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Safety Recommendation Details

Safety Recommendation A-96-119
Details
Synopsis: On March 3, 1991, at 0944 mountain standard time, United Airlines flight 585, a Boeing 737-291 airplane, crashed during an approach to the Colorado Springs, Colorado, airport. The crew of 5 and the 20 passengers were killed. The airplane was destroyed by the impact and a postcrash fire. The weather was clear with unlimited visibility. There were windshear reports during the day. At the time of the accident the surface winds were reported to be out of the northwest at 20 knots gusting to 28. The safety board has not determined the cause(s) of the accident and an investigation of airframe, operational and weather factors is continuing.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require the Boeing Commercial Airplane Group to develop operational procedures for B-737 flightcrews that effectively deal with a sudden uncommanded movement of the rudder to the limit of its travel for any given flight condition in the airplane's operational envelope. Once the operational procedures have been developed, require B-737 operators to provide this training to their pilots. (Superseded by A-97-18)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Superseded
Mode: Aviation
Location: COLORADO SPGS, CO, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA91MA023
Accident Reports: Uncontrolled Descent and Collision with Terrain, United Airlines Flight 585, Boeing 737-200, N999UA, 4 Miles South of Colorado Springs Municipal Airport
Report #: AAR-92-06
Accident Date: 3/3/1991
Issue Date: 10/18/1996
Date Closed: 2/20/1997
Addressee(s) and Addressee Status: FAA (Closed - Superseded)
Keyword(s): Flightcrew, Rudder, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/15/1997
Response: A-96-119 ASKED THE FAA TO REQUIRE THE BOEING COMMERCIAL AIRPLANE GROUP TO DEVELOP OPERATIONAL PROCEDURES FOR B-737 FLIGHTCREWS THAT EFFECTIVELY DEAL WITH A SUDDEN UNCOMMANDED MOVEMENT OF THE RUDDER TO THE LIMIT OF ITS TRAVEL FOR ANY GIVEN FLIGHT CONDITION IN THE AIRPLANE'S OPERATIONAL ENVELOPE. ONCE THE PROCEDURES ARE DEVELOPED, REQUIRE B-737 OPERATORS TO PROVIDE THIS TRAINING TO THEIR PILOTS. HOWEVER,THE POTENTIAL FOR A RUDDER MOVEMENT OPPOSITE FROM THAT COMMANDED BY PILOT INPUT ON THE RUDDER PEDALS WAS NOT ADDRESSED BY A-96-119; THEREFORE, A-96-119 IS CLASSIFIED "CLOSED--SUPERSEDED ACCEPTABLE ACTION." IN ITS STEAD, ON 2/20/97, THE BOARD ISSUED A-97-18, WHICH IS DISCUSSED IN THIS LETTER.

From: FAA
To: NTSB
Date: 4/18/1997
Response: THE FAA AGREES WITH THE INTENT OF THIS RECOMMENDATION & HAS DIRECTED THE SEATTLE AIRCRAFT EVALUATION GROUP, IN CONJUNCTION WITH THE BOEING AIRCRAFT COMPANY & THE SEATTLE AIRCRAFT CERTIFICATION OFFICE, TO DEVELOP A PILOT OPERATING PROCEDURE FOR RECOVERY TECHNIQUES OF SUDDEN UNCOMMANDED MOVEMENT OF THE RUDDER TO ITS MAXIMUM LIMIT. THIS NEW PROCEDURE WILL BE INCORPORATED INTO THE BOEING 737 AIRPLANE FLIGHT MANUAL. IT IS ANTICIPATED THAT THE PROCEDURE WILL BE DEVELOPED FEBRUARY 1997. ONCE THE PROCEDURE IS DEVELOPED & THE AIRPRLANE FLIGHT MANUAL REVISED,THE FAA WILL ISSUE A FLIGHT STANDARDS INFO BULLETIN DIRECTING PRINCIPAL OPERATIONS INSPECTORS,WHOSE CARRIERS OPERATE BOEING 737 AIRCRAFT, TO INFORM PILOTS OF THE NEW PROCEDURE & TO ENSURE THAT THEY ARE TRAINED DURING THEIR NEXT SCHEDULED RECURRENT TRAINING.

From: NTSB
To: FAA
Date: 2/20/1997
Response: (CLOSED IN A GREENSHEET) THE BOARD BELIEVES THAT THE FAA SHOULD REQUIRE BOEING TO DEVELOP OPERATIONAL PROCEDURES FOR B-737 FLIGHTCREWS THAT EFFECTIVELY DEAL WITH A SUDDEN UNCOMMANDED MOVEMENT OF THE RUDDER TO THE LIMIT OF ITS TRAVEL FOR ANY GIVEN FLIGHT CONDITION IN THE AIRPLANE'S OPERATIONAL ENVELOPE, INCLUDING SPECIFIC INITIAL & PERIODIC TRAINING IN THE RECOGNITION OF & RECOVERY FROM UNUSUAL ATTITUDES & UPSETS CAUSED BY REVERSE RUDDER RESPONSE. ONCE THE PROCEDURES ARE DEVELOPED, REQUIRE B-737 OPERATORS TO PROVIDE THIS TRAINING TO THEIR PILOTS. THEREFORE, THE BOARD CLASSIFIES A-96-119 "CLOSED--SUPERSEDED ACCEPTABLE RESPONSE" BY RECOMMENDATION A-97-18.

From: FAA
To: NTSB
Date: 1/16/1997
Response: IN A 1/16/97, RESPONSE TO THIS RECOMMENDATION, THE FAA INDICATED THAT IT AGREED WITH THE INTENT OF A-96-119 & WAS WORKING WITH BOEING TO DEVELOP APPROPRIATE TRAINING FOR B-737 FLIGHTCREW.