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Safety Recommendation Details

Safety Recommendation A-97-091
Details
Synopsis: About 1638 eastern daylight time, on 10/19/96, a McDonnell Douglas MD-88, N914dl, operated by Delta Airlines, Inc., as Flight 554, struck the approach light structure and the end of the runway deck during the approach to land on runway 13 at the LaGuardia airport, in Flushing, New York. Flight 554 was being operated under the provisions of 14 Code of Federal Regulations (CFR) Part 121, as a scheduled, domestic passenger flight from Atlanta, Georgia, to Flushing. The flight departed the Williams B. Hartsfield International Airport in Atlanta Georgia, about 1441, with two flightcrew members, three flight attendants, and 58 passengers on board. Three passengers reported minor injuries; no injuries were reported by the remaining 60 occupants. The airplane sustained substantial damage to the lower fuselage, wings (including slats and flaps), main landing gear, and both engines. Instrument meteorological conditions prevailed for the approach to runway 13; flight 554 was operating on an instrument flight rules flight plan.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require all 14 CFR Part 121 and 135 operators to convert, where practical, the non-instantaneous vertical speed instrumentation on airplanes that have inertial reference units installed to provide flightcrews with instantaneous vertical speed info.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: FLUSHING, NY, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: NYC97MA005
Accident Reports: Descent Below Visual Glidepath and Collision with Terrain Delta Air Lines Flight 554 McDonnell Douglas MD-88, N914DL
Report #: AAR-97-03
Accident Date: 10/19/1996
Issue Date: 8/29/1997
Date Closed: 10/7/2002
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 10/7/2002
Response: In its January 19, 2000, response to the FAA, the Safety Board indicated that it disagreed with the FAA's assessment that the recommended change was not feasible and that pilot training was an acceptable alternate response. At that time, the recommendation was classified "Open--Unacceptable Response." With the issuance of FSAT 98-10, the FAA satisfied the intent of Safety Recommendation A-97-90, stated below, that was issued at the same time as Safety Recommendation A-97-91. A-97-90 Require all 14 CFR Part 121 and 135 air carriers to make their pilots aware (through specific training, placards, or other means) of the type of vertical speed information (instantaneous/non-instantaneous) provided by the vertical speed indicators installed in their airplanes, and to make them aware of the ramifications that type of information could have on their perception of their flight situation. On November 20, 1998, the Safety Board classified Safety Recommendation A-97-90 "Closed--Acceptable Action." However, the Board continues to believe that the action requested in Safety Recommendation A-97-91 is needed because the mix of instantaneous and noninstantaneous VSIs is often random, even within an airplane type within a single carrier's fleet. In a critical situation, a pilot who may fly several different airplanes in a day may not be aware of the type of instrument being used at that particular time. The need for standardization is most critical in those fleets having a mix of instantaneous and noninstantaneous VSIs. The Board believes that an implementation schedule that would allow the retrofit to be accomplished at routine major inspection or service intervals, such as a "C" or a "D" check, would minimize the economic impact. Since, the FAA has stated that it does not intend to take the recommended action Safety Recommendation A-97-91 is classified "Closed--Unacceptable Action."

From: FAA
To: NTSB
Date: 6/4/2002
Response: Letter Mail Controlled 06/17/2002 4:01:12 PM MC# 2020602 The Federal Aviation Administration (FAA) stated in its letter dated September 21, 1999, that it does not believe a retrofit rule change is feasible. The FAA had determined that pilot training on the characteristics and capabilities of noninstantaneous versus instantaneous vertical speed instruments would be a more viable and much less costly option than retrofitting aircraft with instantaneous vertical speed instruments. On April 23, 1998, the FAA issued Flight Standards Information Bulletin for Air Transportation (FSAT) 98-10, Vertical Speed Indicator Knowledge Needed by Pilots. The bulletin includes the general circumstances of the accident and specific information regarding the characteristic lag time when using a noninstantaneous vertical speed instrument. The bulletin includes the following language: "Operators may provide this information in a manner (via training, placards, or other means) that will ensure that pilots are aware of the impact that VSI information can have on their perceptions of vertical speed." Although the bulletin does not explicitly mention use of a noninstantaneous vertical speed instrument at night or in instrument meteorological conditions, it clearly meets the intent of this safety recommendation by pointing to the " . . . impact that VSI information can have on [pilots'] perceptions of vertical speed...." The bulletin directed FAA inspectors to ensure that the air carriers for which they have oversight responsibility inform their pilots of the contents of the bulletin. The bulletin remains in effect as outlined in appendices to FAA Order 8400.10. It is also posted on the FAA's web site for easy access by inspectors and operators. Subsequently, the FAA reviewed data recorded by inspectors in response to FSAT 98-10 and found the data to be inconclusive as to the scope of the response by operators. Consequently, the FAA will revise FSAT 98-10 by August 31, 2002, to emphasize the importance of the training message regarding characteristics and capabilities of noninstantaneous vertical speed instruments. Principal operations inspectors will be directed to convey the background surrounding the pertinent accident and the Board's safety recommendation to the director of safety at each 14 CFR Part 121 operator and the director of operations at each 14 CFR Part 135 operator. Inspectors will be required to log in Program Tracking and Reporting Subsystem database or in the Air Transport Oversight System database, as applicable, the actions prescribed in the revised FSAT. I will provide the Board with a copy of revised FSAT 98-10 as soon as it is issued.

From: NTSB
To: FAA
Date: 1/19/2000
Response: The FAA reports that it agrees with the intent of this safety recommendation but has determined that a retrofit rule change is not feasible. The FAA has determined that pilot training on the characteristics and capabilities of noninstantaneous versus instantaneous vertical speed instruments (VSI) is a more viable and much less costly option than retrofitting aircraft with instantaneous VSIs. Consequently, the FAA states that it will issue a flight standards handbook bulletin for air transportation that will direct principal operations inspectors to ensure that their 14 CFR Parts 121 and 135 operators who operate airplanes equipped with noninstantaneous VSIs revise their training programs to include training on the characteristics and capabilities of those instruments for operations at night and in instrument meteorological conditions. The FAA anticipates that the bulletin will be issued by February 2000. The Safety Board is disappointed in the FAA’s response to this safety recommendation. We believe that the recommended change is feasible and do not agree that pilot training is a more viable option than retrofitting aircraft. The Safety Board believes that pilots of modern airliners need to have instantaneous vertical speed indication instrumentation available. Pending the development and issuance of a requirement for all 14 CFR Parts 121 and 135 operators to convert, where practical, the noninstantaneous vertical speed instrumentation on airplanes that have inertial reference units installed to systems that provide flight crews with instantaneous vertical speed information, Safety Recommendation A-97-91 is classified "Open--Unacceptable Response."

From: FAA
To: NTSB
Date: 9/21/1999
Response: Letter Mail Controlled 9/24/99 3:03:29 PM MC# 991071: The Federal Aviation Administration (FAA) agrees with the intent of this safety recommendation but has determined that a retrofit rule change is not feasible. The FAA has determined that pilot training on the characteristics and capabilities of noninstantaneous vs. instantaneous vertical speed instruments would be a more viable and much less costly option than retrofitting aircraft with instantaneous vertical speed instruments. Consequently, the FAA will address this safety issue with the issuance of a flight standards handbook bulletin for air transportation. The bulletin will direct principal operations inspectors to ensure that their 14 CFR Parts 121 and 135 operators who operate airplanes equipped with noninstantaneous vertical speed instruments revise their training programs to include training on the characteristics and capabilities of those instruments for operations at night and in instrument meteorological conditions. It is anticipated that the bulletin will be issued by February 2000. I believe that this alternate action addresses the full intent of the safety issue identified by the Board, which is to ensure that flightcrews understand the type of vertical speed information provided by the vertical speed indicators installed in their airplanes and the possible ramifications of that information. I will provide the Board with a copy of the bulletin as soon as it is issued.

From: NTSB
To: FAA
Date: 8/17/1998
Response: The FAA has stated that it is considering issuing a notice of proposed rulemaking to address this issue. The FAA is conducting a review to identify if the rulemaking project is feasible and in the best interest of aviation safety. Pending further information from the FAA, the Safety Board classifies Safety Recommendation A-97-91 "Open--Acceptable Response."

From: FAA
To: NTSB
Date: 11/13/1997
Response: The FAA agrees with the intent of this safety recommendation and is considering the issuance of a notice of proposed rulemaking to address this issue. The FAA is conducting a review to identify if the rulemaking project is feasible and in the best interest of aviation safety. I will keep the Board informed of the FAA's progress on this safety recommendation.