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Safety Recommendation Details

Safety Recommendation A-95-022
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: AMEND THE REQUIREMENTS OF PART 25.1323 (E) TO REQUIRE THAT, FOR NEWLY CERTIFICATED AIRPLANES, ANTI-ICE PROTECTION FOR THE AIR DATA SENSOR HEATING SYSTEMS IS PROVIDED AUTOMATICALLY (WITHOUT FLIGHTCREW ACTION) FOLLOWING ENGINE START.
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: 11/1/2002
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Icing,Weather

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: 11/1/2002
Response: The Safety Board disagrees with the FAA that current regulations and operational procedures provide an adequate level of safety in alerting flight crews to nonactivated air data sensor heating systems. The Board notes that the pitot tube heaters were not turned on in an April 7, 1999, accident involving a Turkish Airlines Boeing 737-400 that lost control and crashed shortly after takeoff from Adana, Turkey. Although we understand that most newly certified aircraft have pitot tube heaters, the Board continues to believe that this should be a requirement on all aircraft. Because the FAA does not intend to take the recommended action on the older aircraft, Safety Recommendation A-95-22 is classified "Closed--Unacceptable Action."

From: FAA
To: NTSB
Date: 6/7/2002
Response: Letter Mail Controlled 06/20/2002 2:38:30 PM MC# 2020610 The survey conducted by the Federal Aviation Administration's (FAA) Aircraft Certification Offices revealed that many newly certificated airplanes are designed to activate the air data sensor heating systems automatically without flightcrew action. The Board's staff also conducted an informal survey of transport-category aircraft to determine the type of air data sensing ice protection systems installed and found that a significant number of airplane models already have automatic pitot probe heating. For example, the MD-11, Boeing 757/767, Boeing 777, and A320/330/340 series airplanes have automatic systems that do not require crew actions to ensure that pitot-static probes are heated. As stated in the FAA's letter dated January 11, 2000, older airplanes require that the pilot activate the air data sensor heating system. The operational procedures for these older aircraft require that pilots activate the air data sensor heating system as a mandatory item on the preflight checklist. The flightcrew is required to verify proper pitot, static, and angle-of-attack heater operation as part of the preflight checklist. On some aircraft, failure to turn on the heater systems is annunciated as a "level 2 caution message" to the flightcrew and activates the master caution alert. For newly certificated airplanes, automatic activation of anti-ice protection for the air data sensor heating systems following engine start would require a revision to 14 CFR 25.1323(e). However, a review of FAA's rulemaking activity shows that the agency's regulatory resources are already severely taxed to address the safety agenda that currently exists and is expected to continue to exist in the foreseeable future. In order to adopt this action in addition to what is already being considered would require replacing something that is currently in process, and the FAA does not believe that there is sufficient safety justification to proceed immediately. I believe that current FAA regulations and operational procedures provide an adequate level of safety in alerting flightcrews to nonactivated air data sensor heating systems. Existing transport-category airworthiness standards provide for an adequate level of safety in alerting flightcrews to nonactivated air data sensor heating systems. A review of newly certificated airplanes provides further assurance that newly certificated airplanes are often designed to activate the air data sensor heating systems automatically without flightcrew action, even in the absence of a specific regulatory requirement. In addition, to assure this safety concern is fully addressed for all newly certificated airplanes, the FAA's Transport Airplane Directorate has committed to address this issue through the issue paper process for all new transport airplane programs. This is the process by which technical issues are raised, tracked, and resolved in the certification process. In many recent programs, this auto-ice protection feature is already a de facto standard without specific language addressing it in 14 CFR Part 25. Raising this as a technical concern through the issue paper process for all designs not already incorporating this feature assures that the safety concern will be fully addressed in all new airplane programs. I believe that the FAA has addressed the full intent of this safety recommendation, and I consider the FAA's action to be completed.

From: NTSB
To: FAA
Date: 2/25/2000
Response: THE SAFETY BOARD APPRECIATES THE EFFORTS OF THE ARAC PROCESS AND UNDERSTANDS THE VALUE THE ARAC MIGHT ADD TO THE RULEMAKING PROCESS. HOWEVER, THE BOARD BELIEVES THAT AFTER 5 YEARS OF NO ACTION, AN ADDITIONAL 2 YEARS WILL PUSH THE ADEQUATE LEVEL OF SAFETY AS DESCRIBED IN YOUR REPLY. ALTHOUGH A-95-22 REMAINS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE," THE SAFETY BOARD STRONGLY URGES THE FAA TO RECONSIDER THE PROPOSED RULEMAKING PROCESS AND INITIATE IN ITS PLACE A MORE EXPEDITIOUS PROGRAM THAT WILL RESULT IN RULEMAKING WITHIN THIS FISCAL YEAR.

From: FAA
To: NTSB
Date: 1/11/2000
Response: Letter Mail Controlled 01/14/2000 2:42:35 PM MC# 2000070 THE FAA IS CONTINUING ITS EFFORTS TO INITIATE RULEMAKING ACTION TO REVISE 14 CFR PART 25 TO REQUIRE THAT NEWLY CERTIFICATED AIRPLANES INCLUDE AN AUTOMATIC ACTIVATION OF AIR DATA SENSOR HEATING SYSTEMS. HOWEVER, DUE TO THE CURRENT WORKLOAD OF THE AVIATION RULEMAKING ADVISORY COMMITTEE (ARAC) AND THE OTHER HIGHER PRIORITIES, IT IS EXPECTED TO TAKE SEVERAL YEARS TO COMPLETE. I WILL INFORM THE BOARD AS SOON AS THE ARAC BEGINS ITS TASKING ON THIS EFFORT. IN THE MEANTIME, CURRENT FAA REGULATIONS AND OPERATIONAL PROCEDURES PROVIDE AN ADEQUATE LEVEL OF SAFETY IN ALERTING FLIGHTCREWS TO NONACTIVATED AIR DATA SENSOR HEATING SYSTEMS. EXISTING TRANSORT-CATEGORY AIRWORTHINESS STANDARDS PROVIDE FOR AN ADEQUATE LEVEL OF SAFETY IN ALERTING FLIGHTCREWS TO NONACTIVATED AIR DATA SENSOR HEATING SYSTEMS. 14 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. A SURVEY CONDUCTED BY THE FAA'S AIRCRAFT CERTIFICATION OFFICES REVEALED THAT SOME NEWLY CERTIFICATED AIRPLANES ARE DESIGNED TO ACTIVATE THE AIR DATA SENSOR HEATING SYSTEMS AUTOMATICALLY WITHOUT FLIGHTCREW ACTION. OLDER AIRPLANES, HOWEVER, REQUIRE THAT THE PILOT ACTIVATE THE AIR DATA SENSOR HEATING. THE OPERATIONAL PROCEDURES FOR THESE OLDER AIRCRAFT REQUIRE THAT PILOTS ACTIVATE THE AIR DATA SENSOR HEATING AS A MANDATORY ITEM ON THE PREFLIGHT CHECKLIST. THE FLIGHTCREW IS REQUIRED TO VERIFY PROPER PITOT, STATIC, AND ANGLE-OF-ATTACK HEATER OPERATION AS PART OF THE PREFLIGHT CHECKLIST. ON SOME AIRCRAFT, FAILURE TO TURN ON THE HEATER SYSTEMS IS ANNUNCIATED AS A "LEVEL 2 CAUTION MESSAGE" TO THE FLIGHTCREW AND ACTIVATES THE MASTER CAUTION ALERT. I BELIEVE THAT CURRENT FAA REGULATIONS AND OPERATIONAL PROCEDURES PROVIDE AN ADEQUATE LEVEL OF SAFETY IN ALERTING FLIGHTCREWS TO NONACTIVATED AIR DATA SENSOR HEATING SYSTEMS WHILE REGULATORY ACTION IS PENDING. I WILL KEEP THE BOARD INFORMED OF THE FAA'S PROGRESS ON THIS SAFETY RECOMMENDATION.

From: NTSB
To: FAA
Date: 11/10/1998
Response: THE BOARD IS PLEASED THAT THE FAA WILL CONSIDER RULEMAKING ACTION TO REVISE TITLE 14 CFR PART 25 TO REQUIRE THAT NEWLY CERTIFICATED AIRPLANES INCLUDE AN AUTOMATIC ACTIVATION OF AIR DATA SENSOR HEATING SYSTEMS. PENDING FURTHER INFO, A-95-22 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 6/5/1998
Response: (Letter Mail Controlled 6/9/98 2:46:29 PM MC# 980741) AS STATED IN RESPONSE TO A-95-21, EXISTING REGULATIONS & OPERATING PROCEDURES PROVIDE ADEQUATE SAFETY MEASURES TO ENSURE THAT THE FLIGHTCREW TURNS ON THE AIR DATA SENSOR HEATING ELEMENTS. THE FAA WILL CONSIDER RULEMAKING ACTION TO REVISE 14 CFR PART 25 TO REQUIRE THAT NEWLY CERTIFICATED AIRPLANES INCLUDE AN AUTOMATIC ACTIVATION OF AIR DATA SENSOR HEATING SYSTEMS. I WILL KEEP BOARD INFORMED OF THE FAA'S PROGRESS ON THIS RECOMMENDATION.

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 ARE AVAILABALE TO DISCUSS THESE RECOMMENDATION WITH YOUR STAFF IF NECESSARY.

From: FAA
To: NTSB
Date: 2/18/1997
Response: THE FAA DOES NOT AGREE THAT AUTOMATIC ACTIVATION OF AIR DATA SENSOR HEATING IS NECESSARY. CURRENT REGULATIONS REQUIRE A CAUTION INDICATION IN THE COCKPIT THAT WARNS OF AIR DATA SENSOR HEATER SYSTEM FAILURE, THE FAA ALSO IDENTIFIES SEVERAL POTENTIAL SYSTEM PROBLEMS WITH SENSOR OVERHEATING & FAILURE ANNUNCIATION.

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 TRANPORT 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.