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NTSB Ruling & Recommendation on Flt. 587

 NTSB PRESS RELEASE

National Transportation Safety Board
Washington, DC 20594
FOR IMMEDIATE RELEASE: October 26, 2004
SB-04-31

 

NTSB SAYS PILOT’S EXCESSIVE RUDDER PEDAL INPUTS LED TOCRASH OF AMERICAN FLIGHT 587; AIRBUS RUDDER SYSTEM DESIGN &ELEMENTS OF AIRLINE’S PILOT TRAINING PROGRAM CONTRIBUTED

WASHINGTON, D.C. – American Airlines flight 587 crashed into a Queens neighborhood because the plane’s vertical stabilizer separated in flight as a result of aerodynamic loads that were created by the first officer’s unnecessary and excessive rudder pedal inputs after the aircraft encountered wake turbulence, according to a final report adopted by the National Transportation Safety Board today. The Board said that contributing to the crash were characteristics of the airplane’s rudder system design and elements of the airline’s pilot training program. At about 9:16 a.m. on November 12, 2001, flight 587, an Airbus A300-605R (N14053), crashed in Belle Harbor, New York shortly after taking off from John F. Kennedy International Airport on a flight to Santo Domingo. All 260 people aboard the plane died, as did five persons on the ground. This is the second deadliest aviation accident in American history. The aircraft’s vertical stabilizer and rudder were found in Jamaica Bay, about a mile from the main wreckage site. The engines, which also separated from the aircraft seconds before ground impact, were found several blocks from the wreckage site. The Safety Board found that the first officer, who was the flying pilot, inappropriately manipulated the rudder back and forth several times after the airplane encountered the wake vortex of a preceding Boeing 747 for the second time. The aerodynamic loads placed on the vertical stabilizer due to the sideslip that resulted from the rudder movements were beyond the ultimate design strength of the vertical stabilizer. (Simply stated, sideslip is a measure of the “sideways” motion of the airplane through the air.) The Board found that the composite material used in constructing the vertical stabilizer was not a factor in the accident because the tail failed well beyond its certificated and design limits. The Safety Board said that, although other pilots provided generally positive comments about the first officer’s abilities, two pilots noted incidents that showed that he had a tendency to overreact to wake turbulence encounters. His use of the rudder was not an appropriate response to the turbulence, which in itself provided no danger to the stability of the aircraft, the Board found. The Board said that American Airlines’ Advanced Aircraft Maneuvering Program contributed to the accident by providing an unrealistic and exaggerated view of the effects of wake turbulence on heavy transport-category aircraft. In addition, the Board found that because of its high sensitivity, the A300-600 rudder control system is susceptible to potentially hazardous rudder pedal inputs at higher speeds. In particular, the Board concluded that, before the crash of flight 587, pilots were not being adequately trained on what effect rudder pedal inputs have on the A300-600 at high airspeeds, and how the airplane’s rudder travel limiter system operates. The Safety Board’s airplane performance study showed that the high loads that eventually overstressed the vertical stabilizer were solely the result of the pilot’s rudder pedal inputs and were not associated with the wake turbulence. In fact, had the first officer stopped making inputs at any time before the vertical stabilizer failed, the natural stability of the aircraft would have returned the sideslip angle to near 0 degrees, and the accident would not have happened. (The Board estimated that the sideslip angle at the time the vertical stabilizer separated was between 10 and 12.5 degrees.) The NTSB issued eight recommendations in today’s report. Among the seven sent to the Federal Aviation Administration were those calling for adopting certification standards for rudder pedal sensitivity, modifying the A300-600 and A310 rudder control systems to increase protection from potentially hazardous rudder pedal inputs at high speeds (a similar recommendation was issued to the French equivalent of the FAA, the DGAC), and publishing guidance for airline pilot training programs to avoid the kind of negative training found in American Airlines’ upset recovery training. Because this crash occurred two months after the September 11 terrorist attacks, there was initial concern that it might have been the result of an intentional criminal act. The Board found no such evidence, nor did any law enforcement agencies provide evidence that the accident may have stemmed from criminal conduct. The Board said that witnesses who reported observing the airplane on fire were most likely observing misting fuel released from broken fuel lines, a fire from the initial release of fuel or the effects of engine compressor surges. A summary of the Board’s report may be found under “Publications” on the agency’s website at www.ntsb.gov. The full report will appear on the website in about four weeks.

NTSB SAFETY RECOMMENDATION

National Transportation Safety Board Washington, DC 20594

December 15, 2004

Safety Recommendation A-04-64 through -67 

The National Transportation Safety Board recommends that the Federal Aviation Administration expeditiously do the following: Require all pilots and operators of Cessna 208 series airplanes equipped for flight into known icing conditions to undergo seasonal training for ground deicing and flight into icing conditions on an annual basis. This seasonal training should be timed to precede the operator’s cold weather operations and should specifically address (1) the limitations of the Cessna 208 in icing situations; (2) the Cessna 208 deice and anti-icing systems and controls and their use; (3) pilot actions during cold weather ground operations, with emphasis on the need for careful visual and tactile examination of wing and horizontal stabilizer upper surfaces during the preflight inspection to ensure that they are free of ice before takeoff; (4) pilot actions during cold weather flight operations, with emphasis on the timely recognition of potentially dangerous accumulations of ice and the importance of having an appropriate strategy for escaping the icing conditions and acting on that strategy promptly; (5) the hazards of performance degradation caused by ice that remains after activation of the deice boots; and (6) Cessna 208 Pilot Operating Handbook icing-related limitations, warnings, and notes. (A-04-64) Require Cessna Aircraft Company, working with Cessna 208 operators, to develop effective operational strategies (for example, cold weather preflight strategies in remote locations, viable methods of collecting icing- related weather information before and during flight, ice detection and monitoring cues, optimal use of anti- ice and deice systems, minimum airspeeds for all phases of flight, proper use of flaps and engine power in icing conditions, and development of ice accumulation limitations and exit strategies for pilots in icing conditions) and related guidance materials to minimize the chance of Cessna 208 ground and in-flight icing accidents or incidents; the FAA should then verify that these strategies and guidance materials are incorporated into Cessna 208 operator manuals and training programs in a timely manner. (A-04-65) Require all pilots and operators of Cessna 208 series airplanes to conduct a visual and tactile examination of the wing and horizontal stabilizer leading edges and upper surfaces to ensure that those surfaces are free of ice and/or snow contamination before any flight from a location at which the temperatures are conducive to frost or ground icing. (A-04-66) Evaluate its current procedures for surveillance of operators of Cessna 208 series airplanes equipped for flight into known icing conditions to determine whether the surveillance effectively ensures that these operators are in compliance with Federal deicing requirements and, if necessary, modify the surveillance procedures to ensure such compliance. (A-04-67)

http://www.ntsb.gov/recs/letters/2004/A04_64_67.pdf

The complete recommendation letter is available on the Web at the URL indicated above. The letter is in the Portable Document Format (PDF) and can be read using the Acrobat Reader 3.0 or later from Adobe (http://www.adobe.com/prodindex/acrobat/readstep.html). An archive of recommendation letters is available at http://www.ntsb.gov/recs/letters/letters.htm. Please note that the electronic version of this letter may not include enclosures; however, related publications, accident briefs, and aviation accident synopses are also available on the web site.

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