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Safety Recommendation Details

Safety Recommendation A-95-021
Details
Synopsis: ON 3/2/94, ABOUT 1759:46 EASTERN STANDARD TIME CONTINENTAL AIRLINES FLIGHT 795 (COA FLIGHT 795), A MCDONNELL DOUGLAS MD-82, REGISTRATION N18835, SUSTAINED SUBSTANTIAL DAMAGE WHEN THE CAPTAIN REJECTED THE TAKEOFF FROM RUNWAY 13 AT LAGUARDIA AIRPORT, FLUSHING, NEW YORK. THE AIRPLANE CONTINUED BEYOND THE TAKEOFF END OF RUNWAY 13 & CAME TO REST ON THE MAIN GEAR WHEELS WITH THE NOSE PITCHED DOWNWARD, SO THAT THE FUSELAGE WAS BALANCED ON TOP OF A DIKE. THE UNDERSIDE OF THE NOSE LAY ON A TIDAL MUD FLAT OF FLUSHING BAY. THERE WERE 110 PASSENGERS, 2 FLIGHTCREW MEMBERS & 4 FLIGHT ATTENDANTS ABOARD THE AIRPLANE. THERE WERE NO FATALITIES, & NO SERIOUS INJURIES WERE REPORTED. THERE WERE 29 MINOR INJURIES TO PASSENGERS, ALL OF WHICH WERE SUSTAINED DURING THE EVACUATION, AND 1 MINOR INJURY TO A FLIGHTCREW MEMBER. THERE WAS NO POSTCRASH FIRE.
Recommendation: THE NTSB RECOMMENDS THAT THE FAA: REQUIRE THE MODIFICATION OF TRANSPORT CATEGORY AIRPLANES TO INCORPORATE THE AUTOMATIC ACTIVATION OF AIR DATA SENSOR HEATING SYSTEMS WITHOUT FLIGHTCREW ACTION.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: FLUSHING, NY, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA94MA038
Accident Reports: Runway Overrun Following Rejected Takeoff, Continental Airlines Flight 795 McDonnell Douglas MD-82, N18835
Report #: AAR-95-01
Accident Date: 3/2/1994
Issue Date: 3/6/1995
Date Closed: 11/10/1998
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 9/13/2007
Response: Safety Recommendations A-95-021 and A-95-022 were reiterated in the letter issuing Safety Recommendations A-07-055 and A-07-056 sent on 9/13/2007. The letter discusses the May 12, 2005 incident where a Boeing 717-200, experienced unreliable airspeed indications during climb out in heavy rain and icing conditions over Union Star, Missouri. The crew diverted to Kirksville, Missouri.

From: NTSB
To: FAA
Date: 2/16/2007
Response: In accordance with international aviation agreements, the National Transportation Safety Board, as the accident investigation authority for the United States, occasionally receives safety recommendations directly from other states’ investigating authorities. (See the Convention on International Civil Aviation, Aircraft Accident and Incident Investigation, Annex 13, Chapter 6, Final Report, paragraphs 6.8, 6.9, and 6.10) It is the Safety Board’s responsibility to transmit such safety recommendations to the appropriate government agencies and/or industry organizations within the United States that are in a position either to take appropriate action or to determine why no action is necessary. In exercising these requirements, I am forwarding to the Federal Aviation Administration (FAA) an investigation report by the Ministry of Transport and Communications, Directorate General of Civil Aviation (DGCA) of the Republic of Turkey, concerning the April 7, 1999, loss of control and collision with terrain near Ceyhan, Adana, Turkey, of Turkish Airlines flight 5904, a Boeing 737-400. This report contains two Safety Recommendation to the FAA. The Safety Board notes that one of these recommendations is a reiteration of Safety Recommendation A-95-21, issued by the Safety Board on March 6, 1995, as a result of our investigation of the runway overrun of Continental Airlines flight 795, a McDonnell-Douglas MD-82, at LaGuardia Airport, Flushing, New York. On November 10, 1998, Safety Recommendation A-95-21 was classified Closed Unacceptable Action. The DGCA believes that in light of the findings from the Turkish Airlines flight 5904 accident, the FAA should reconsider its opposition to automatic activation of air data sensor heating systems. The international agreements require the agencies that receive the recommendations to provide a response to the state proposing them. These responses should either describe the preventative action taken or under consideration, or explain why no action will be taken. In addition, I request that you send the Safety Board copies of all the FAA’s responses to these recommendations so that the correspondence can be entered into our database for future reference and retrieval. The Board would appreciate receiving your initial response within 90 days of receipt of this letter.

From: NTSB
To: FAA
Date: 11/10/1998
Response: THE BOARD NOTES THAT THE FAA BELIEVES THAT CURRENT REGULATIONS & OPERATIONAL PROCEDURES PROVIDE AN ADQUATE LEVEL OF SAFETY IN ALERTING FLIGHTCREWS TO NONACTIVATED AIR DATA SENSOR HEATING SYSTEMS. THE BOARD DISAGREES & NOTES THAT IT WAS UNDER THESE REGULATIONS & PROCEDURES THAT SEVERAL ACCIDENTS OCCURRED INCLUDING THAT INVOLVING CONTINENTAL AIRLINES FLIGHT 795, AS A RESULT OF PILOTS FAILING TO TAKE THE REQUIRED ACTIONS. FOR MORE INFO SEE AIRCRAFT ACCIDENT REPORT - "RUNWAY OVERRUN FOLLOWING REJECTED TAKEOFF, CONTINENTAL AIRLINES FLIGHT 795, MCDONNELL DOUGLAS MD-82, N18835, LAGUARDIA AIRPORT, FLUSHING, NEW YORK, 3/2/94." THE BOARD IS DISAPPOINTED THAT THE FAA REMAINS OPPOSED TO REQUIRING THE MODIFICATION OF TRANSPORT CATEGORY AIRPLANES TO INCORPORATE THE AUTOMATIC ACTIVATION OF AIR DATA SENSOR HEATING SYSTEMS WITHOUT FLIGHTCREW ACTION. THE BOARD CONTINUES TO BELIEVE THAT SUCH MODIFICATION WOULD PROVIDE A LEVEL OF SAFETY THAT IS SUPERIOR TO THE PROVIDED BY CURRENT FAA REGULATIONS & OPERATIONAL PROCEDURES. CONSEQUENTLY A-95-21 IS CLASSIFIED "CLOSED--UNACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 6/5/1998
Response: (Letter Mail Controlled 6/9/98 2:46:29 PM MC# 980741) THE FAA REVIEWED THE AIR DATA SENSOR HEATING SYSTEM DESIGN STANDARDS & CONCLUDED THAT EXISTING TRANSPORT CATEGORY AIRWORTHINESS STANDARDS PROVIDE FOR AN ADEQUATE LEVEL OF SAFETY IN ALERTING FLIGHTCREWS TO NONACTIVATED AIR DATA SENSOR HEATING SYSTEMS. CFR 25.1323 (E) REQUIRES THAT EACH AIRSPEED SYSTEM MUST HAVE A HEATED PITOT TUBE OR AN EQUIVALENT MEANS OF PREVENTING MALFUNCTION DUE TO ICING. 14 CFR 25.1326 PROVIDES THAT IF A FLIGHT INSTRUMENT PITOT HEATING SYSTEM IS INSTALLED, AN INDICATION SYSTEM MUST BE PROVIDED TO INDICATE TO THE FLIGHTCREW WHEN THAT PITOT HEATING SYSTEM IS NOT OPERATING. THE FAA RECOGNIZES THAT MANY OF THE MORE RECENTLY CERTIFICATED AIRPLANES HAVE THE AUTOMATIC FEATURE INSTALLED & ARE EXPERIENCING GOOD PERFORMANCE & RELIABILITY. HOWEVER, THIS FEATURE WAS INCORPORATED INTO THE BASIC DESIGN CONCEPT OF THESE AIRCRAFT & DOES NOT INVOLVE THE RETROFIT OR MODIFICATION OF THE EXISTING AIRFRAME & SYSTEMS. I BELIEVE THAT CURRENT FAA REGULATIONS & OPERATIONAL PROCEDURES PROVIDE AN ADEQUATE LEVEL OF SAFETY IN ALERTING FLIGHTCREWS TO NONACTIVATED AIR DATA SENSOR HEATING SYSTEMS.

From: NTSB
To: FAA
Date: 6/19/1997
Response: THE BOARD PREVIOUSLY CLASSIFIED THE FAA'S ACTION "OPEN--ACCEPTABLE RESPONSE," PENDING THE RESULTS OF THE DESIGN REVIEW. THE BOARD BELIEVES THAT AUTOMATIC ACTIVATION OF AIR DATA SENSOR HEATING SYSTEMS WOULD PROVIDE AN ADDITIONAL NEEDED LEVEL OF SAFETY TO PASSENGERS & AIRCRAFT. THE CONTINENTAL AIRLINES ACCIDENT ON 3/2/94, AT LAGUARDIA PROVIDES AN EXCELLENT EXAMPLE OF THE POTENTIAL FOR TRAGIC CONSEQUENCES IF AIR DATA SENSOR HEATING SYSTEMS FAIL OR ARE NOT ACTIVATED IN THE CONTINENTAL AIRLINES ACCIDENT ON 3/2/94, AT LAGUARDIA PROVIDES AN EXCELLENT EXAMPLE OF THE POTENTIAL FOR TRAGIC CONSEQUENCES IF AIR DATA SENSOR HEATING SYSTEMS FAIL OR ARE NOT ACTIVATED BY THE PILOTS. THE LACK OF ADHERENCE TO CHECKLISTS & OTHER HUMAN ERRORS WERE INVOLVED IN THE CONTINENTAL AIRLINES ACCIDENT. THERE IS REASON TO BELIEVE THAT SIMILAR ERRORS COULD BE REPEATED IN THE FUTURE UNLESS POSITIVE PREVENTION MEASURES ARE TAKEN TO REDUCE THE POTENTIAL FOR SIMILAR ACCIDENTS. BEFORE ISSUING A-95-21 & -22 & FOLLOWING THE FAA'S LATEST RESPONSE, THE BOARD STAFF CONDUCTED AN INFORMAL SURVEY OF TRANSPORT-CATEGORY AIRCRAFT TO DETERMINE THE TYPE OF AIR DATA SENSING ICE PROTECTION SYSTEMS THAT ARE INSTALLED & FOUND THAT A SIGNIFICANT NUMBER OF AIRPLANE MODELS ALREADY HAVE AUTOMATIC PITOT PROBE HEATING. FOR EXAMPLE, THE MD-11, B-757/767, B-777, & A-320/330/340 AIRPLANES HAVE AUTOMATIC SYSTEMS THAT DO NOT REQUIRE CREW ACTIONS TO ENSURE THAT PITOT-STATIC PROBES ARE HEATED. CONSEQUENTLY, THE BOARD DOES NOT AGREE WITH THE FAA'S STATEMENT THAT THE IMPLEMENTATION OF AUTOMATIC SYSTEMS WOULD POSSIBLE REDUCE AIRCRAFT SAFETY BY ADDING THE POTENTIAL FOR NUISANCE ALERTS DURING THE TAKEOFF ROLL. AIRCRAFT SAFETY WAS NOT DIMINISHED WHEN AUTOMATED PITOT HEAT SYSTEMS WERE INCORPORATED & APPROVED BY THE FAA FOR NEWER TRANSPORT-CATEGORY AIRCRAFT. THEREFORE, THE BOARD DOES NOT AGREE WITH THE FAA'S RATIONALE FOR NOT PROMULLGATING AN NPRM WHEN MANY AIRCRAFT HAVE ALREADY PROVEN THE MERIT OF SUCH SYSTEMS. THE BOARD BELIEVES THAT THE FAA SHOULD REQUIRE INSTALLATION OF THESE SYSTEMS ON ALL TRANSPORT AIRCRAFT TO PREVENT ACCIDENTS & TO RAISE THE REMAINDER OF THE FLEET TO THE SAME LEVEL OF SAFETY AS THAT ALREADY APPROVED BY THE FAA ON THE PREVIOUSLY MENTIONED TRANSPORT-CATEGORY AIRPLANES. PENDING A REEVALUATION OF THIS MATTER. THE BOARD CLASSIFIES A-95-21 & A-95-22, "OPEN--UNACCEPTABLE RESPONSE." OUR STAFF IS AVAILABLE TO DISCUSS THESE RECOMMENDATIONS WITH YOUR STAFF IF NECESSARY.

From: FAA
To: NTSB
Date: 2/18/1997
Response: The Federal Aviation Administration (FAA) does not agree that automatic activation of the air data sensor heating systems is necessary. Current FAA regulations require a caution indication in the cockpit which alerts pilots that the air data sensor heating systems (pitot, static, angle-of-attack) are not activated. The amber caution message on annunciator panels or EICAS displays provides positive and unmistakable warning of nonactivation of the systems to the flightcrew. Even before engine start, the flightcrew must verify proper pitot, static, and angle-of-attack heater operation. Failure of the pilot to turn on the systems or the failure of the heater systems is annunciated as a level 2 caution message to the flightcrew, and in some aircraft activates a master caution alert. Consequently, the FAA believes that there are proper systems in place to alert a flightcrew when the air data sensor heating systems are not activated. The automatic activation of the air data sensor heating systems would cause several problems. The heating elements of the systems are designed to provide proper heat to the sensing systems using the cooling effects of the airflow over the sensors in operational flight conditions. The heat generated to protect the sensors in flight can damage the elements if left on for a prolonged time while on the ground. This would lead to frequent heating element failures of existing elements which would make the air data sensors inoperative. If a decision was made to incorporate an automatic means to activate the sensor system heat, the retrofit program would be very complex and expensive. Logic would have to be developed which was capable of determining that an aircraft is not only on the ground but is also ready for takeoff and then is starting the takeoff roll yet not activate the system too early to prevent heater element damage. This retrofit program would be extensive yet not give an appreciable advantage to the warning indicators already available to the flightcrew. Finally, some form of system monitor would be required to advise the flightcrew if the automatic activation system was not functioning properly. I believe that current FAA regulations which require a caution indication in the cockpit to alert pilots that the air data sensor heating systems are not activated address this issue. I consider the FAA's action to be completed, and I plan no further action on this safety recommendation.

From: FAA
To: NTSB
Date: 11/10/1995
Response:

From: NTSB
To: FAA
Date: 11/7/1995
Response: THE BOARD IS PLEASED THAT THE FAA IS CONDUCTING A DESIGN REVIEW OF AIR DATA SENSOR HEATING SYSTEM DESIGN STANDARDS FOR TRANSPORT AIRCRAFT. THEREFORE, PENDING THE FAA'S COMPLETION OF THAT REVIEW & SUBSQUENT ACTION, THE BOARD CLASSIFIES A-95-21 & -22 "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 5/15/1995
Response: THE FAA IS CONDUCTING A DESIGN REVIEW OF THE AIR DATA SENSOR HEATING SYSTEM DESIGN STANDARDS FOR TRANSPORT CATEGORY AIRPLANES TO DETERMINE IF THERE IS A NEED TO REVISE CURRENT REGULATIONS OR INITIATE MODIFICATIONS TO EXISTING TRANSPORT CATEGORY AIRPLANES. BASED ON THE RESULTS OF THE REVIEW, THE FAA WILL TAKE APPROPRIATE CORRECTIVE ACTION. I WILL KEEP THE BOARD APPRISED OF THE FAA'S PROGRESS ON THIS RECOMMENDATION.