: REVIEW FOKKER 28-4000 PASSENGER SAFETY BRIEFING CARDS TO ENSURE THAT THEY CLEARLY AND ACCURATELY DEPICT THE OPERATION OF THE TWO TYPES OF FORWARD CABIN DOORS IN BOTH THEIR NORMAL AND EMERGENCY MODES AND THAT THEY DESCRIBE CLEARLY AND ACCURATELY HOW TO REMOVE THE OVERWING EMERGENCY EXIT HANDLE COVER.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable 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: 7/17/1995
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/17/1995
Response: THE BOARD NOTES THAT THE FAA ISSUED FLIGHT STANDARDS INFO BULLETINS FOR AIR TRANSPORTATION 93-27 & 93-29 CONCRNING THE FOKKER 28-4000 PASSENGER SAFETY INFO CARDS & CABIN DOOR OPERATING MECHANISMS. THESE BULLETINS DIRECT PRINCIPAL OPERATIONS INSPECTORS TO REVIEW & ENSURE THT THE SAFETY INFO CARDS SHOW THE CORRECT PROCEDURES FOR OPERATING THE DOORS ON F-28 AIRPLANES. THEY ALSO DIRECT POIS TO ALERT THEIR ASSIGNED AIR CARRIERS OF THE POTENTIAL PROBLEMS OF PASSENGERS MOVING AN EXIT MECHANISM & TO HAVE PROCEDURES FOR CREWMEMBERS TO CHECK THE POSITION OF DOOR HANDLES PERIODICALLY DURING FLIGHT. THEREFORE THE BOARD CLASSIFIES A-93-30 "CLOSED--ACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 2/27/1995
Response: ON 5/27/93, THE FAA STATED THAT IT AGREED WITH THE INTENT OF THIS RECOMMENDATION BUT BELIEVED THAT PASSENGERS WOULD BE CONFUSED DURING AN EMERGENCY SITUATION IF MORE THAN ONE METHOD OF OPENING THE TWO TYPES OF FORWARD CABIN DOORS WAS DEPICTED. THE INFO ON THE PASSENGER SAFETY BRIEFING CARDS DEPICT THE METHOD WHICH WOULD BE USED IN AN EMERGENCY WHEN IT WAS NECESSARY TO OPEN THE LEFT & RIGHT FORWARD CABIN DOOR. THE CARDS ALSO ILLUSTRATE THE MEDHOD OF OPENING THE WINDOW EXIT. TO ADDRESS THE INTENT OF THIS SAFETY RECOMMENDATION THE FAA TOOK THE FOLLOWING ACTIONS.

From: FAA
To: NTSB
Date: 12/20/1993
Response: The Federal Aviation Administration (FAA) agrees with the intent of this safety recommendation and on August 13, 1993, issued a Flight Standards Information Bulletin for Air Transportation No. 93-27, Fokker 28-4000 Passenger Safety Information Cards. This bulletin directs principal operations inspectors assigned to air carriers operating Fokker 28-4000 airplanes to review and ensure that the passenger safety information cards show the correct procedures for operation of the two forward doors, removal of the overwing emergency exit handle covers, and a warning to passengers that the plastic cover should only be removed in emergency situations. I have enclosed a copy of this bulletin for the Board's information. On October 5, 1993, the FAA issued Flight Standards Information Bulletin for Air Transportation No. 93-29, Cabin Door Operating Mechanisms. This bulletin directs principal operations inspectors to alert their assigned air carriers of the potential problem of passengers moving an exit mechanism and to have procedures for crewmembers to check the position of the door handles periodically during flight. I have enclosed a copy of this bulletin for the Board's information. I consider the FAA's action to be completed, and I plan no further action on this safety recommendation.

From: FAA
To: NTSB
Date: 5/27/1993
Response: The FAA agrees with the intent of this safety recommendation but does not agree that passengers need to know how to operate the forward cabin doors in a normal mode. To show information on more than one method of opening the two types of forward cabin doors would only confuse passengers. Consequently, the FAA will issue a Flight Standards Information Bulletin to direct principal operations inspectors (POI) assigned to air carriers operating the Fokker 4000 to review the passenger information cards to ensure that they comply with existing regulations and accurately depict the method which would be used in an emergency of opening the left and right forward cabin doors and the method of opening the window exit. The Flight Standards Information Bulletin will also direct the POI's to request that the air carriers provide information regarding plastic door covers on the passenger information cards when they are revised. I will provide the Board with a copy of the bulletin as soon as it is issued.