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Safety Recommendation Details

Safety Recommendation A-09-026
Details
Synopsis: On September 28, 2007, about 1313 central daylight time, American Airlines flight 1400, a McDonnell Douglas DC-9-82 (MD-82),2 N454AA, experienced an in-flight engine fire during departure climb from Lambert-St. Louis International Airport (STL), St. Louis, Missouri. During the return to STL, the nose landing gear failed to extend, and the flight crew executed a go-around, during which the crew extended the nose gear using the emergency procedure. The flight crew conducted an emergency landing, and the 2 flight crewmembers, 3 flight attendants, and 138 passengers deplaned on the runway. No occupant injuries were reported, but the airplane sustained substantial damage from the fire. The scheduled passenger flight was operating under the provisions of 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require that operators provide pilots with guidance requiring that pilots and flight attendants actively monitor exit availability and configure the airplane and cabin for an evacuation when the airplane is stopped away from the gate after a significant event to help expedite an emergency evacuation if one becomes necessary.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: St. Louis, MO, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA07MA310
Accident Reports: In-Flight Left Engine Fire, American Airlines Flight 1400, McDonnell Douglas DC-9-82
Report #: AAR-09-03
Accident Date: 9/28/2007
Issue Date: 5/19/2009
Date Closed: 3/18/2014
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Evacuation, Flight Attendants, Flightcrew, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 3/18/2014
Response: The May 20, 2011, SNPRM contained the recommended requirement, and in our comments we stated that, if implemented as proposed, the final rule would close this recommendation. Unfortunately, the November 12, 2013, final rule does not contain the relevant provisions that were included in the SNPRM. Consequently, Safety Recommendation A-09-26 is classified CLOSED—UNACCEPTABLE ACTION.

From: NTSB
To: FAA
Date: 3/22/2013
Response: The NTSB is encouraged that the FAA is working to publish a final rule as soon as possible to implement the recommended requirement, which was specified in the supplemental notice of proposed rulemaking “Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers,” published by the FAA on May 20, 2011. Pending publication of the final rule as proposed, Safety Recommendation A-09-26 remains classified OPEN—ACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 1/18/2013
Response: -From Michael P. Huerta, Administrator: On May 20, 2011, the Federal Aviation Administration (FAA) published the Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers Supplemental Notice of Proposed Rulemaking (SNPRM). The preamble lists over 20 recommendations that the FAA feels would be addressed by this rulemaking, including Safety Recommendation A-09-26. In its July 15, 2011, comments to the SNPRM, the Board agreed with the f AA that the proposed changes in the SNPRM would address this recommendation. The Board stated that "[t]he SNPRM contains language requiring that flight and cabin crewmembers be trained to actively monitor exit availability and to configure the airplane and cabin for an evacuation when it is stopped away from the gate after a significant event. If this language is retained in the resulting final rule, it will likely represent an acceptable response to this recommendation and it will be closed." Specifically, Appendix S, Flight Attendant Qualification Performance Standards, Task 2, (d), (4), Land and Water Evacuation, under "Flight Attendant Duties and Responsibilities - Emergency" of the SNPRM, states that when the "airplane is stopped away from the gate after a significant event, ensure exits are armed and actively monitor exit availability in case an emergency evacuation is necessary" as a required training task. Additionally, Appendix Q. Pilot Qualification Performance Standards, Table 2A, (b), (8) requires training regarding communication and coordination between pilots and flight attendants during an emergency situation, which would also address this issue. We are working to publish a final rule as expeditiously as possible. The draft Advisory Circular, Flight Attendant Training and Evaluation, published with the SNPRM for comment, contains guidance that certificate holders should conduct flightcrew member and flight attendant crew resource management emergency scenarios together. When this is not possible, certificate holders should include information in flight attendant training that addresses the role of flightcrew members during emergency situations. In addition, the Safety Alert for Operators (SAFO) mentioned in our last letter, which discusses crew coordination, monitoring exit availability, and configuring the cabin for evacuation away from the gate, continues to be worked. This SAFO was delayed due to internal coordination and is expected to be released by the end of2013. I will keep the Board informed of the FAA's progress on this recommendation and provide an update by December 31, 2013.

From: NTSB
To: FAA
Date: 7/15/2011
Response: Notation 8106A: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration's (FAA) supplemental notice of proposed rulemaking (SNPRM) titled "Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers," published at 76 Federal Register 29336-29526 on May 20, 2011. The notice proposes to amend the regulations for flight and cabin crewmember and aircraft dispatcher training programs in domestic, flag, and supplemental operations. The proposed regulations are intended to contribute significantly to reducing aviation accidents by requiring the use of flight simulation training devices (FSTD) for flight crewmembers and including additional training and evaluation requirements for all crewmembers and aircraft dispatchers in areas that are critical to safety. The proposal also reorganizes and revises the qualification, training, and evaluation requirements. The SNPRM is based on the FAA's review of comments submitted in response to the January 12, 2009, notice of proposed rulemaking (NPRM) on these issues and its determination that the NPRM did not adequately address or clarify some topics; it is also based on provisions of the Airline Safety and Federal Aviation Administration Extension Act of 2010. The SNPRM contains language requiring that flight and cabin crewmembers be trained to actively monitor exit availability and to configure the airplane and cabin for an evacuation when it is stopped away from the gate after a significant event. If this language is retained in the resulting final rule, it will likely represent an acceptable response to this recommendation and it will be closed.

From: NTSB
To: FAA
Date: 1/10/2011
Response: The FAA previously informed the NTSB that a notice of proposed rulemaking (NPRM), titled “Qualification, Service, and use of Crewmembers and Aircraft Dispatchers,” published January 12, 2009, addressed this recommendation. The NTSB replied that we could not identify which sections of the NPRM addressed the specific actions recommended, and we asked the FAA to describe these revisions. In its June 25, 2010, letter, the FAA stated that it would be necessary to develop a supplemental notice of proposed rulemaking (SNPRM) for the NPRM to satisfy Safety Recommendation A-09-26. In addition, the FAA cited sections of 14 Code of Federal Regulations Part 121 that establish the requirement for pilots and flight attendants to actively monitor exit availability to prepare for an evacuation if one becomes necessary. Consequently, pending publication of the SNPRM and a final rule that contain appropriate language to address this recommendation, Safety Recommendation A-09-26 remains classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/25/2010
Response: MC# 2100238 - From J. Randolph Babbitt, Administrator: In its last letter, the Board requested a description of the specific portion of the Qualification, Service, and use of Crewmembers and Aircraft Dispatchers Notice of Proposed Rule Making (NPRM) that addressed this recommendation. We have finished drafting a Qualification, Service, and use of Crewmembers and Aircraft Dispatchers Supplemental Notice of Proposed Rule Making (SNPRM), which will appropriately address this recommendation. We expect to publish the SNPRM later this year. The Federal Aviation Administration agrees that pilots and flight attendants should be at their duty station and demonstrate situational awareness during critical phases of flight. We note that Title 14 Code of Federal Regulations (14 CFR) § 121.542(b), Flight Crewmember Duties, describes the requirements for flight crewmembers during movement on the surface. Specifically, § 121.391(d), Flight Attendants, describes the conditions where flight attendants must be uniformly distributed throughout the airplane in order to provide the most effective egress of passengers in the event of an emergency evacuation. During taxi, flight attendants required by this section must remain at their duty stations with safety belts and shoulder harnesses fastened except to perform duties related to the safety of the airplane and its occupants. These two rules establish the requirement for pilots and flight attendants to actively monitor exit availability to prepare for an evacuation if one becomes necessary. In addition to the SNPRM and current regulations, the FAA has drafted and will release by the end of Fiscal Year 2010 a Safety Alert for Operators (SAFO) citing this recommendation to provide additional guidance for operators. The SAFO will stress the importance of crew coordination, actively monitoring exit availability, and configuring the airplane and cabin for evacuation when an airplane is stopped away from the gate after a significant event. I will keep the Board informed of the FAA's progress on this safety recommendation, and provide an updated response by November 30, 2010.

From: NTSB
To: FAA
Date: 4/2/2010
Response: The FAA stated that the January 12, 2009, NPRM also addresses this recommendation with detailed curriculum requirements for flight crewmembers and flight attendants. The NTSB acknowledges the FAA’s positive response to this recommendation but could not identify which sections of the proposed revisions will address the specific actions recommended here and asks the FAA to describe these revisions. Pending a description of the specific portion of the revised regulation that will address the recommendation and issuance of the final rule proposed in the January 12, 2009, NPRM, Safety Recommendation A-09-26 is classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/11/2009
Response: Letter Mail Controlled 8/31/2009 2:09:47 PM MC# 2090551: - From J. Randolph Babbitt, Administrator: On January 12, 2009, the FAA published NPRM Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers. The comment period for the NPRM closed on August 10, 2009. The NPRM proposed to amend the regulations for crewmember and dispatcher training programs in domestic, flag, and supplemental operations. The proposed regulations enhance traditional training programs by requiring the use of flight simulation training devices for flight crewmembers and include additional training requirements in areas that are critical to safety. As indicated in the preamble of the NPRM, to make the proposed training requirements as effective as possible, the FAA reviewed several safety recommendations issued by the Board, which included many concerning training that have since been closed. The FAA also reviewed NTSB Report, Flight Attendant Training and Performance During Emergency Situations (NTSB/SIR-92/02), and 169 accidents related to training. The proposed rule addresses this recommendation with detailed curriculum requirements for flight crewmembers and flight attendants. The proposed curriculum includes: Workload management and situational awareness; Preparation and planning; Vigilance and workload distribution; Distraction avoidance; Notification between flightcrew and flight attendants of emergency or unusual situations; Actions (and alternate actions) for each emergency situation and emergency communications with passengers and other crewmembers; Recognition of the need for evacuation and recognition of the importance of maintaining situational awareness; and The ability to anticipate and adapt as an emergency progresses.