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Safety Recommendation Details

Safety Recommendation A-98-097
Details
Synopsis: On January 9, 1997, an Empresa Brasileira de Aeronautica, S/A (Embraer) EMB-120RT, operated by COMAIR Airlines, Inc., crashed during a rapid descent after an uncommanded roll excursion near Monroe, Michigan. The flight was a scheduled, domestic passenger flight from the Cincinnati/Northern Kentucky International Airport, Covington, Kentucky, to Detroit Metropolitan/Wayne County Airport, Detroit, Michigan. The flight departed Covington with 2 flightcrew, 1 flight attendant, and 26 passengers on board. There were no survivors. The airplane was destroyed by ground impact forces and a postaccident fire. IMC prevailed at the time of the accident, and the flight was operating on an IFR flight plan.The probable cause of this accident was the FAA's failure to establish adequate aircraft certification standardds for flight in icing conditions.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require all operators of turbopropeller-driver air carrier airplanes to require pilots to disengage the autopilot and fly the airplane manually when they activate the anti-ice systems.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: MONROE, MI, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA97MA017
Accident Reports: In-Flight Icing Encounter and Uncontrolled Collision with Terrain, Comair Flight 3272, Embraer EMB-120RT, N265CA
Report #: AAR-98-04
Accident Date: 1/9/1997
Issue Date: 11/30/1998
Date Closed: 1/12/2001
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Icing, Weather

Safety Recommendation History
From: NTSB
To: FAA
Date: 1/12/2001
Response: IN THE SAFETY BOARD'S 3/9/00, RESPONSE TO THE FAA'S 2/26/99, LETTER, THE BOARD INDICATED IT WAS NOT CONVINCED THAT THE USE OF THE AUTOPILOT IN CERTAIN ICING CONDITIONS MAY BE WARRANTED. THE BOARD STATED THAT IT WOULD CAREFULLY REVIEW THE GUIDANCE THE FAA PROVIDES ON THIS SUBJECT. THE BOARD IS DISAPPOINTED BY THE RESULT AND BELIEVES IT WAS INAPPROPRIATE FOR THE FAA TO ADDRESS THIS RECOMMENDATION AS IT RELATES TO DEICING SYSTEMS RATHER THAN ANTI-ICE SYSTEMS. THE RECOMMENDATION WAS ISSUED WITH THE INTENT OF GIVING PILOTS THE EARLIEST WARNING OF DEVELOPING PROBLEMS WHEN THERE IS THE POTENTIAL FOR ICING TO START. THE BOARD BELIEVES THAT THESE ARE THE CONDITIONS IN WHICH THE ANTI-ICE SYSTEMS WILL BE USED, LONG BEFORE THE DEICE SYSTEMS ARE IN USE, AND DISAGREES WITH THE FAA THAT THERE ARE TIMES WHEN THE USE OF THE AUTOPILOT MAY BE NECESSARY OR HIGHLY DESIRABLE, EVEN IN ICING CONDITIONS. THE BOARD BELIEVES IT IS ESSENTIAL THAT WHEN THE ANTI-ICE SYSTEMS ARE IN USE, PILOTS MANUALLY FLY THEIR AIRCRAFT IN ORDER TO RECEIVE THE EARLIEST WARNINGS OF A DEVELOPING ICING PROBLEM. WITH REGARD TO PILOT WORKLOAD ISSUES, THE BOARD NOTES THAT THE AUTOPILOT IS NOT ON THE MINIMUM EQUIPMENT LIST (MEL) AND THAT THERE ARE CURRENTLY MODELS OF TURBOPROPELLER-DRIVEN AIR CARRIER AIRPLANES THAT DO NOT HAVE AUTOPILOTS. THE BOARD BELIEVES THAT IF PILOT WORKLOAD WERE A SUFFICIENTLY SIGNIFICANT ISSUE TO WARRANT USE OF THE AUTOPILOT WHEN THE ANTI-ICE SYSTEM WAS ON, THE AUTOPILOT WOULD BE ON THE MEL AND TURBOPROPELLER-DRIVEN AIR CARRIER AIRPLANES WOULD NOT BE ABLE TO BE CERTIFIED WITHOUT AN AUTOPILOT. THEREFORE, ALTHOUGH THE FAA HAS COMPLETED ITS WORK ON THIS RECOMMENDATION, THE BOARD CONSIDERS THE RESULTING ACTION INSUFFICIENT TO SATISFY THE RECOMMENDATION'S INTENT. ACCORDINGLY, A-98-97 IS CLASSIFIED "CLOSED--UNACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 7/7/2000
Response: Letter Mail Controlled 07/12/2000 9:46:00 AM MC# 2000878 ON 2/26/99, THE FAA INFORMED THE BOARD THAT IT WAS ADDRESSING THIS RECOMMENDATION AS IT RELATES TO DEICING SYSTEMS AS OPPOSED TO THE ANTI-ICE SYSTEMS. THE FAA STATED THAT IT IS WIDELY UNDERSTOOD THAT, IN SOME CONDITIONS, USE OF THE AUTOPILOT MAY MASK THE DEVELOPMENT OF A PROBLEM. HOWEVER, THERE ARE TIMES WHEN THE USE OF THE AUTOPILOT MAY BE NECESSARY OR HIGHLY DESIRABLE, EVEN IN ICING CONDITIONS WITH DEICING SYSTEMS ACTIVATED. THE FAA TOLD THE BOARD THAT IT WOULD WORK WITH INDUSTRY TO INDENTIFY SOME USEFUL PRINCIPLES REGARDING THE USE OF FLIGHTDECK AUTOMATION AND WOULD INCLUDE THESE PRINCIPLES IN GUIDANCE MATERIALS AND POSSIBLE RULE CHANGES. THE FAA HAS COMPLETED ITS ACTION TO ADDRESS THIS RECOMMENDATION. ON 2/17/00, THE FAA ISSUED JOINT FLIGHT STANDARDS INFORMATION BULLETIN FOR AIR TRANSPORTATION 00-02 AND GENERAL AVIATION 00-01, USE OF AUTOPILOT DURING IN-FLIGHT ICING CONDITIONS FOR TURBOPROPELLER-DRIVEN AIRPLANES. I HAVE ENCLOSED A COPY OF THE BULLETIN FOR THE BOARD'S INFORMATION. THE BULLETIN DIRECTS PRINCIPAL OPERATIONS INSPECTORS (POI) TO ENSURE THAT THE INFORMATION AND PROCEDURES IN THE BULLETIN AND ANY OTHER APPROVED PILOT TRAINING FOR OPERATIONS DURING IN-FLIGHT ICING ARE PROVIDED TO EACH AIR CARRIER AND THAT THE MATERIAL BE INCLUDED IN THE CARRIER'S TRAINING PROGRAM. THE MATERIAL SHOULD BE ADDRESSED IN GROUND TRAINING AND FLIGHT TRAINING, INCLUDING SIMULATOR TRAINING. EACH OPERATOR SHOULD INCLUDE, AS PART OF ITS PILOT TRAINING PROGRAM, SPECIFIC GUIDANCE TO PILOTS FOR EACH OF ITS AIRPLANE TYPES REGARDING FLIGHT IN ICING CONDITIONS. THE GUIDANCE SHOULD INCLUDE THE USE OF THE AUTOPILOT AND PROCEDURES TO CHECK FOR UNUSUAL TRIM FORCES AND AIRCRAFT RESPONSE. IF DISCONNECTING THE AUTOPILOT IS AN APPROVED PROCEDURE, THE GUIDANCE TO PILOTS SHOULD ADDRESS WHEN AND HOW OFTEN TO DISCONNECT THE AUTOPILOT AND UNDER WHAT CONDITIONS. THE POI'S ARE TO ENCOURAGE OPERATORS TO ADDRESS THESE ISSUES AS SOON AS PRACTICAL. I BELIEVE THAT THE BULLETIN ADDRESSES THE FULL INTENT OF THIS SAFETY RECOMMENDATION, AND I CONSIDER THE FAA'S ACTION TO BE COMPLETED.

From: NTSB
To: FAA
Date: 3/9/2000
Response: THE SAFETY BOARD IS NOT CONVINCED THAT THE USE OF THE AUTOPILOT IN CERTAIN ICING CONDITIONS MAY BE WARRANTED. HOWEVER, THE BOARD WILL CAREFULLY REVIEW THE GUIDANCE THAT THE FAA PROVIDES ON THIS SUBJECT. THE BOARD URGES THE FAA TO ACT QUICKLY TO ENSURE THAT GUIDANCE IS ESTABLISHED IN TIME FOR THE UPCOMING WINTER SEASON. THEREFORE, A-98-97 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE," PENDING RECEIPT OF THE GUIDANCE MATERIAL THAT THE FAA INTENDS TO PROVIDE TO INDUSTRY AND ANY APPROPRIATE SUPPORTING MATERIAL.

From: FAA
To: NTSB
Date: 2/26/1999
Response: THE FAA IS ADDRESSING THIS SAFETY RECOMMENDATION AS IT RELATES TO DEICING SYSTEMS AS OPPOSED TO THE ANTI-ICE SYSTEMS. IT IS WIDELY UNDERSTOOD THAT IN SOME CONDITIONS, USE OF THE AUTOPILOT MAY MASK THE DEVELOPMENT OF A PROBLEM. HOWEVER, THERE ARE TIMES WHEN THE USE OF THE AUTOPILOT MAY BE NECESSARY OR HIGHLY DESIRABLE, EVEN IN ICING CONDITIONS WITH DEICING SYSTEMS ACTIVATED. TWO EXAMPLES ARE: (1) WHEN EXECUTING A CATEGORY 2 OR CATEGORY 3 APPROACH; OR, (2) WHEN OPERATING IN TURBULENCE, WHEN THE USE OF AN AUTOPILOT TURBULENCE MODE (OR EQUIVALENT) IS THE MANUFACTURER'S RECOMMENDED AUTOMATION STATE FOR AIRCRAFT CONTROL AND PASSENGER COMFORT. FURTHERMORE, JUDICIOUS USE OF THE AUTOPILOT DURING ICING CONDITIONS MIGHT BE DESIRABLE DURING TIMES OF HIGH COCKPIT WORKLOAD, PARTICULARLY IF THE FLIGHT CREWMEMBERS ARE FATIGUED. THE FAA HAS WORKED WITH INDUSTRY TO IDENTIFY SOME USEFUL PRINCIPLES REGARDING THE USE OF FLIGHT DECK AUTOMATION. THE FAA WILL INCLUDE THESE PRINCIPLES IN GUIDANCE MATERIALS AND POSSIBLE RULE CHANGES. THE DISCUSSION WITH INDUSTRY HAS RESULTED IN A PROTOTYPE AUTOMATION PHILOSOPHY, WHICH GIVES SIMPLE, PRACTICAL GUIDELINES FOR PILOTS IN CHOOSING APPROPRIATE LEVELS OF AUTOMATION. THE PROTOTYPE INCLUDES GUIDANCE THAT THE AUTOPILOT SHOULD BE DISCONNECTED ANY TIME THAT THE PILOT'S CONTROL INPUT MUST BE IMMEDIATE, DECISIVE, AND CORRECT. THE PROTOTYPE DOES NOT INCLUDE RECOMMENDING THAT THE AUTOPILOT BE DISENGAGED WHENEVER DEICING SYSTEMS ARE ACTIVATED. THE FAA WILL CONTINUE ITS DISCUSSION WITH INDUSTRY AND FURTHER REFINEMENTS IN FLIGHTDECK AUTOMATION DESIGN, IMPLEMENTATION, AND PILOT TRAINING ARE ANTICIPATED. THE SUBJECT OF AUTOPILOT OPERATION IN ICING CONDITIONS WAS DISCUSSED AT THE IN-FLIGHT ICING CONFERENCE HELD FEBRUARY 2-4, 1999, WITH AIRFRAME MANUFACTURERS, AIRLINE OPERATORS, WORLDWIDE CIVIL AVIATION AUTHORITIES, AND OTHER AVIATION ORGANIZATIONS. IF THE FAA DECIDES TO PROMULGATE RULEMAKING REGARDING THE USE OF THE AUTOPILOT IN ICING CONDITIONS, IT WILL DO SO TAKING FULL ADVANTAGE OF THE CUMULATIVE WISDOM OF THE STAKEHOLDERS. THE GUIDANCE CONTAINED IN FAA AC 120-51C, CREW RESOURCE MANAGEMENT TRAINING, ALREADY CONTAINS A RECOMMENDATION THAT PILOT TRAINING 11..SHOULD IDENTIFY CONDITIONS IN WHICH ADDITIONAL VIGILANCE IS REQUIRED, SUCH AS HOLDING IN ICING..TRAINING SHOULD EMPHASIZE THE NEED FOR MAXIMUM SITUATIONAL AWARENESS. 11 LANGUAGE WILL BE ADDED TO THE RECOMMENDATION TO POINT OUT THAT DISCONNECTING THE AUTOPILOT AT REGULAR INTERVALS IS ONE WAY THAT THE PILOT MAY STAY IN TOUCH WITH THE FEEL OF THE AIRPLANE DURING TIMES OF POSSIBLE IN-FLIGHT ICE ACCRETION. I BELIEVE THE FAA IS ADDRESSING THE INTENT OF THIS RECOMMENDATION. I WILL KEEP THE BOARD INFORMED OF ANY FURTHER POLICY OR REGULATORY CHANGES WITH RESPECT TO USE OF THE AUTOPILOT IN IN-FLIGHT ICING CONDITIONS ONCE THEY ARE IDENTIFIED.