Source: https://ntsb.gov/investigations/AccidentReports/_layouts/ntsb.recsearch/Recommendation.aspx?Rec=A-12-044
Timestamp: 2019-09-21 08:54:02
Document Index: 630321415

Matched Legal Cases: ['art 121', 'art 121', 'art 12', 'art 121', 'art 135', 'art 121', 'art 9', 'art 121', 'art 142', 'art 121', 'art 121']

Safety Recommendation A-12-044
Synopsis: December 29, 2010, incident involving American Airlines flight 2253, a Boeing 757-200, N668AA, which ran off the departure end of runway 19 and came to a stop in deep snow after landing at Jackson Hole Airport (JAC), Jackson Hole, Wyoming. The occupants were not injured, and the airplane sustained minor damage. The National Transportation Safety Board determines that the probable cause of this incident was a manufacturing defect in a clutch mechanism that prevented the speedbrakes from automatically deploying after touchdown and the captain‘s failure to monitor and extend the speedbrakes manually. Also causal was the failure of the thrust reversers to deploy when initially commanded. Contributing to the incident was the captain‘s failure to confirm speedbrake extension before announcing their deployment and his distraction caused by the thrust reversers‘ failure to initially deploy after landing.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require all operators of existing speedbrake-equipped transport-category airplanes to develop and incorporate training to specifically address recognition of a situation in which the speedbrakes do not deploy as expected after landing.
Location: Jackson Hole, WY, United States
Accident #: DCA11IA015
Accident Reports: Runway Overrun of American Airlines Flight 2253, Boeing 757-200, N668AA
Report #: AAR-12-01
Accident Date: 12/29/2010
Issue Date: 7/3/2012
Date Closed: 8/9/2017
Response: We note that, on September 9, 2016, you published advisory circular (AC) 120-114, “Pilot Training and Checking (14 CFR Part 121 subparts N and O, Including Appendices E and F),” which provides guidance on pilot speedbrake training and is intended to be a resource for developing, implementing, and revising an air carrier’s pilot training and qualification program. The AC defines performance criteria for pilots when they conduct ground training, flight training, and checking, and its publication satisfies Safety Recommendation A-12-44, which is classified CLOSED—ACCEPTABLE ACTION.
Response: -From Michael P. Huerta, Administrator: In our previous letter to the Board dated December J 3, 2013, the Federal Aviation Administration (FAA) stated that we intended to issue a Safety Alert for Operators (SAFO) to alert all air carriers to review and consider the inclusion of training elements addressing the non-deployment of speed brakes. In its letter dated February I 0. 2014. the Board stated issuance of the SAFO would not constitute an acceptable response without any followup to ensure that the safety information is actually being disseminated and appropriate responses are resulting. As a result, we published Advisory Circular (AC), Pi lot Training and Checking (14 CFR Part 121 Subparts N and 0, Including Appendices E and F), on September 29, 2016, rather than a SAFO. ACs provide information and guidance concerning an acceptable means, but not the only means, of demonstrating compliance with the requirements of Title 14. Code of Federal Regulations, and the responsibility to implement any action recommended in the guidance rests with the operator. This AC is available at: http://www.faa.gov/documentLibrary/media/ Advisory_ Circular/AC_ l 20- 114.pdf. We also note that some aircraft manufacturers use the term "speedbrakes"' that essentially mean the same as "spoilers." which is the term we primarily use in the AC discussed above. This AC describes procedures to include the use of spoilers (speedbrakes) while completing tasks during ground training, flight training, and checking and also provides information regarding pilot training and checking under part 12 1. The FAA intends that air carriers use this AC as a resource during their development, implementation, and revision or an air carrier's pilot training and qualification program and believe it may be valuable to the following: • Air carriers conducting operations under part 121. including air carriers using an Advanced Qualification Program; • Air carriers and operators conducting operations under part 135 in compliance with part 121, subparts N and O; • Program managers conducting operations under part 9 I K complying with part 121. Subparts N and O; and • Part 142 training centers conducting training and checking under contract to a part I 19 air earner. Furthermore, chis AC defines performance criteria for pi lots when conducting the tasks and operations discussed above. This includes an act ion item that the pi lot that is flying ensures the throttles arc al idle. and that the spoilers (speedbrakes) have deployed (if applicable), as touchdown occurs during landing. There is another action item that the monitoring pilot observe spoiler deployment and advise the flying pilot of the spoiler status. Additionally, this AC includes awareness criteria for causes of a bounced landing calling attention to the act of touching down with power on possibly preventing the automatic extension of ground spoilers. I believe that the FAA has effectively addressed this safety recommendation and consider our actions complete.
Response: Although, after evaluating operators’ speedbrake procedures and training methods, you believe that issuing a Safety Alert for Operators (SAFO) is the most appropriate action for addressing this recommendation, we do not agree that issuing a SAFO will be sufficient to close this recommendation. We have previously expressed concern that a SAFO is not an effective substitute for a requirement. In past and current investigations, we have frequently found that neither the operator nor regional FAA personnel providing oversight of the operator were aware of, let alone following, guidance contained in relevant SAFOs. For example, as a result of our investigation of the February 12, 2009, crash in Clarence Center, New York of Colgan Continental Connection flight 3407, a Bombardier DHC 8 400, while on approach to Buffalo Niagara International Airport, Buffalo, New York, on February 23, 2010, we issued Safety Recommendation A-10-31: A-10-31 Implement a process to document that all 14 Code of Federal Regulations Part 121, 135, and 91K operators have taken appropriate action in response to safety-critical information transmitted through the safety alert for operators process or another method. Your September 24, 2012, letter regarding Safety Recommendation A-10-31 stated that the intent of a SAFO was to disseminate directly to operators important safety information that is often critical, but the responsibility to implement any action recommended in a SAFO rests with the operator. The FAA did not intend to develop its own process for tracking operator action in response to safety-critical information, as recommended. At that time, you proposed that a coming requirement for Part 121 operators to develop and implement safety management systems (SMS) would address operators’ responding appropriately to guidance in SAFOs. On February 7, 2013, we replied that a mature SMS would (1) provide operators with the tools and framework to potentially manage safety proactively and (2) provide the FAA with a systematic approach for evaluating the effectiveness of operators’ management of safety?including actions taken in response to safety-critical information transmitted through the SAFO process or another method. Although we recognized the benefits of an SMS, we emphasized that transmitting safety-critical information to operators without measuring results was inconsistent with the basic principles of SMS. Accordingly, on February 7, 2013, Safety Recommendation A-10-31 was classified “Open—Unacceptable Response.” In our accident and incident investigations, we have found and continue to find that operators and FAA regional staff providing oversight of the operator are frequently not aware of the existence of relevant SAFOs. This calls into question whether SAFOs are effective at disseminating important safety information, let alone bringing about an appropriate response from operators. Were a SAFO effective in bringing about the needed action, it might constitute an acceptable alternate response to Safety Recommendation A-12-44. But issuance of the SAFO does not constitute an acceptable response without any follow-up to ensure that the safety information is actually being disseminated, and appropriate responses are resulting. Therefore, although development of the SAFO is an acceptable alternate response for the moment, it will not be a basis for closure of Safety Recommendation A-12-44 without acceptable action to address Safety Recommendation A-10-31. Accordingly, pending development of the SAFO, and action that satisfies Safety Recommendation A 10 31, Safety Recommendation A-12-44 is classified OPEN--ACCEPTABLE ALTERNATE RESPONSE.
Response: In our previous letter to the Board, dated August 29, 2012, the federal Aviation Administration (FAA) stated that we planned to evaluate operators' speedbrake procedures and training methods. After review of these procedures, the F AI\ has determined that issuing a Safety Alert for Operators (SAFO) is the most appropriate action. Issuing a SAFO ensures wide and immediate information dissemination. The SAFO would alert all air carriers to review and consider the inclusion of training elements addressing the non-deployment of speed brakes. We expect to publish this SAFO by March 31, 2014. I will keep the Board informed of the FAA's progress on this safety recommendation and provide an update by August 31, 2014.
Response: The FAA is working with air carriers that operate speedbrake-equipped airplanes to evaluate their procedures and training methods. Pending completion of the recommended action, Safety Recommendation A-12-44 is classified OPEN-ACCEPTABLE RESPONSE.
Response: -From Michael P. Huerta, Acting Administrator: The Federal Aviation Administration (FAA) agrees that situations in which speed brakes do not deploy as expected after landing merits our attention. We are working with air carriers that operate speed brake-equipped transport -category airplanes to evaluate their procedure s and training methods. We expect to complete this evaluation by July 31, 2013 . I will keep the Board informed of the FAA's progress on this safety recommendation and provide an update by December 31, 2013.