Pertinent NTSB Safety
Recommendations to the FAA with FAA Responses
As of date: 1/15/04
http://www1.faa.gov/avr/aai/A-03-022.txt
On February 16,
2000, about 1951 Pacific
standard time, Emery
Worldwide Airlines, Inc.,
(Emery) flight 17, a McDonnell
Douglas DC-8-71F (DC-8), N8079U, crashed into an automobile
salvage yard shortly after takeoff, while attempting to
return
to Sacramento Mather Airport (MHR), Rancho Cordova,
California, for an emergency landing. Emery flight
17 was
operating under the provisions of 14 CFR Part 121 as a
scheduled cargo flight from MHR to James M. Cox Dayton
International Airport (DAY), Dayton, Ohio. The flight
departed MHR about 1949, with two pilots and a flight
engineer
on board. The
three flight crewmembers were killed, and the
airplane was destroyed.
Night visual meteorological
conditions prevailed for the flight, which operated on an
instrument flight rules flight plan.
A-03-22. Require all
DC-8 operators to train DC-8 flight
crewmembers to look for symmetry between the right and left
side elevators, control tabs, and geared tabs during the
preflight inspection, consistent with Boeing's June 2001
flight operations bulletin guidance.
FAA LTR DTD: 1/12/04
The Federal Aviation
Administration (FAA) agrees with the
intent of this safety recommendation and will issue a
notice to principal operations inspectors to request that
they inform their DC-8 operators to train flight
crewmembers to conduct an elevator flight control rollout
check in accordance with Flight Operations Bulletin
No. DC-8-01-02. The FAA plans to issue the notice by
December 2003.
I will provide the Board
with a copy of the notice as
soon as it is issued.
http://www1.faa.gov/avr/aai/A-03-023.txt
On February 16, 2000, about 1951 Pacific standard time, Emery
Worldwide Airlines, Inc., (Emery) flight 17, a McDonnell
Douglas DC-8-71F (DC-8), N8079U, crashed into an automobile
salvage yard shortly after takeoff, while attempting to return
to Sacramento Mather Airport (MHR), Rancho Cordova,
California, for an emergency landing. Emery flight 17 was
operating under the provisions of 14 CFR Part 121 as a
scheduled cargo flight from MHR to James M. Cox Dayton
International Airport (DAY), Dayton, Ohio. The flight
departed MHR about 1949, with two pilots and a flight engineer
on board. The three flight crewmembers were killed, and the
airplane was destroyed. Night visual meteorological
conditions prevailed for the flight, which operated on an
instrument flight rules flight plan.
A-03-23. Require the development of DC-8 80-knot elevator
check procedures that will ensure that pilots are clearly made
aware of whether the elevator is functioning properly before
the airplane lifts off, then require all DC-8 operators to
incorporate these procedures into their training and normal
operations. The procedures should contain specific guidance
regarding an expected range of elevator position indicator
(EPI) needle movement (including EPI needle movement well
below the neutral mark with forward control column movement)
and specific criteria for aborting a takeoff as a result of an
inadequate elevator movement indication.
FAA LTR DTD: 1/12/04
The FAA believes that the procedures outlined in Boeing
Flight Operations Bulletin No. DC-8-01-02 addresses the
intent of this safety recommendation completely. The
bulletin includes the most appropriate and safest
procedure for ensuring the proper function of the
elevator control system. It was not intended to use the
elevator position indicator with the optional 80-knot
check. Additionally, the elevator position indicator is
not easily observed from the pilot-in-command duty
position, thus making the 80-knot check difficult and
possibly unsafe if the second-in-command is conducting
the takeoff. This issue is further discussed in our
response to Safety Recommendation A-03-25.
I believe that the FAA has satisfactorily responded to
this safety recommendation, and I look forward to your
response.
http://www1.faa.gov/avr/aai/A-03-024.txt
On February 16,
2000, about 1951 Pacific
standard time, Emery
Worldwide Airlines, Inc.,
(Emery) flight 17, a McDonnell
Douglas DC-8-71F (DC-8), N8079U, crashed into an automobile
salvage yard shortly after takeoff, while attempting to
return
to Sacramento Mather Airport (MHR), Rancho Cordova,
California, for an emergency landing. Emery flight
17 was
operating under the provisions of 14 CFR Part 121 as a
scheduled cargo flight from MHR to James M. Cox Dayton
International Airport (DAY), Dayton, Ohio. The flight
departed MHR about 1949, with two pilots and a flight
engineer
on board. The
three flight crewmembers were killed, and the
airplane was destroyed.
Night visual meteorological
conditions prevailed for the flight, which operated on an
instrument flight rules flight plan.
A-03-24. Require all
DC-8 operators to incorporate periodic
elevator position indicator (EPI) calibration inspections
into
their maintenance programs to ensure that the EPI
indications
observed by pilots accurately represent the condition of the
elevator.
FAA LTR DTD: 1/12/04
Boeing does not currently
have a calibration requirement
for the elevator position indicator. Boeing is reviewing
the service bulletin that installed the elevator
position
indicator, accuracies of the elevator position indicator,
and this safety recommendation. At the present time, the
service bulletin is the only source of information, and
it does not contain calibration information. The FAA
will continue to work with Boeing on this matter.
http://www1.faa.gov/avr/aai/A-03-025.txt
On February 16,
2000, about 1951 Pacific
standard time, Emery
Worldwide Airlines, Inc.,
(Emery) flight 17, a McDonnell
Douglas DC-8-71F (DC-8), N8079U, crashed into an automobile
salvage yard shortly after takeoff, while attempting to
return
to Sacramento Mather Airport (MHR), Rancho Cordova,
California, for an emergency landing. Emery flight
17 was
operating under the provisions of 14 CFR Part 121 as a
scheduled cargo flight from MHR to James M. Cox Dayton
International Airport (DAY), Dayton, Ohio. The flight
departed MHR about 1949, with two pilots and a flight engineer
on board. The
three flight crewmembers were killed, and the
airplane was destroyed.
Night visual meteorological
conditions prevailed for the flight, which operated on an
instrument flight rules flight plan.
A-03-25. Require DC-8
elevator position indicators to be
located and sized so that they are visible and usable for
both
the captain and first officer.
FAA LTR DTD: 1/12/04
The elevator position
indicator (EPI) was originally
installed per instructions contained in Service
Bulletin 27-264 and mandated
by Airworthiness
Directive
78-01-15. The service bulletin defined the
installation of the EPI on the first officer's instrument
panel at a location that is not obstructed by the control
column or wheel. The
location of the EPI on the first
officer's instrument panel can vary from operator to
operator. The EPI was
originally intended to be used
during the static preflight check when the aircraft was
parked. The EPI was
not intended to be used with the
80-knot check, which was an
optional procedure to be used
if a successful preflight check could not be
accomplished
at the gate due to tail winds. Under this optional
procedure the pilot is to check "aircraft response due to
small up and down elevator inputs" (reference DC-8
All
Operators Letter No. 53A
dated May 25, 1977).
Following the Emery
accident, Boeing issued a Flight
Operations Bulletin (FOB) to
all DC-8 operators on
June 19, 2001. The FOB
discussed the recommended
procedures for checking the flight controls prior to
takeoff, including checking the alignment of the control
and geared tabs during the preflight exterior inspection
of the airplane, with the gust lock on and off, and the
recommended procedure for conducting flight control
checks prior to initiating takeoff. Boeing continues to
endorse the procedures described in the FOB, which do not
include use of the EPI during takeoff. I have enclosed a
copy of the FOB for your information.
The FAA believes that proper
adherence to the FOB is the
most appropriate means of ensuring proper function of the
elevator control system.
The 80-knot check is not
mandated and is not believed to be a better method than
the elevator system check that is outlined in the
FOB.
The FAA believes that the
safety of the aircraft is best
served by ensuring the proper function of the elevator
system prior to the takeoff roll. In the letter to the
FAA dated August 18, 2003, the Board states:
"The
80-knot elevator check
provides flight crews with their
last chance to detect abnormal elevator
performance…."
The FAA believes that if
proper adherence is made to the
FOB, the only value of the
80-knot check is to evaluate
whether the elevator system has experienced a failure
between the time of the performance of the check in the
FOB and when the aircraft is
at 80-knots. The added
safety provided by this is not sufficient to offset the
added workload on the pilot.
The FAA does not believe the
80-knot check should be
mandated and, therefore, believes it is not necessary for
the elevator position indicator to be resized or
relocated. In light of
the above discussion, we believe
no further action is required.
I believe that the FAA has
satisfactorily responded to
this safety recommendation, and I look forward to your
response.
http://www1.faa.gov/avr/aai/A-03-026.txt
On February 16, 2000, about 1951 Pacific standard time, Emery
Worldwide Airlines, Inc., (Emery) flight 17, a McDonnell
Douglas DC-8-71F (DC-8), N8079U, crashed into an automobile
salvage yard shortly after takeoff, while attempting to return
to Sacramento Mather Airport (MHR), Rancho Cordova,
California, for an emergency landing. Emery flight 17 was
operating under the provisions of 14 CFR Part 121 as a
scheduled cargo flight from MHR to James M. Cox Dayton
International Airport (DAY), Dayton, Ohio. The flight
departed MHR about 1949, with two pilots and a flight engineer
on board. The three flight crewmembers were killed, and the
airplane was destroyed. Night visual meteorological
conditions prevailed for the flight, which operated on an
instrument flight rules flight plan.
A-03-26. Require Boeing to redesign DC-8 elevator control tab
installations and require all DC-8 operators to then retrofit
all DC-8 airplanes with these installations such that pilots
are able to safely operate the airplane if the control tab
becomes disconnected from the pushrod.
FAA LTR DTD: 1/12/04
The FAA concurs with the safety recommendation. Boeing
is developing an enhanced design of the DC-8 control tab
pushrod that will prevent the pushrod from dropping down
in front of or otherwise moving in front of the control
tab crank, should the bolt migrate out of the connecting
joint (as a result of either an incorrect assembly or a
bolt failure). Boeing plans to issue a service bulletin
to the operators by June 2004. Following the issuance of
the service bulletin, the FAA plans to issue a notice of
proposed rulemaking to make it mandatory.
I will keep the Board informed of the FAA's progress on
this safety recommendation.
http://www1.faa.gov/avr/aai/A-03-027.txt
On February 16,
2000, about 1951 Pacific standard time, Emery Worldwide Airlines, Inc., (Emery)
flight 17, a McDonnell Douglas DC-8-71F (DC-8), N8079U, crashed into an
automobile salvage yard shortly after takeoff, while attempting to return to
Sacramento Mather Airport (MHR), Rancho Cordova, California, for an emergency landing. Emery flight 17 was
operating under the provisions of 14 CFR Part 121 as a scheduled cargo flight
from MHR to James M. Cox Dayton International Airport (DAY), Dayton, Ohio. The flight departed MHR about 1949, with two pilots
and a flight engineer on board. The three flight crewmembers were killed, and
the airplane was destroyed. Night visual meteorological conditions prevailed
for the flight, which operated on an instrument flight rules flight plan.
A-03-27. Evaluate airplanes other than the DC-8 certificated
to Civil Aviation Regulations 4b standards to evaluate whether disconnection or
failure of critical flight control systems could have catastrophic results and,
if so, require that they also be redesigned and retrofitted and/or equipped
with dual-locking devices to preclude such catastrophic results.
FAA LTR DTD: 1/12/04 The recommendation focuses
on airplanes certificated to CAR 4b because current regulations (14 CFR 25.607)
require two separate locking devices. However, the FAA notes that this
requirement was not introduced until Amendment 25-23. Therefore, any evaluation
should address airplanes certified to CAR 4b, as well as airplanes that include
14 CFR 25.607 at Amendment 25-0 in the certification basis. Based on the scope
of the recommendation, the FAA intends to conduct a service history review
focused on the service difficulty reports related to the failure of dual
locking devices. Upon completion of this review, the FAA will determine the
appropriate next steps and actions if warranted. It is anticipated that the
review will be completed by October 31, 2004. I will inform the Board of the FAA's course of
action to address this safety recommendation after the review is completed.
http://www1.faa.gov/avr/aai/A-03-028.txt
On February 16, 2000, about 1951 Pacific standard time, Emery
Worldwide Airlines, Inc., (Emery) flight 17, a McDonnell
Douglas DC-8-71F (DC-8), N8079U, crashed into an automobile
salvage yard shortly after takeoff, while attempting to return
to Sacramento Mather Airport (MHR), Rancho Cordova,
California, for an emergency landing. Emery flight 17 was
operating under the provisions of 14 CFR Part 121 as a
scheduled cargo flight from MHR to James M. Cox Dayton
International Airport (DAY), Dayton, Ohio. The flight
departed MHR about 1949, with two pilots and a flight engineer
on board. The three flight crewmembers were killed, and the
airplane was destroyed. Night visual meteorological
conditions prevailed for the flight, which operated on an
instrument flight rules flight plan.
A-03-28. Require all DC-8 operators to replace all DC-8
aluminum elevator geared tab crank arms on their DC-8
airplanes with stainless steel elevator geared tab crank arms.
FAA LTR DTD: 1/12/04
In the letter to the FAA dated August 18, 2003, the Board
correctly found that the past history of aluminum geared
tab crank arm failures was not a factor in this accident.
The FAA concurs with Boeing that replacement of the
aluminum geared tab crank arm with a steel crank arm is a
product improvement. However, the existing aluminum
geared tab crank arm meets all of the type design
requirements for strength and durability. The FAA, in
conjunction with Boeing, is reviewing the service history
of the aluminum crank arm to determine if an unsafe
condition exists that would require mandating replacement
of the aluminum crank arms with steel.
It is anticipated that the review will be completed by
April 2004. I will inform the Board of the FAA's course
of action to address this safety recommendation after the
review is completed.
http://www1.faa.gov/avr/aai/A-03-029.txt
On February 16, 2000, about 1951 Pacific standard time, Emery
Worldwide Airlines, Inc., (Emery) flight 17, a McDonnell
Douglas DC-8-71F (DC-8), N8079U, crashed into an automobile
salvage yard shortly after takeoff, while attempting to return
to Sacramento Mather Airport (MHR), Rancho Cordova,
California, for an emergency landing. Emery flight 17 was
operating under the provisions of 14 CFR Part 121 as a
scheduled cargo flight from MHR to James M. Cox Dayton
International Airport (DAY), Dayton, Ohio. The flight
departed MHR about 1949, with two pilots and a flight engineer
on board. The three flight crewmembers were killed, and the
airplane was destroyed. Night visual meteorological
conditions prevailed for the flight, which operated on an
instrument flight rules flight plan.
A-03-29. Require all DC-8 operators to create or revise DC-8
work cards to ensure they specifically include a postrigging
inspection of the elevator assembly, including verifying the
security of elevator control tab attachments.
FAA LTR DTD: 1/12/04
After the Emery accident, Boeing reviewed the elevator
control rod procedures contained in the DC-8 Airplane
Maintenance Manual (AMM). On May 8, 2002, Boeing issued
Temporary Revisions 27-207, 27-208, 27-561, 27-562, and
27-563 to the DC-8 AMM to state that proper connection of
the control tab pushrod to the control tab crank (and the
geared tab drive rod to the geared tab crank) requires
that the bolt, washer, and nut are installed and that the
nut is tightened and held in place with the cotter pin.
The revisions also included illustrations of the bolt,
nut, washer, and cotter pin. Boeing is presently
reviewing post-rigging inspection of the elevator
assembly and security procedures of the elevator control
tab attachments.
The FAA will continue to work with Boeing on this matter.
It is anticipated that the Boeing review will be
completed January 2004. I will inform the Board of the
FAA's course of action when the review is completed.
http://www1.faa.gov/avr/aai/A-03-030.txt
On February 16, 2000, about 1951 Pacific standard time, Emery
Worldwide Airlines, Inc., (Emery) flight 17, a McDonnell
Douglas DC-8-71F (DC-8), N8079U, crashed into an automobile
salvage yard shortly after takeoff, while attempting to return
to Sacramento Mather Airport (MHR), Rancho Cordova,
California, for an emergency landing. Emery flight 17 was
operating under the provisions of 14 CFR Part 121 as a
scheduled cargo flight from MHR to James M. Cox Dayton
International Airport (DAY), Dayton, Ohio. The flight
departed MHR about 1949, with two pilots and a flight engineer
on board. The three flight crewmembers were killed, and the
airplane was destroyed. Night visual meteorological
conditions prevailed for the flight, which operated on an
instrument flight rules flight plan.
A-03-30. Require all DC-8 operators to review their work
cards related to critical flight controls, and revise them as
necessary to ensure that appropriate tasks are identified as
discrete tasks with individual inspection signoff
requirements.
FAA LTR DTD: 1/12/04
Work cards associated with the DC-8 were produced several
years ago as part of the On-Aircraft Maintenance Planning
Document. Many DC-8 operators developed their own work
cards that may have deviated from the manufacturer's
details. Boeing is presently reviewing critical flight
controls (including elevator), maintenance procedures,
and associated task cards. The details contained on
these work cards are unknown at the present time.
The FAA will continue to work with Boeing on this matter.
It is anticipated that the Boeing review will be
completed January 2004. I will inform the Board of the
FAA's course of action when the review is completed.
http://www1.faa.gov/avr/aai/A-03-031.txt
On February 16, 2000, about 1951 Pacific standard time, Emery
Worldwide Airlines, Inc., (Emery) flight 17, a McDonnell
Douglas DC-8-71F (DC-8), N8079U, crashed into an automobile
salvage yard shortly after takeoff, while attempting to return
to Sacramento Mather Airport (MHR), Rancho Cordova,
California, for an emergency landing. Emery flight 17 was
operating under the provisions of 14 CFR Part 121 as a
scheduled cargo flight from MHR to James M. Cox Dayton
International Airport (DAY), Dayton, Ohio. The flight
departed MHR about 1949, with two pilots and a flight engineer
on board. The three flight crewmembers were killed, and the
airplane was destroyed. Night visual meteorological
conditions prevailed for the flight, which operated on an
instrument flight rules flight plan.
A-03-31. Require all 14 CFR Part 121 air carrier operators to
revise their task documents and/or work cards to describe
explicitly the process to be followed in accomplishing
maintenance tasks.
FAA LTR DTD: 1/12/04
Consistent with the Board's findings and Safety
Recommendations A-03-24, -29, and -30 as stated in the
Board's letter to the FAA Administrator dated August 18,
2003, the FAA believes that Safety
Recommendations A-03-31 and -32 are appropriately limited
to DC-8 operators only. Temporary revisions to the DC-8
AMM issued by Boeing on May 8, 2002, are explicit and
describe the process to be followed. Boeing is reviewing
elevator maintenance procedures.
The FAA will continue to work with Boeing on this matter.
It is anticipated that this will take 60-90 days. When
the DC-8 was produced, installation drawings were
reproduced in large paper format. Because the DC-8 is an
older era airplane, installations drawings are not
readily available and have not been converted to more
readily useable forms such as CD-ROM. The Illustrated
Parts Catalog is not intended to serve as a reassembly
document but rather a means of locating a particular
part. At the present time, Boeing is currently reviewing
installation drawing and detailed maintenance procedure
availability for the DC-8.
It is anticipated that the Boeing review will be
completed January 2004. I will inform the Board of the
FAA's course of action when the review is completed.
http://www1.faa.gov/avr/aai/A-03-032.txt
On February 16, 2000, about 1951 Pacific standard time, Emery
Worldwide Airlines, Inc., (Emery) flight 17, a McDonnell
Douglas DC-8-71F (DC-8), N8079U, crashed into an automobile
salvage yard shortly after takeoff, while attempting to return
to Sacramento Mather Airport (MHR), Rancho Cordova,
California, for an emergency landing. Emery flight 17 was
operating under the provisions of 14 CFR Part 121 as a
scheduled cargo flight from MHR to James M. Cox Dayton
International Airport (DAY), Dayton, Ohio. The flight
departed MHR about 1949, with two pilots and a flight engineer
on board. The three flight crewmembers were killed, and the
airplane was destroyed. Night visual meteorological
conditions prevailed for the flight, which operated on an
instrument flight rules flight plan.
A-03-32. Require all air carrier operators to either:
1) provide all pertinent maintenance personnel with the
manufacturer's current installation drawings for pertinent
airplanes, update those installation drawings as needed, and
require use of those drawings during installation and/or
assembly of that airplane's components; or 2) list the IPC on
that operator's operation specifications, provide maintenance
personnel with up-to-date IPCs for reference, continue to
update those IPCs as needed, and require maintenance personnel
to use the pertinent updated IPCs during installation and/or
assembly of an airplane's components.
FAA LTR DTD: 1/12/04
Consistent with the Board's findings and Safety
Recommendations A-03-24, -29, and -30 as stated in the
Board's letter to the FAA Administrator dated August 18,
2003, the FAA believes that Safety
Recommendations A-03-31 and -32 are appropriately limited
to DC-8 operators only. Temporary revisions to the DC-8
AMM issued by Boeing on May 8, 2002, are explicit and
describe the process to be followed. Boeing is reviewing
elevator maintenance procedures.
The FAA will continue to work with Boeing on this matter.
It is anticipated that this will take 60-90 days. When
the DC-8 was produced, installation drawings were
reproduced in large paper format. Because the DC-8 is an
older era airplane, installations drawings are not
readily available and have not been converted to more
readily useable forms such as CD-ROM. The Illustrated
Parts Catalog is not intended to serve as a reassembly
document but rather a means of locating a particular
part. At the present time, Boeing is currently reviewing
installation drawing and detailed maintenance procedure
availability for the DC-8.
It is anticipated that the Boeing review will be
completed January 2004. I will inform the Board of the
FAA's course of action when the review is completed.
http://www1.faa.gov/avr/aai/A-03-033.txt
On February 16, 2000, about 1951 Pacific standard time, Emery
Worldwide Airlines, Inc., (Emery) flight 17, a McDonnell
Douglas DC-8-71F (DC-8), N8079U, crashed into an automobile
salvage yard shortly after takeoff, while attempting to return
to Sacramento Mather Airport (MHR), Rancho Cordova,
California, for an emergency landing. Emery flight 17 was
operating under the provisions of 14 CFR Part 121 as a
scheduled cargo flight from MHR to James M. Cox Dayton
International Airport (DAY), Dayton, Ohio. The flight
departed MHR about 1949, with two pilots and a flight engineer
on board. The three flight crewmembers were killed, and the
airplane was destroyed. Night visual meteorological
conditions prevailed for the flight, which operated on an
instrument flight rules flight plan.
A-03-33. Require operators of airplanes manufactured before
August 18, 2000, that have been retrofitted with additional
flight data recorder (FDR) parameters in compliance with
Federal requirements and for which an operator maintains a
common correlation document for that airplane type to conduct
a full correlation of all such airplanes' FDR parameters at
the airplanes' next required FDR maintenance inspection to
verify accurate FDR system documentation and sensor function.
FAA LTR DTD: 1/12/04
This safety recommendation proposes that the FAA require
operators to perform a full correlation on each aircraft
that was manufactured before August 18, 2000. The FAA's
staff met with the Board's staff on September 25, 2003,
to discuss this safety recommendation and to agree to an
acceptable course of action. It was agreed at this
meeting that FAA would revise Advisory Circular
(AC) 20-141, Airworthiness and Operational Approval of
Digital Flight Data Recorder Systems, to address the
common correlation issues raised by the Board in this
safety recommendation. It is anticipated that the
revision to AC 20-141 will be published by June 2004.
I will provide the Board with a copy of the revision as
soon as it is issued.
http://www1.faa.gov/avr/aai/A-03-034.txt
On February 16, 2000, about 1951 Pacific standard time, Emery
Worldwide Airlines, Inc., (Emery) flight 17, a McDonnell
Douglas DC-8-71F (DC-8), N8079U, crashed into an automobile
salvage yard shortly after takeoff, while attempting to return
to