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Safety Recommendation Details

Safety Recommendation A-98-107
Details
Synopsis: Information from the CVR indicates that the flightcrew activated the anti-ice equipment for the windshield, propellers, pitot probes, angle-of attack vanes, sideslip angle vane, and total air temperature probes. There is no evidence from the CVR, FDR, performance of the aircraft, or aircraft wreckage to determine if the flightcrew activated the de-icing boots. These facts and the airplane's degraded aerodynamic performance strongly suggest that ice had accumulated on airframe, but may not have seen or recognized as a hazard by the flight crew of Comair 3272. There were seven accidents involving aircraft Embraer EMB- 120: (1) 1/9/97, Embraer EMB-120, Monroe, Michigan, (2) in April of 1995, Embraer EMB -120, Tallahassee, Florida, (3) 10/16/94, Embraer EMB-120, Elko, Nevada, (4) 4/29/93, Embraer EMB -120, Pine Bluff, Arkansas, (5) 11/22/91, Embraer EMB -120, Clermont-Ferrand, France, (6) in September, 1991, Embraer EMB -120, Fort Smith, Arkansas, and (7) 6/28/89, Embraer EMB- 120, Klamath Falls, Oregon.
Recommendation: TO THE NATIONAL AERONAUTICS AND SPACE ADMINISTRATION: With the FAA and other interested aviation organizations, organize and implement an industry-wide training effort to educate manufacturers, operators, and pilots of air carrier and general aviation turbopropeller-driven airplanes regarding the hazards of thin, possibly imperceptible, rough ice accumulations, the importance of activating the leading edge deicing boots as soon as the airplane enters icing conditions (for those airplanes in which ice bridging is not a concern), and the importance of maintaining minimum airspeeds in icing conditions.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable 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: 8/19/2004
Addressee(s) and Addressee Status: National Aeronautics and Space Administration (Closed - Acceptable Action)
Keyword(s): Icing, Training and Education, Weather

Safety Recommendation History
From: NTSB
To: National Aeronautics and Space Administration
Date: 8/19/2004
Response: NASA reported that it has completed a computer-based training module for general aviation pilots, titled A Pilot's Guide to In-Flight Icing, and three training videos for pilots, titled Icing for General Aviation Pilots, Icing for Regional and Corporate Pilots, and Tailplane Icing. The training module and videos, developed in cooperation with the FAA, educate pilots on how to operate in and avoid icing conditions. Copies of the materials were provided to Safety Board staff. The Safety Board appreciates NASA's work on this issue. The training materials are informative and meet the intent of the recommendation to provide training about the hazards associated with flight in icing conditions. Accordingly, Safety Recommendation A-98-107 is classified "Closed--Acceptable Action."

From: National Aeronautics and Space Administration
To: NTSB
Date: 3/3/2004
Response: Letter Mail Controlled 3/15/2004 9:38:45 AM MC# 2040117 NASA completed a computer-based training module for general aviation pilots entitled A Pilots Guide to In-Flight Icing and three training videos for pilots entitled Icing for General Aviation Pilots, Icing for Regional and Corporate Pilots, and Tailplane Icing. The training module and videos, developed in cooperation with the Federal Aviation Administration, educate pilots on how to operate in and avoid icing conditions.

From: NTSB
To: National Aeronautics and Space Administration
Date: 12/10/2003
Response: The Safety Board's records indicate that the most recent correspondence from NASA concerning these recommendations was dated October 19, 2000. In this correspondence, NASA indicated that, regarding Safety Recommendation A-98-107, it had produced two training videos on icing and was planning to produce another, as well as a computer-based training module, for general aviation pilots. Regarding Safety Recommendation A-98-108, NASA indicated that it intended to conduct additional testing in a dry-air tunnel in fiscal year 2001. NASA stated that this testing was in support of the FAA and would eventually provide a better understanding of residual ice and small ice accumulations for incorporation in training materials. Based on NASA's plans, Safety Recommendations A-98-107 and -108 were classified "Open--Acceptable Response," pending NASA's development of the additional training materials and completion and analysis of the additional testing. The Safety Board would appreciate receiving an update from NASA regarding actions taken to address Safety Recommendations A-96-14, A-98-107, and A-98-108.

From: NTSB
To: National Aeronautics and Space Administration
Date: 3/12/2001
Response: The actions being taken by NASA are responsive to the recommendation. The Safety Board has received copies of the two videos that have been released and would appreciate receiving a copy of the computer-based training aid for airline operators and any future training aids or videos produced. Pending receipt of a copy of the computer-based training aid for airline operators and the development and release of additional training aids for in-flight icing, Safety Recommendation A-98-107 remains classified "Open--Acceptable Response."

From: National Aeronautics and Space Administration
To: NTSB
Date: 10/19/2000
Response: Letter Mail Controlled 11/01/2000 8:13:05 AM MC# 2001575 NASA is working as a technical advisor to the FAA, the principal investigator for this recommendation, on a Residual Ice/Intercycle Ice project that was initiated in FY1999. · The work is a collaborative effort between both agencies, with representation from an ice protection manufacturer and two airframe manufacturers. At NASA, the work is conducted by the Icing Research group at our Glenn Research Center and is supported by their subject matter experts and facilities that incorporate results from the Icing Research Tunnel and the Icing Research Aircraft. · In FY2000, two tests have been conducted in an icing wind tunnel to examine the residual ice characteristics, and a follow-on test will be conducted in FY2001 in a NASA dry-air tunnel test will catalogue the aerodynamic effects. · This work will eventually provide the basis for a better understanding of residual ice and small ice accumulations and be included in training materials.

From: NTSB
To: National Aeronautics and Space Administration
Date: 7/26/2000
Response: THE BOARD'S RECORDS INDICATE THAT THE MOST RECENT CORRESPONDENCE FROM NASA CONCERNING THESE RECOMMENDATIONS WAS DATED 1/13/99. THE SAFETY BOARD WOULD APPRECIATE LEARNING OF ANY FURTHER ACTIONS NASA HAS TAKEN OR INTENDS TO TAKE TO ADDRESS A-88-19, A-96-14, A-98-107 AND A-98-108.

From: NTSB
To: National Aeronautics and Space Administration
Date: 3/12/1999
Response: A-98-107 ASKED NASA, ALONG WITH THE FAA AND OTHER INTERESTED AVIATION ORGANIZATIONS, TO ORGANIZE AND IMPLEMENT AN INDUSTRYWIDE TRAINING EFFORT TO EDUCATE MANUFACTURERS, OPERATORS, AND PILOTS OF AIR CARRIER AND GENERAL AVIATION TURBOPROPELLER-DRIVEN AIRPLANES REGARDING THE HAZARDS OF THIN, POSSIBLY IMPERCEPTIBLE, ROUGH ICE ACCUMULATIONS; THE IMPORTANCE OF ACTIVATING THE LEADING EDGE DEICING BOOTS AS SOON AS THE AIRPLANE ENTERS ICING CONDITIONS (FOR THOSE AIRPLANES IN WHICH ICE BRIDGING IS NOT A CONCERN); AND THE IMPORTANCE OF MAINTAINING MINIMUM AIRSPEEDS IN ICING CONDITIONS. PENDING MORE DETAILED INFORMATION ON NASA'S EDUCATION MATERIALS AND RESEARCH REGARDING ICING CONDITIONS, A-98-107 AND -108 ARE CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: National Aeronautics and Space Administration
To: NTSB
Date: 1/13/1999
Response: Letter Mail Controlled 02/19/1999 10:02:22 AM MC# 990021 NASA IS WELL POSITIONED TO FULFILL A-98-107 AND -108. NASA, THE FAA, AND OTHER AVIATION ORGANIZATIONS WILL WORK TOGETHER TO DEVELOP AND IMPLEMENT A PLAN TO AGGRESSIVELY PURSUE AN INDUSTRY-WIDE TRAINING PROGRAM ON THE HAZARDS OF ICING. ADDITIONALLY, NASA WILL WORK WITH THESE SAME ORGANIZATIONS TO INCREASE UNDERSTANDING OF THE ADVERSE EFFECTS OF ICE ACCUMULATIONS ON AIRCRAFT. NASA AND THE FAA ARE PARTNERS IN THE JOINT SAFETY WORKING GROUP (SWG) SPECIFICALLY TO ADDRESS ISSUES IN RESEARCH AND DEVELOPMENT IN AVIATION SAFETY. THE SWG COORDINATES EFFORTS FOR BOTH AGENCIES IN THIS FIELD, AND THAT COORDINATION, ESSENTIAL TO THE FUNCTIONING OF NASA'S AVIATION SAFETY PROGRAM OFFICE, WIN PROVIDE THE FOCUS FOR RESPONDING TO THE RECOMMENDATIONS. THE FAA'S FLIGHT STANDARDS AND AIRCRAFT CERTIFICATION SERVICES HAVE TAKEN THE LEAD IN A WEATHER-ACCIDENT PREVENTION TRAINING EFFORT BY SETTING UP A WORKSHOP ON IN-FLIGHT OPERATIONS AND ICING CONDITIONS. NASA'S AVIATION SAFETY PROGRAM OFFICE WILL PARTICIPATE IN THAT WORKSHOP. NASA WILL WORK WITH THE FAA AND OTHER INTERESTED AVIATION ORGANIZATIONS TO DEVELOP EDUCATIONAL MATERIALS THAT WILL FOCUS ON THE HAZARDS, TECHNOLOGY, AND OPERATIONAL PROCEDURES ASSOCIATED WITH CONDUCTING FLIGHT OPERATIONS DURING ICING CONDITIONS. AN IMPORTANT PART OF NASA'S INVESTMENT IN AVIATION SAFETY RESEARCH IS WEATHER-RELATED. NASA WILL EXAMINE ITS RESEARCH PLANS TO ENSURE THAT AN UNDERSTANDING OF THE EFFECTS AND CRITICALITY OF ICE ACCUMULATIONS IS AGGRESSIVELY PURSUED. KNOWLEDGE GAINED FROM THIS RESEARCH WILL BE PROVIDED TO THE FAA FOR INCORPORATING IN AIRCRAFT CERTIFICATION REQUIREMENTS AND PILOT TRAINING PROGRAMS. NASA WILL WORK CLOSELY WITH THE FAA ACROSS MANY DIFFERENT ORGANIZATIONAL LEVELS TO ADDRESS THE PROBLEMS OF AIRCRAFT SAFETY, SUCH AS ICING. AFTER COLLABORATION WITH THE FAA, WE WILL PROVIDE YOUR STAFF WITH A MORE DETAILED APPROACH TO SATISFY A-98-107 AND -108.