Aviation Safety
Icing and Winter Weather-Related Recommendations That NTSB Has Issued Since 1996 (GAO-10-679SP), an E-supplement to (GAO-10-678) Gao ID: GAO-10-679SP July 29, 2010This document is an E-supplement to GAO-10-678. Ice formation on aircraft can disrupt the smooth flow of air over the wings and prevent the aircraft from taking off or decrease the pilot's ability to maintain control of the aircraft. Taxi and landing operations can also be risky in winter weather. Despite a variety of technologies designed to prevent ice from forming on planes and to remove ice that has formed, as well as persistent efforts by the Federal Aviation Administration (FAA) and other stakeholders to mitigate icing risks, icing remains a serious concern. Since 1996, the National Transportation Safety Board (NTSB) has issued 89 recommendations aimed at reducing risks from in-flight structural icing, engine and aircraft component icing, runway condition and contamination, ground icing, and winter weather operations. Eighty-two of the recommendations were addressed to FAA, four were addressed to air carriers, one was addressed to the National Oceanic and Atmospheric Administration (NOAA), and one was addressed to the National Atmospheric and Space Administration (NASA). This e-supplement lists icing and winter weather-related recommendations that NTSB has issued since 1996, including the number, issue date, close data, most-wanted status, and description of each recommendation.
GAO-10-679SP, Aviation Safety: Icing and Winter Weather-Related Recommendations That NTSB Has Issued Since 1996 (GAO-10-679SP), an E-supplement to (GAO-10-678)
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Supplement to GAO-10-678)' which was released on July 29, 2010.
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GAO-10-679SP:
Aviation Safety during Winter: Icing and Winter Weather-Related
Recommendations That NTSB Has Issued Since 1996 (an E-Supplement to
GAO-10-678):
Introduction:
Ice formation on aircraft can disrupt the smooth flow of air over the
wings and prevent the aircraft from taking off or decrease the pilot's
ability to maintain control of the aircraft. Taxi and landing
operations can also be risky in winter weather. Despite a variety of
technologies designed to prevent ice from forming on planes and to
remove ice that has formed, as well as persistent efforts by the
Federal Aviation Administration (FAA) and other stakeholders to
mitigate icing risks, icing remains a serious concern.
Since 1996, the National Transportation Safety Board (NTSB) has issued
89 recommendations aimed at reducing risks from in-flight structural
icing, engine and aircraft component icing, runway condition and
contamination, ground icing, and winter weather operations. Eighty-two
of the recommendations were addressed to FAA, four were addressed to
air carriers, one was addressed to the National Oceanic and
Atmospheric Administration (NOAA), and one was addressed to the
National Atmospheric and Space Administration (NASA). This e-
supplement lists icing and winter weather-related recommendations that
NTSB has issued since 1996, including the number, issue date, close
data, most-wanted status, and description of each recommendation.
[End of section]
Table of Contents:
Background:
Table 1: Definitions of NTSB's Recommendation Status Categories:
Aircraft Icing and Winter Weather-Related NTSB Recommendations Issued
Since 1996:
American Eagle Flight #4184:
Table 2: NTSB recommendations resulting from the crash of American
Eagle Flight #4184:
Tower Air Inc. Flight #41:
Table 3: Recommendations Resulting from the Accident Involving Tower
Air Inc. Flight #41:
ValuJet Airlines Flight #558:
Table 4: Recommendations Resulting from the Accident Involving ValuJet
Flight #558:
Comair Airlines Flight #3272:
Table 5: Recommendations Resulting from the Crash of Comair Airlines
Flight #3272:
Reno Air Flight #153:
Table 6: Recommendations Resulting from the Incident Involving Reno
Air Flight #153:
Garuda Indonesia Airlines Flight #421:
Table 7: Recommendations Resulting from the Accident Involving Garuda
Indonesia Airlines Flight #4184:
Spirit Airlines Flight #970:
Table 8: Recommendations Resulting from the Incident Involving Spirit
Airlines Flight #970:
Accidents and Incidents Involving Cessna 208 Series Airplanes:
Table 9: Recommendations Made to Address Accidents and Incidents
Involving Cessna 208 Series Airplanes:
Engine Power Loss in Raytheon Beechjet 400 Series Airplanes:
Table 10: Recommendations Resulting from Power Loss in Raytheon
Beechjet 400 Series Airplanes:
Glo-Air Flight #73:
Table 11: Recommendations Resulting from the Crash of Glo-Air Flight
#73:
Martinair Circuit City Accident in Pueblo, Colorado:
Table 12: Recommendations Resulting from the Martinair Circuit City
Crash:
Midwest Airlines Flight #490:
Table 13: Recommendations Resulting from the Crash of Midwest Airlines
Flight #490:
Southwest Airlines Flight #1248:
Table 14: Recommendations Resulting from the Southwest Airlines Flight
#1248 Accident:
International Cessna 208 Series Aircraft Accidents:
Table 15: Recommendations Resulting from Two International General
Aviation Accidents:
American Eagle Flight #3008:
Table 16: Recommendations Resulting from the Incident Involving
American Eagle Flight #3008:
Delta Connection Flight #6448:
Table 17: Recommendations Resulting from the Crash of Delta Connection
Flight #6448:
Pinnacle Airlines Flight #4712:
Table 18: Recommendations Resulting from the Accident Involving
Pinnacle Airlines Flight #4712:
[End of section]
Background:
A safety recommendation originates from NTSB's accident investigation
reports, safety studies, or special investigations. NTSB tracks a
safety recommendation from the date of issue until it is closed;
safety recommendations are closed only by vote of the Safety Board.
NTSB assigns a status to each recommendation, descriptions of which
are listed below in table 1.
Table 1: Definitions of NTSB's Recommendation Status Categories:
Status category; Closed--exceeds recommended action;
Definition of status category: Response by recipient indicates action
on the safety recommendation has been completed. The action taken
surpasses what the Safety Board envisioned.
Status category; Closed--acceptable action;
Definition of status category: Response by the recipient indicates
action on the safety recommendation has been completed. The action
complies with the safety recommendation.
Status category; Closed--acceptable alternate action;
Definition of status category: Response by the recipient indicates an
alternate course of action has been completed that meets the objective
of the safety recommendation.
Status category; Closed--unacceptable action;
Definition of status category: Response by recipient expresses
disagreement with the need outlined in the recommendation. There is no
further evidence to offer, and the Safety Board concludes that further
correspondence on, or discussion of, the matter would not change the
recipient's position. This status can also be used when the time frame
goals outlined in this order have not been met.
Status category; Closed--unacceptable action/no response received;
Definition of status category: No response to the recommendation was
ever received.
Status category; Closed--reconsidered;
Definition of status category: Recipient rejects the safety
recommendation and supports this rejection with a rationale with which
the board concurs. Reasons for the "reconsidered" status would include
situations where the recipient is able to convince the board that the
proposed action would not be effective or that it might create other
problems. This status is also assigned when the recipient of a
recommendation was in compliance before the recommendation was issued
or when the recipient was incorrectly chosen and cannot perform the
recommended action.
Status category; Closed--no longer applicable;
Definition of status category: The recommended action has been
overtaken by events. For example, if technology and/or regulatory
action have eliminated the reason for the recommendation or if a
company has gone out of business.
Status category; Closed--superseded;
Definition of status category: Applied to recommendations held in an
open status when a new, more appropriate safety recommendation is
issued that includes the necessary elements of the recommendation to
be closed.
Status category; Closed--acceptable/acceptable alternate/unacceptable
action superseded;
Definition of status category: Applied to recommendations held in an
open status when a new, more appropriate safety recommendation is
issued that includes the necessary elements of the recommendation to
be closed. The board determines the acceptable/acceptable
alternate/unacceptable status based on the criteria defined above
prior to superseding the recommendation.
Status category; Open--acceptable response;
Definition of status category: Response by recipient indicates a
planned action that would comply with the safety recommendation when
completed.
Status category; Open--acceptable alternate response;
Definition of status category: Response by recipient indicates an
alternate plan or implementation program that would satisfy the
objective of the safety recommendation when implemented.
Status category; Open--unacceptable response;
Definition of status category: Response by recipient expresses
disagreement with the need outlined in the recommendation or attempts
to convince the board (unsuccessfully) that an alternative course of
action is acceptable. The board believes, however, that there is
enough supporting evidence to ask the recipient to reconsider its
position. This status can also be used when the board believes that
action is not being taken in a timely manner.
Status category; Open--response received;
Definition of status category: Response has been received from
recipient, but staff evaluation of the response has not been approved
by the board members.
Status category; Open--await response;
Definition of status category: When a safety recommendation is issued,
the status "open-await response" is automatically assigned.
Source: NTSB.
[End of table]
Of the 82 recommendations addressed to FAA, NTSB has closed 41 (50
percent) as implemented, and has classified another 22 (27 percent) as
FAA having made acceptable progress.[Footnote 1] This combined 77
percent acceptance rate is similar to the rate for all of NTSB's
aviation recommendations. Of the 7 recommendations addressed to other
stakeholders, NTSB closed 6 as implemented and the remaining
recommendation remains open, with an acceptable response provided by
the recipient.
To develop this complete listing of and information on NTSB's icing-
related recommendations made since 1996, we obtained data from NTSB
and summarized it in the tables below. A more detailed discussion of
aviation safety in icing and winter weather operating conditions is
contained in our report (GAO-10-678). We conducted our review from
August 2009 to July 2010 in accordance with generally accepted
government auditing standards. We provided a draft of this e-
supplement to NTSB officials to obtain their comments and incorporated
their comments where appropriate.
Aircraft Icing and Winter Weather-Related NTSB Recommendations Issued
Since 1996:
American Eagle Flight #4184:
On October 31, 1994, American Eagle Flight #4184, an Avions de
Transport Regional model 72-212 (ATR 72), crashed in Roselawn, Ind.
All 68 passengers and crewmembers were killed. NTSB determined that
accident was caused by loss of control, which occurred after a ridge
of ice built up beyond deicing equipment. The aircraft was flying in
icing conditions beyond its certification criteria. Additionally, NTSB
found that FAA's requirements did not adequately account for the
hazards of flight in freezing rain.
Table 2: Recommendations Resulting from the Crash of American Eagle
Flight #4184:
Recommendation number, date issued, and date closed (where
applicable): A-96-51; Issued 8/15/1996; Closed 4/28/2010;
Recipient: FAA;
Summary of recommendation: Revise the criteria used to report icing
conditions so that it relates to specific types of aircraft and is
consistent with existing regulations;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-96-52; Issued 8/15/1996; Closed 5/31/2005;
Recipient: FAA;
Summary of recommendation: Publish the definition of the phrase "icing
in precipitation" in the appropriate aeronautical publications,
emphasizing that the condition may exist both near the ground and at
altitude;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-96-53; Issued 8/15/1996; Closed 8/20/1997;
Recipient: FAA;
Summary of recommendation: Continue to sponsor the development of
weather forecast production methods that both define specific
locations of icing conditions and identify icing conditions for a
specific time frame within a specific area;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-96-54 (Most Wanted recommendation)[A]; Issued 8/15/1996;
Recipient: FAA;
Summary of recommendation: Revise aircraft certification criteria to
reflect research on aircraft ice buildup under various atmospheric
conditions and changes in aircraft design and use. Also, expand
aircraft certification criteria to include a wider range of
atmospheric conditions;
Status: Open--unacceptable response; Supersedes A-81-116 and A-81-118.
Recommendation number, date issued, and date closed (where
applicable): A-96-55; Issued 8/15/1996; Closed 2/16/2000;
Recipient: FAA;
Summary of recommendation: Revise icing certification requirements and
advisory material to specify methods for icing certification testing;
Status: Closed--acceptable alternate action.
Recommendation number, date issued, and date closed (where
applicable): A-96-56; Most Wanted; Issued 8/15/1996;
Recipient: FAA;
Summary of recommendation: Revise certification criteria to ensure
that aircraft are tested for all conditions in which they are
authorized to operate, or are otherwise shown to be capable of safe
flight into such conditions. FAA should prohibit operation in
conditions beyond the capability of an aircraft and flight crews
should be given the means to determine when they are in such
conditions;
Status: Open--unacceptable response.
Recommendation number, date issued, and date closed (where
applicable): A-96-57; Issued 8/15/1996; Closed 2/5/2003;
Recipient: FAA;
Summary of recommendation: Require aircraft manufacturers to provide
information to FAA and operators about any known undesirable
characteristics of flight beyond the protected flight regime;
Status: Closed--unacceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-96-58; Issued 8/15/1996;
Recipient: FAA;
Summary of recommendation: Develop an icing certification test
procedure to determine the susceptibility of airplanes to control
anomalies with and without ice on the wing. Revise icing certification
requirements to include such a test;
Status: Open--acceptable response.
Recommendation number, date issued, and date closed (where
applicable): A-96-59; Issued 8/15/1996; Closed 2/5/2003;
Recipient: FAA;
Summary of recommendation: Encourage ATR (a manufacturer of airplanes)
to test the newly developed stabilization system design changes. When
design changes show that the stabilization problem has been corrected,
require these changes on all new and existing ATR airplanes;
Status: Closed--unacceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-96-60; Issued 8/15/1996; Closed 11/20/2009;
Recipient: FAA;
Summary of recommendation: Ensure that regulations governing small
commercial and noncommercial airplanes are compatible with the
published definition of severe icing and eliminate the implied
authorization of flight into severe icing conditions[B];
Status: Closed--acceptable alternate action.
Recommendation number, date issued, and date closed (where
applicable): A-96-61; Issued 8/15/1996; Closed 8/20/1997;
Recipient: FAA;
Summary of recommendation: Require FAA inspectors to ensure that
training programs for large commercial and small commercial airplane
operators include information about all icing conditions, including
freezing rain and freezing drizzle[C];
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-96-65; Issued 8/15/1996; Closed 8/20/1997;
Recipient: FAA;
Summary of recommendation: Evaluate the need to prohibit nonessential
activities in the cockpit for airplanes holding in weather conditions
such as icing, hail, and thunderstorms;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-96-68; Issued 8/15/1996; Closed 8/20/1997;
Recipient: FAA;
Summary of recommendation: Revise an FAA order governing pilot
reporting of weather information to include freezing drizzle and
freezing rain and clearly define these conditions in the
pilot/controller glossary;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-96-69; Issued 8/15/1996; Closed 1/27/2003;
Recipient: FAA;
Summary of recommendation: Conduct or sponsor research and development
of systems which would alert flight crews when the airplane is
encountering freezing drizzle and freezing rain and accumulating
resultant ice;
Status: Closed--acceptable alternate action.
Recommendation number, date issued, and date closed (where
applicable): A-96-70; Issued 8/15/1996; Closed 3/20/1997;
Recipient: NOAA;
Summary of recommendation: Develop methods to produce weather
forecasts that define specific locations of atmospheric icing
conditions and produce forecasts for a specific time frame and
location;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-96-71; Issued 8/15/1996; Closed 1/30/2001;
Recipient: American Eagle;
Summary of recommendation: Require dispatchers to provide flight crews
with weather information pertinent to the route of flight to aid in
preflight and in-flight decisions;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-96-72; Issued 8/15/1996; Closed 1/30/2001;
Recipient: American Eagle;
Summary of recommendation: Encourage captains to forgo unnecessary
activity and conversation in the cockpit when an airplane is holding
in weather conditions such as icing, hail, or thunderstorms;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-96-73; Issued 8/15/1996; Closed 1/30/2001;
Recipient: American Eagle;
Summary of recommendation: Audit aircraft flight manuals, flight
operations manuals, and other published material to eliminate
conflicts in guidance and procedures;
Status: Closed--acceptable action.
Source: NTSB.
[A] NTSB's Most Wanted list includes important safety recommendations
identified for special attention and intensive follow-up. NTSB
established the list in 1990 and annually updates it.
[B] By small commercial airplanes, we mean those airplanes operating
under part 135 of title 14 C.F.R. Among other things, part 135 covers
commuter operations on airplanes, other than turbojet powered
airplanes, with nine passenger seats or less, and a payload capacity
of 7,500 pounds or less. Most commuter, air tour, and air taxi
operators and medical services (when a patient is on board) fall under
the purview of part 135. By noncommercial airplanes, we mean airplanes
that are privately operated under 14 C.F.R. part 91. These types of
operations are often referred to as "general aviation" and include
flights for recreation and training. Although noncommercial flights
usually involve small aircraft, the definition depends on the nature
of the operation not the size of the aircraft.
[C] By large commercial airplanes, we mean those airplanes operating
under part 121 of title 14 C.F.R. part 121. Among other things, part
121 applies to air carrier operations involving turbojet airplanes or
any airplane with a seating capacity of more than nine passenger seats
or a maximum payload capacity of more than 7,500 pounds, as defined
under 14 C.F.R. § 119.3. See 14 C.F.R. section § 121.1.
[End of table]
Tower Air Inc. Flight #41:
On December 20, 1995, Tower Air Flight #41, a Boeing B-747, veered off
the side of the runway during an attempted takeoff at John F. Kennedy
International Airport. Twenty-four of the 468 people on board
sustained minor injuries, one person received serious injuries, and
the airplane sustained substantial damage. NTSB found that the
probable cause of the accident was the captain's failure to reject
takeoff in a timely manner when the airplane lost control on a
slippery runway. Inadequate operating procedures by Boeing and Tower
Air also contributed to the accident.
Table 3: Recommendations Resulting from the Accident Involving Tower
Air Inc. Flight #41:
Recommendation number, date issued, and date closed (where
applicable): A-96-150; Issued 12/20/1996; Closed 5/13/1998;
Recipient: FAA;
Summary of recommendation: Require Boeing to revise its operating
procedures to warn flight crews against using the tiller during
slippery runway operations and to provide appropriate limitations on
tiller use during these operations;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-96-151; Issued 12/20/1996; Closed 10/6/1998;
Recipient: FAA;
Summary of recommendation: Inform FAA inspectors of the circumstances
of this accident. Require the review, and modification as required, of
each air carrier's takeoff procedure regarding pilot hand position
with respect to the tiller;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-96-152; Issued 12/20/1996; Closed 10/6/1998;
Recipient: FAA;
Summary of recommendation: Require Boeing to develop criteria for
making a rapid and accurate decision to reject a takeoff under
slippery runway conditions;
then require that B-747 flight, operating, and training manuals be
revised accordingly;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-96-153; Issued 12/20/1996; Closed 12/26/2001;
Recipient: FAA;
Summary of recommendation: Ensure that Boeing 747 air carrier flight
crew training simulators accurately simulate the aircraft's slippery
runway handling characteristics;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-96-154; Issued 12/20/1996; Closed 12/26/2001;
Recipient: FAA;
Summary of recommendation: Direct FAA inspectors assigned to Boeing
747 operators to enhance simulator training for slippery runway
operations;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-96-164; Issued 12/20/1996; Closed 6/14/2002;
Recipient: FAA;
Summary of recommendation: Require a rulemaking advisory group to
establish runway friction measurements that are useful to pilots and
air carriers during slippery runway operations;
Status: Closed--reconsidered.
Source: NTSB.
[End of table]
ValuJet Airlines Flight #558:
On January 7, 1996, ValuJet Airlines Flight #558 touched down short of
the runway at the Nashville International Airport. Of the 93 people on
board, 5 received minor injuries. The airplane sustained substantial
damage. NTSB found that this accident was caused by flight crew error
and that ValuJet's incomplete manuals and guidance contributed to the
accident.
Table 4: Recommendations Resulting from the Accident Involving ValuJet
Flight #558:
Recommendation number, date issued, and date closed (where
applicable): A-96-166; Issued 12/20/1996; Closed 12/19/1997;
Recipient: FAA;
Summary of recommendation: Require all airlines to review their
operations and maintenance manuals and, if necessary, adjust or expand
these manuals to reflect the manufacturer's recommended cold weather
nosegear servicing procedures;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-96-172; Issued 12/20/1996; Closed 7/25/2001;
Recipient: ValuJet;
Summary of recommendation: Develop, immediately, a more extensive and
accurate winter operations manual, with corresponding adjustments to
maintenance procedures, to reflect the manufacturer's cold weather
nosegear servicing procedures;
Status: Closed--acceptable action.
Source: NTSB.
[End of table]
Comair Airlines Flight #3272:
On January 9, 1997, Comair Flight #3272 (an Embraer EMB-120 aircraft)
crashed near Monroe, Michigan. All 29 people on board were killed. The
airplane was destroyed by impact forces and postcrash fire. NTSB found
that the airplane lost control when it accumulated a layer of ice on
its lifting surfaces and failed to maintain sufficient airspeed.
Table 5: Recommendations Resulting from the Crash of Comair Airlines
Flight #3272:
Recommendation number, date issued, and date closed (where
applicable): A-97-31; Issued 5/21/1997; Closed 8/20/1999;
Recipient: FAA;
Summary of recommendation: Require air carriers to reflect FAA-
approved minimum airspeeds, including those for flight in icing
conditions, in their EMB-120 operating manuals;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-97-32; Issued 5/21/1997; Closed 8/20/1999;
Recipient: FAA;
Summary of recommendation: Ensure that the deicing information and
procedures in air carrier's EMB-120 operating manuals and training
programs are consistent with the revised Embraer EMB-120 airplane
flight manual;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-97-33; Issued 5/21/1997; Closed 8/20/1999;
Recipient: FAA;
Summary of recommendation: Direct FAA inspectors to ensure that EMB-
120 operators train flight crews to recognize icing conditions and
emphasize the need to adhere to the flight manual's procedure for
using deicing equipment;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-97-34; Issued 5/21/1997; Closed 7/8/1998;
Recipient: FAA;
Summary of recommendation: Require that all EMB-120 aircraft be
equipped with automated ice detection and crew alerting systems for
structural ice buildup;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-98-88; Issued 11/30/1998; Closed 3/9/2000;
Recipient: FAA;
Summary of recommendation: Amend the definition of trace ice in FAA
documents so that they do not indicate that trace icing is not
hazardous;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-98-89; Issued 11/30/1998;
Recipient: FAA;
Summary of recommendation: Require FAA inspectors to discuss airplane
flight manual revisions or manufacturers' operational bulletins with
affected air carrier operators. Encourage air carriers to share the
information with pilots;
Status: Open--acceptable response.
Recommendation number, date issued, and date closed (where
applicable): A-98-90; Issued 11/30/1998; Closed 1/3/2002;
Recipient: FAA;
Summary of recommendation: Educate manufacturers, operators, and
pilots of turboprop airplanes in which ice bridging is not a concern
on the dangers of accumulating thin, rough ice; the importance of
activating deice boots as soon as the airplane enters icing conditions;
and the importance of maintaining minimum airspeeds in icing
conditions[A];
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-98-91; Issued 11/30/1998; Closed 2/27/2007;
Recipient: FAA;
Summary of recommendation: Require manufacturers and operators of
turboprop airplanes in which ice bridging is not a concern to review
and revise their manuals and training programs to emphasize that
deicing equipment as soon as the airplane enters icing conditions;
Status: Closed--unacceptable action/superseded; Superseded by A-07-14.
Recommendation number, date issued, and date closed (where
applicable): A-98-92; Issued 11/30/1998; Closed 10/16/2008;
Recipient: FAA;
Summary of recommendation: Conduct research to identify realistic ice
accumulations and determine the effects and dangers of such ice
accumulations. The information developed through such research should
be incorporated into aircraft certification requirements and pilot
training programs;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-98-93; Issued 11/30/1998; Closed 3/12/2001;
Recipient: FAA;
Summary of recommendation: Work with industry to develop effective ice
detection and protection systems that will keep aircraft surfaces free
of ice. Then, require installation of such systems on aircraft
certified for flight in icing conditions;
Status: Closed--unacceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-98-94; Issued 11/30/1998; Closed 1/19/2006;
Recipient: FAA;
Summary of recommendation: Require jet engine aircraft manufacturers
to provide minimum airspeed information, with consideration of various
types, amounts, and locations of ice accumulation;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-98-95; Issued 11/30/1998; Closed 9/15/2003;
Recipient: FAA;
Summary of recommendation: Require jet engine aircraft operators to
incorporate the manufacturer's minimum airspeeds in their operating
manuals and pilot training programs, with emphasis on maintaining
minimum safe airspeeds while operating in icing conditions;
Status: Closed--acceptable alternate action.
Recommendation number, date issued, and date closed (where
applicable): A-98-96; Issued 11/30/1998;
Recipient: FAA;
Summary of recommendation: Require the manufacturers and operators of
aircraft certified to operate in icing conditions to install systems
that provide a cockpit warning before the onset of a stall when the
aircraft is operating in icing conditions;
Status: Open--unacceptable response.
Recommendation number, date issued, and date closed (where
applicable): A-98-97; Issued 11/30/1998; Closed 1/12/2001;
Recipient: FAA;
Summary of recommendation: Require operators of turboprop aircraft to
require pilots to disengage the autopilot and fly the aircraft
manually when anti-ice systems are activated;
Status: Closed--unacceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-98-98; Issued 11/30/1998; Closed 7/8/2009;
Recipient: FAA;
Summary of recommendation: Require all manufacturers of transport-
category airplanes with autopilot to provide a cockpit aural warning
to alert pilots when the airplane's pitch or roll angle increases
beyond the autopilot's maximum limits.[B];
Status: Closed--unacceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-98-99; Issued 11/30/1998; Closed 3/9/2000;
Recipient: FAA;
Summary of recommendation: Ensure that airplanes are adequately tested
for the conditions in which they are certified to operate. This should
include identifying ice shapes that form on aircraft surfaces,
determining the effects of these ice shapes on flight performance, and
incorporating this information into certification requirements;
Status: Closed--unacceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-98-100; Issued 11/30/1998; Closed 2/27/2007;
Recipient: FAA;
Summary of recommendation: When the revised icing certification
standards are complete, ensure that all turboprop airplanes that are
currently certified to fly in icing conditions meet the requirements
of the revised standards;
Status: Closed--unacceptable action/superseded; Superseded by; A-07-16.
Recommendation number, date issued, and date closed (where
applicable): A-98-101; Issued 11/30/1998; Closed 5/10/2006;
Recipient: FAA;
Summary of recommendation: Review turboprop airplane manufacturers'
flight manuals and air carrier operating manuals to ensure that they
provide operational procedures for flight in icing conditions;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-98-102; Issued 11/30/1998;
Recipient: FAA;
Summary of recommendation: Require air carriers to adopt the operating
procedures in the manufacturer's flight manual or provide written
justification that an alternative procedure is equally safe;
Status: Open--acceptable response.
Recommendation number, date issued, and date closed (where
applicable): A-98-105; Issued 11/30/1998; Closed 5/6/2003;
Recipient: FAA;
Summary of recommendation: Periodically remind pilots of their
responsibility to report weather conditions that could affect the
safety of other flights;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-98-106; Issued 11/30/1998; Closed 3/23/2000;
Recipient: FAA;
Summary of recommendation: Require that information provided to
arriving and departing aircraft includes information on pilot reports
of icing conditions;
Status: Closed--reconsidered.
Recommendation number, date issued, and date closed (where
applicable): A-98-107; Issued 11/30/1998; Closed 8/19/2004;
Recipient: NASA;
Summary of recommendation: Educate manufacturers, operators, and
pilots of turboprop airplanes on the hazards of thin, rough ice
buildup; the importance of activating 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;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-98-108; Issued 11/30/1998;
Recipient: NASA;
Summary of recommendation: Identify realistic ice accumulation
configurations and determine their effect on aircraft performance.
Incorporate this information into aircraft certification requirements
and pilot training programs;
Status: Open--acceptable response.
Source: NTSB.
[A] A turboprop airplane is an airplane with a turboprop engine, which
is a hybrid engine that provides jet thrust and also drives a
propeller.
[B] In general, a transport category airplane is an airplane with
maximum takeoff weight (MTOW) greater than 12,500 pounds or with 10 or
more passenger seats, except for propeller-driven, multi-engine
airplanes, in which case the transport category airplanes are those
with MTOW greater than 19,000 pounds or with 20 or more passenger
seats. FAA certifies the design of transport category airplanes under
14 CFR part 25.
[End of table]
Reno Air Flight #153:
On March 14, 1997, Reno Air Flight #153, a McDonnell Douglas MD-87
airplane experienced a partial power loss in both engines during
takeoff from Detroit, Michigan. The airplane returned to Detroit and
landed without further incident. NTSB found that ice was present on
the wings at takeoff, despite tactile wing inspections by the flight
crew. The wing ice was ingested by the engines, blocking engine
airflow.
Table 6: Recommendations Resulting from the Incident Involving Reno
Air Flight #153:
Recommendation number, date issued, and date closed (where
applicable): A-97-121; Issued: 12/22/1997; Closed: 7/20/1998;
Recipient: FAA;
Summary of recommendation: Alert FAA inspectors, and through them all
affected air carrier flight crews, of the details of the Reno Air
incident and the need to reduce power when engine airflow is blocked
to minimize engine damage and ensure safe landing;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-97-122; Issued 12/22/1997; Closed 7/25/2001;
Recipient: FAA;
Summary of recommendation: Require MD-80 and MD-90 airplanes to have
more reliable equipment for preventing or detecting wing ice before
every flight in lieu of tactile inspection;
Status: Closed--acceptable action.
Source: NTSB.
[End of table]
Garuda Indonesia Airlines Flight #421:
On January 16, 2002, Garuda Indonesia Airlines Flight #421 lost power
in both engines when approaching the city of Yogyakrta on Java Island
in Indonesia. After several unsuccessful attempts to restart the
engines, the flight crew made an emergency water landing. Of the 60
people on board, 1 was killed, 12 received serious injuries, and 10
received minor injuries. The airplane was substantially damaged. Based
on weather data and the cockpit recording, NTSB suspects that rain and
hail ingestion may have caused the engine failure.
Table 7: Recommendations Resulting from the Accident Involving Garuda
Indonesia Airlines Flight #4184:
Recommendation number, date issued, and date closed (where
applicable): A-05-019; Issued 8/31/2005;
Recipient: FAA;
Summary of recommendation: Complete the review of the current turbofan
engine certification standards for rain and hail intake and revise
these standards if necessary[A];
Status: Open--acceptable response.
[End of table]
Source: NTSB.
[A] A turbofan engine is a type of jet engine in which the core engine
is surrounded by a fan in the front and an additional turbine in the
rear.
Spirit Airlines Flight #970:
On June 4, 2002, Spirit Airlines Flight #970 experienced a gradual
power loss in both engines and a stall warning while in flight near
Wichita, Kansas. Pilots disengaged autopilot, turned on engine
ignition, activated the engine anti-ice system, and initiated a
descent. The flight landed safely and there were no injuries.
Table 8: Recommendations Resulting from the Incident Involving Spirit
Airlines Flight #970:
Recommendation number, date issued, and date closed (where
applicable): A-04-34; Issued 4/29/2004; Closed 10/21/2004;
Recipient: FAA;
Summary of recommendation: Have FAA inspectors alert affected air
carrier flight crews about the Spirit Airlines Flight #970 encounter
with icing conditions. Emphasize the need to be alert to the signs of
high-altitude icing conditions, the effect of these conditions on
airplane and engine performance, and the need for appropriate use of
engine icing protection equipment;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-04-35; Issued 4/29/2004;
Recipient: FAA;
Summary of recommendation: Pursue research to develop an ice detector
that would alert pilots to icing of certain aircraft equipment and
require that the ice detector be installed on new production turbojet
airplanes and retrofitted to existing turbojet airplanes;
Status: Open--acceptable response.
Source: NTSB.
[End of table]
Icing Accidents and Incidents Involving Cessna 208 Series Airplanes:
From 1987 to 2003, there were 26 icing-related accidents and incidents
involving Cessna 208 series airplanes, resulting in at least 36
fatalities. NTSB's findings raised concerns about possible
deficiencies the certification standards applicable to Cessna 208
series airplanes, the cold weather operational procedures used by
Cessna 208 pilots, or the design of the airplane and its deicing and
anti-icing systems.
Table 9: Recommendations Made to Address Accidents and Incidents
Involving Cessna 208 Series Airplanes:
Recommendation number, date issued, and date closed (where
applicable): A-04-64; Issued 12/15/2004; Closed 1/29/2009;
Recipient: FAA;
Summary of recommendation: Require all pilots and operators of those
Cessna 208 series airplanes equipped for flight in icing conditions to
undergo annual training for ground deicing and flight into icing
conditions;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-04-65; Issued 12/15/2004; Closed 1/7/2009;
Recipient: FAA;
Summary of recommendation: Require the Cessna Aircraft Company to
develop effective procedures and guidance to minimize the chance of
ground and in-flight icing accidents and incidents for Cessna 208
series aircraft. FAA should then verify that these procedures and
guidance materials are incorporated into Cessna 208 operator manuals
and training programs;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-04-66; Issued 12/15/2004; Closed 1/7/2009;
Recipient: FAA;
Summary of recommendation: Require pilots and operators of Cessna 208
series airplanes to examine the wing and other surfaces to ensure that
they are free of ice, snow, or both before any flight from a location
where temperatures are conducive to frost and ground icing;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-04-67; Issued 12/15/2004;
Recipient: FAA;
Summary of recommendation: Evaluate FAA's current surveillance
procedures for operators of Cessna 208 series airplanes equipped for
flight into icing conditions to determine whether the surveillance
effectively ensures that these operators are in compliance with
federal deicing requirements. If necessary, modify the surveillance
procedures to ensure such compliance;
Status: Open--acceptable response.
Source: NTSB.
[End of table]
Engine Power Loss in Raytheon Beechjet 400 Series Airplanes:
From 2004 to 2006, three incidents occurred in the United States in
which Raytheon Beechjet airplanes lost power in both Pratt & Whitney
JT15D engines. A similar incident occurred in Brazil in 2000. NTSB is
concerned about this recent onset of dual-engine failures and the
sustained loss of power that occurred in each event after several
attempts to restart the engine. A study by Pratt & Whitey Canada (the
engine manufacturer) found that with the engine anti-ice turned off,
it was possible for ice crystals to build up in the engines and that
the buildup could lead to airflow disruption, engine failure, or both.
Table 10: Recommendations Resulting from Power Loss in Raytheon
Beechjet 400 Series Airplanes:
Recommendation number, date issued, and date closed (where
applicable): A-06-56; Issued 8/25/2006; Closed 5/18/2007;
Recipient: FAA;
Summary of recommendation: Immediately require Beechjet 400 pilots to
activate engine ice protection systems in weather conditions conducive
to engine icing or before a power reduction in certain weather
conditions;
Status: Closed--exceeds recommended action.
Recommendation number, date issued, and date closed (where
applicable): A-06-57; Issued 8/25/2006; Closed 5/18/2007;
Recipient: FAA;
Summary of recommendation: Require Raytheon to incorporate information
on ice protection system operation and ice formation into the Beechjet
400 airplane flight manual;
Status: Closed--exceeds recommended action.
Recommendation number, date issued, and date closed (where
applicable): A-06-58; Issued 8/25/2006; Closed 2/29/2008;
Recipient: FAA;
Summary of recommendation: Incorporate information on ice protection
system operation and ice formation into the flight manuals of aircraft
with JT15D engines;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-06-59; Issued 8/25/2006;
Recipient: FAA;
Summary of recommendation: Pursue research to develop an ice detector
that would alert pilots of engine icing. Require that such an ice
detector be installed on new turbojet engines and retrofitted to
existing turbojet engines;
Status: Open--acceptable alternate response.
Source: NTSB.
[End of table]
Glo-Air Flight #73:
On November 28, 2004, Glo-Air Flight #73 crashed during an attempted
takeoff in snowing conditions. Before the accident flight, the
airplane was parked for 45 minutes while wet snow fell, and the
airplane was not deiced before takeoff. Three people on board were
killed, and three received serious injuries. The airplane was
destroyed by impact forces and postcrash fire. NTSB found that the
accident was caused by the flight crew's failure to ensure that the
airplane's wings were free of ice and snow prior to takeoff.
Table 11: Recommendations Resulting from the Crash of Glo-Air Flight
#73:
Recommendation number, date issued, and date closed (where
applicable): A-06-042; Issued 8/4/2006;
Recipient: FAA;
Summary of recommendation: Develop training aids to accurately depict
small amounts of wing ice buildup and require all commercial airplane
operators to use them in their initial and recurrent training;
Status: Open--unacceptable response.
Source: NTSB.
[End of table]
Martinair Circuit City Accident in Pueblo, Colorado:
On February 16, 2005, a Cessna Citation 560, operated by Martinair for
Circuit City Stores, crashed near Pueblo, Colorado. Eight people were
killed, and the airplane was destroyed by impact forces and postcrash
fire. NTSB found that this accident was caused by the flight crew's
failure to monitor and maintain airspeed and comply with deicing
system activation procedures. NTSB also found that FAA's failure to
establish adequate icing certification requirements contributed to the
accident.
Table 12: Recommendations Resulting from the Martinair Circuit City
Crash:
Recommendation number, date issued, and date closed (where
applicable): A-07-12; Issued 2/27/2007;
Recipient: FAA;
Summary of recommendation: Require that operational training in the
Cessna 560 airplane emphasize that the airplane flight manual requires
pilots to increase the airspeed and operate the deice boots in certain
phases of flight when ice is present on the wings;
Status: Open--acceptable response.
Recommendation number, date issued, and date closed (where
applicable): A-07-13; Issued 2/27/2007;
Recipient: FAA;
Summary of recommendation: Require that all pilot training programs
teach and emphasize monitoring skills and workload management and
include opportunities to practice and demonstrate proficiencies in
these areas;
Status: Open--unacceptable response.
Recommendation number, date issued, and date closed (where
applicable): A-07-14; Most Wanted; Issued 2/27/2007;
Recipient: FAA;
Summary of recommendation: Require manufacturers and operators of
airplanes with deice boots to revise their manuals and training
programs to emphasize that deice boots should be activated as soon as
the airplane enters icing conditions;
Status: Open--acceptable response; Supersedes A-98-91.
Recommendation number, date issued, and date closed (where
applicable): A-07-15; Issued 2/27/2007;
Recipient: FAA;
Summary of recommendation: Require all airplanes with deice boots that
are certified to fly in icing conditions to have a mode that would
automatically continue to cycle the deice boots once the system has
been activated;
Status: Open--acceptable response.
Recommendation number, date issued, and date closed (where
applicable): A-07-16; Most Wanted; Issued 2/27/2007;
Recipient: FAA;
Summary of recommendation: When the revised icing certification
standards (recommended in Safety Recommendations A-96-54 and A-98-92)
are complete, ensure that airplanes with deice boots fulfill the
requirements of the revised icing certification standards;
Status: Open--unacceptable response; Supersedes A-98-100.
Recommendation number, date issued, and date closed (where
applicable): A-07-17; Issued 2/27/2007;
Recipient: FAA;
Summary of recommendation: Require modification of the Cessna 506
airplane's stall warning system so that it accounts for the size,
type, and distribution of ice buildup;
Status: Open--acceptable response.
Source: NTSB.
[End of table]
Midwest Airlines Flight #490:
On May 12, 2005, Midwest Airlines Flight #490 experienced unreliable
airspeed indications during flight in heavy rain and icing conditions.
The airplane experienced significant gains and losses in altitude
before the crew was able to regain control and divert to Kirksville,
Missouri. Results of NTSB's investigation indicate that this incident
was caused by the flight crew's failure to activate the air data
sensor heating system and that cockpit warnings were ineffective at
alerting the crew to the air data sensor problem.
Table 13: Recommendations Resulting from the Crash of Midwest Airlines
Flight #490:
Recommendation number, date issued, and date closed (where
applicable): A-07-55; Issued 9/13/2007;
Recipient: FAA;
Summary of recommendation: Require the air data sensor heating systems
on new transport category aircraft to automatically activate after
engine start;
Status: Open--acceptable response.
Recommendation number, date issued, and date closed (where
applicable): A-07-56; Issued 9/13/2007;
Recipient: FAA;
Summary of recommendation: Require modification of existing transport
category aircraft that currently require manual activation of the air
data sensor heating system so that this system is activated
automatically. For airplanes that cannot be modified, require an
upgraded cockpit warning when the heating system fails to activate;
Status: Open--acceptable response.
Source: NTSB.
[End of table]
Southwest Airlines Flight #1248:
On December 8, 2005, Southwest Airlines Flight #1248 landed on a snow-
covered runway in Chicago, Illinois. The airplane departed the end of
the runway and rolled through airport fences and then into traffic on
an off-airport street. The airplane came to a stop after impacting two
cars, which resulted in the death of a child passenger in one of the
vehicles. NTSB found that this accident was caused by the pilots'
failure to use reverse thrust in a timely manner to safely slow or
stop the airplane after landing.
Table 14: Recommendations Resulting from the Accident Involving
Southwest Airlines Flight #1248:
Recommendation number, date issued, and date closed (where
applicable): A-06-16; Issued 1/27/2006; Closed 10/4/2007;
Recipient: FAA;
Summary of recommendation: Immediately prohibit large commercial
operators from factoring use of the reverse thrust deceleration system
into landing performance calculations;
Status: Closed--unacceptable action; superseded; Superseded by A-07-57.
Recommendation number, date issued, and date closed (where
applicable): A-07-57; Issued 10/4/2007;
Recipient: FAA;
Summary of recommendation: Immediately require large commercial, small
commercial, and some noncommercial operators to assess the distance
needed to land before every landing, incorporating a 15 percent safety
margin;
Status: Open--unacceptable response; Supersedes A-06-16.
Recommendation number, date issued, and date closed (where
applicable): A-07-59; Issued 10/16/2007;
Recipient: FAA;
Summary of recommendation: Require large commercial and small
commercial operators to provide clear guidance and training to pilots
and dispatchers on company policy regarding surface condition and
braking performance reporting, as well as landing distance
calculations;
Status: Open--acceptable response.
Recommendation number, date issued, and date closed (where
applicable): A-07-61; Issued 10/16/2007;
Recipient: FAA;
Summary of recommendation: Require large commercial, small commercial,
and some noncommercial operators to make landing distance assessments
before every landing based on standardized methodology, using the most
conservative interpretation available, and including a 15 percent
safety margin;
Status: Open--acceptable response.
Recommendation number, date issued, and date closed (where
applicable): A-07-62; Issued 10/16/2007;
Recipient: FAA;
Summary of recommendation: Develop and issue formal guidance regarding
runway surface condition reports;
Status: Open--acceptable response.
Recommendation number, date issued, and date closed (where
applicable): A-07-63; Issued 10/16/2007;
Recipient: FAA;
Summary of recommendation: Establish a minimum standard for large
commercial and small commercial operators to use in comparing an
airplane's braking ability to runway condition reports;
Status: Open--acceptable response.
Recommendation number, date issued, and date closed (where
applicable): A-07-64; Issued 10/16/2007;
Recipient: FAA;
Summary of recommendation: Show whether it is feasible to outfit
transport-category airplanes with the means to track and communicate
airplane braking ability needed to stop the airplane during landing.
If feasible, require transport category airplane operators to use such
equipment and procedures;
Status: Open--acceptable response.
Source: NTSB.
[End of table]
International Cessna 208 Series Aircraft Accidents:
NTSB participated in two foreign investigations of fatal accidents
involving Cessna 208 series airplanes in icing conditions. These
accidents occurred in Winnipeg, Manitoba, Canada and Moscow, Russia in
2005. NTSB found the following problems with Cessna 208 series
airplanes: in both accidents, the minimum operating airspeed in icing
conditions did not provide an adequate safety margin. Specifically, in
the Winnipeg accident, the pilot had very little time to escape icing
conditions; and in the Moscow accident, the pilots did not have
adequate cues of airplane performance degradation.
Table 15: Recommendations Resulting from Two International General
Aviation Accidents:
Recommendation number, date issued, and date closed (where
applicable): A-06-1; Issued 1/17/2006; Closed 11/15/2006;
Recipient: FAA;
Summary of recommendation: Require all operators of Cessna 208 series
airplanes to maintain sufficient airspeed during flight in icing
conditions;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-06-2; Issued 1/17/2006; Closed 11/15/2006;
Recipient: FAA;
Summary of recommendation: Prohibit operators of Cessna 208 series
airplanes from flying into icing conditions more severe than light
icing;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-06-3; Issued 1/17/2006; Closed 11/15/2006;
Recipient: FAA;
Summary of recommendation: Require all operators of Cessna 208 series
airplanes to disengage the autopilot and fly the airplane manually
when operating in icing conditions;
Status: Closed--acceptable action.
Source: NTSB.
[End of table]
American Eagle Flight #3008:
On January 2, 2006, American Eagle Flight #3008, a Saab-Scania AB
SF340B+, encountered icing conditions in-flight and lost control.
After losing altitude, pilots regained control and continued without
further incident. NTSB found that the aircraft's performance
degradation occurred at airspeeds above the current minimum safe
speeds. NTSB also found that the aircraft's stall warning would have
activated if the "ice speed" modification to the stall warning system
had been used. Furthermore, the airplane did not have an ice detection
system, which would have alerted crew to ice buildup, and use of
autopilot likely reduced the crew's perception of aircraft performance.
Table 16: Recommendations Resulting from the Incident Involving
American Eagle Flight #3008:
Recommendation number, date issued, and date closed (where
applicable): A-06-48; Issued 7/10/2006; Closed 2/4/2009;
Recipient: FAA;
Summary of recommendation: Require operators of Saab SF340 airplanes
to instruct pilots to maintain sufficient airspeed in icing conditions
and to exit icing conditions as soon as degraded performance prevents
the airplane from maintaining sufficient airspeed;
Status: Closed--acceptable action.
Recommendation number, date issued, and date closed (where
applicable): A-06-49; Issued 7/10/2006;
Recipient: FAA;
Summary of recommendation: Require modified stall protection systems
in Saab SF340 series airplanes certified to fly in known icing
conditions;
Status: Open--acceptable response.
Recommendation number, date issued, and date closed (where
applicable): A-06-50; Issued 7/10/2006; Closed 2/4/2009;
Recipient: FAA;
Summary of recommendation: Require the installation of an icing
detection system on Saab SF340 series airplanes;
Status: Closed--acceptable alternate action.
Recommendation number, date issued, and date closed (where
applicable): A-06-51; Issued 7/10/2006;
Recipient: FAA;
Summary of recommendation: Require operators of turboprop airplanes to
instruct pilots to disengage the autopilot and fly manually in icing
conditions, except during periods of high workload;
Status: Open--await response.
Source: NTSB.
[End of table]
Delta Connection Flight #6448:
On February 18, 2007, Delta Connection Flight #6448 overran the end of
the runway while landing in snowy conditions. The aircraft struck an
airport perimeter fence and its nose gear collapsed. Three passengers
received minor injuries. NTSB determined that the accident was caused
by flight crew errors, including failure to recognize that a safe
landing could not be accomplished.
Table 17: Recommendations Resulting from the Crash of Delta Connection
Flight #6448:
Recommendation number, date issued, and date closed (where
applicable): A-08-17; Issued 4/15/2008;
Recipient: FAA;
Summary of recommendation: Require large commercial, small commercial,
and certain noncommercial operators to include practice for landing on
contaminated runways into simulator training for turbojet airplanes;
Status: Open--acceptable alternate response.
Source: NTSB.
[End of table]
Pinnacle Airlines Flight #4712:
On April 12, 2007, Pinnacle Airlines Flight #4712 ran off the runway
after landing in snowy conditions at Traverse City, Michigan. There
were no injuries, but the aircraft was substantially damaged. NTSB
found that this accident was caused by the pilots' decision to land
without performing a landing distance assessment. Airport personnel's
use of ambiguous language in providing runway braking information also
contributed to the accident.
Table 18: Recommendations Resulting from the Accident Involving
Pinnacle Airlines Flight #4712:
Recommendation number, date issued, and date closed (where
applicable): A-08-41; Issued 6/17/2008;
Recipient: FAA;
Summary of recommendation: Address the need for initial training on
conducting landing distance assessments before landing on contaminated
runways;
Status: Open--acceptable response.
Recommendation number, date issued, and date closed (where
applicable): A-08-42; Issued 6/17/2008; Closed 6/22/2009;
Recipient: FAA;
Summary of recommendation: Alert airports of the circumstances of this
accident, urging all airports to ensure that radio communications
criteria are met;
Status: Open--acceptable response.
Recommendation number, date issued, and date closed (where
applicable): A-08-43; Issued 6/17/2008;
Recipient: FAA;
Summary of recommendation: Require airport operators to include
criteria for runway contamination and runway friction assessments in
their airport's snow and ice control plan. Fulfillment of these
criteria should trigger closure of the affected runway;
Status: Open--acceptable response.
Source: NTSB.
[End of table]
[End of section]
Footnote:
[1] NTSB has closed 8 of these recommendations as "unacceptable
response" by FAA; has classified 7 of the open recommendations as
"unacceptable response" by FAA; has closed 3 of these recommendations
after concurring with FAA's rationales for disagreeing with the
recommendations; and is awaiting FAA's response on 1 of these
recommendations.
[End of section]
Contact Information:
If you have questions concerning these data, please contact Gerald L.
Dillingham at (202) 512-2834 or dillinghamg@gao.gov.
Copyright:
This is a work of the U.S. government and is not subject to copyright
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from GAO. However, because this work may contain copyrighted images or
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