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Safety Recommendation Details

Safety Recommendation A-09-027
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: Revise Advisory Circular 120-48, Communication and Coordination Between Flight Crewmembers and Flight Attendants, to update guidance and training provided to flight and cabin crews regarding communications during emergency and unusual situations to reflect current industry knowledge based on research and lessons learned from relevant accidents and incidents over the last 20 years.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Aviation
Location: St. Louis, MO, United States
Is Reiterated: Yes
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:
Addressee(s) and Addressee Status: FAA (Open - Unacceptable Response)
Keyword(s): Communication

Safety Recommendation History
From: FAA
To: NTSB
Date: 7/11/2019
Response: -From Daniel K. Elwell, Acting Administrator: As noted in our August 28, 2012, letter to the Board, the FAA published the Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers Supplemental Notice of Proposed Rulemaking (SNPRM) addressing this recommendation on May 20, 2011. We acknowledge the Board's reply on March 18, 2014, noting that the language in the SNPRM requiring that initial and recurrent flight and cabin crew training include communication during emergencies would satisfy this safety recommendation. On November 12, 2013, the FAA published the Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers Final Rule (78 FR 67799). This final rule enhances air carrier pilot training programs by emphasizing the development of pilots' manual handling skills and adding safety-critical tasks such as recovery from stall and upset. It also requires enhanced runway safety training and pilot monitoring training to be incorporated into existing requirements for scenario-based flight training, and requires air carriers to implement remedial training programs for pilots. The FAA recognizes the critical safety roles and contributions of all crewmembers and aircraft dispatchers in today's integrated operating environment. The agency has taken steps outside of this final rule to ensure that crewmember and aircraft dispatcher training reflects that integrated operating environment. Since the publication of the final rule, however, there have been several changes within the aviation industry, such as changes to the Airline Transport Pilot certification requirements for first officers (second in command pilots) which raised the baseline knowledge and skill set of pilots entering air carrier operations. Many air carriers also developed safety management systems to identify risks unique to their own operating environments (including air carrier training programs), and established mitigations to address those risks. Implementation of the initiatives identified in the FAA' s 2009 Call to Action to Enhance Airline Safety also impacted the training environment. As a result of these changes, the FAA believes it is necessary to consider the cumulative effects of these efforts across the aviation industry before additional regulations are imposed. Our letter to the Board, dated August 28, 2012, discussed revising AC 120-48 to update guidance regarding communications during emergency and unusual situations. Although we previously anticipated publication of the updated AC in 2013, this was delayed while the FAA issued several amendments to the final rule in 2014 and 2016. In light of these activities, we are evaluating whether to proceed with a revision or a new AC.

From: NTSB
To: FAA
Date: 6/6/2018
Response: Your April 26, 2018, letter regarding the American Airlines flight 383 accident recommendations did not discuss the current status of these recommendations. Please update us on your plans regarding Safety Recommendations A-09-27 and A-16-26, which remain classified OPEN--UNACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 2/6/2018
Response: A-09-027 was reiterated in the NTSB Aviation Accident Report “Uncontained Engine Failure and Subsequent Fire American Airlines Flight 383 Boeing 767-323, N345AN Chicago, Illinois October 28, 2016.” Report number AAR-18-01. Adopted on January 30, 2018 and published on February 6, 2018. Notation 57292. Safety Recommendation A-09-27 On May 19, 2009, the NTSB issued Safety Recommendation A-09-27 as a result of its investigation of the September 28, 2007, accident involving American Airlines flight 1400, an MD-82 that experienced an in-flight engine fire during a departure climb from Lambert St. Louis International Airport, St. Louis, Missouri, and made a successful emergency landing on one of the airport’s runways. The NTSB found that, during the emergency situation, the flight attendants did not relay potentially pertinent information to the captain in accordance with company guidance and training. In addition, the NTSB found that the flight crew considered initiating an evacuation but did not communicate with the cabin crew to obtain and exchange information (NTSB 2009).68 Safety Recommendation A-09-27 asked the FAA to do the following: Revise Advisory Circular 120-48, “Communication and Coordination Between Flight Crewmembers and Flight Attendants,” to update guidance and training provided to flight and cabin crews regarding communications during emergency and unusual situations to reflect current industry knowledge based on research and lessons learned from relevant accidents and incidents over the last 20 years.[69] On August 28, 2012, the FAA stated that it was revising AC 120-48 to update the guidance regarding communications during emergency and unusual situations to reflect current industry knowledge based on lessons learned. The FAA indicated that it anticipated issuing the revised AC in 2013. On March 18, 2014, the NTSB stated that, according to its conversations with the FAA, the issuance of revised AC 120-48 was delayed by work associated with a final rule, but the FAA indicated that it still intended to issue the revised AC. As a result, Safety Recommendation A-09-27 remained classified “Open—Acceptable Response” pending completion of that action.70 In its final report on the Delta Air Lines flight 1086 accident, the NTSB noted that the FAA had still not issued revised AC 120-48. Also, given the inadequate communication and coordination among the Delta flight and cabin crewmembers that the NTSB’s investigation found, the NTSB reiterated Safety Recommendation A-09-27 and reclassified it “Open—Unacceptable Response.” In a March 27, 2017, letter to the FAA, the NTSB stated that the FAA’s December 23, 2016, letter about recommendations from the Delta flight 1086 investigation did not include any actions that were planned or taken in response to Safety Recommendation A-09-27. The NTSB noted that the FAA stated that, as part of the response to Safety Recommendation A-16-25, it was reviewing AC 120-48 and was considering needed revisions.71 The NTSB stated that the FAA should consider the requested actions in Safety Recommendation A-09-27 in any revisions to AC 120-48 and that Safety Recommendation A-09-27 remained classified “Open—Unacceptable Response.”

From: NTSB
To: FAA
Date: 3/27/2017
Response: Your December 23, 2016, letter about the recommendations based on our investigation of the Delta flight 1086 accident did not discuss any additional actions that you had taken, or planned to take, to satisfy this recommendation. As discussed in your response to Safety Recommendation A 16-25, you are reviewing AC 120-48 and are considering needed revisions. We believe that you should include the revisions needed to satisfy Safety Recommendation A 09 27 in your activities related to AC 120-48. Please update us on your plans regarding Safety Recommendation A-09-27, which remains classified OPEN--UNACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 10/6/2016
Response: From the NTSB aviation accident report AAR-16-02: Runway Excursion During Landing Boeing MD-88, N909DL New York, New York March 5, 2015, issued on October 6, 2016, notation 8780: On May 19, 2009, the NTSB issued Safety Recommendation A-09-27 as a result of its investigation of the September 28, 2007, accident involving American Airlines flight 1400, an MD-82 that experienced an in-flight engine fire during a departure climb from STL and made a successful emergency landing on one of the airport’s runways. The NTSB found that, during the emergency situation, the flight attendants did not relay potentially pertinent information to the captain in accordance with company guidance and training. In addition, the NTSB found that the flight crew considered initiating an evacuation but did not establish communication with the cabin crew to obtain and exchange information (NTSB 2009).74 Safety Recommendation A-09-27 asked the FAA to do the following: Revise Advisory Circular 120-48, “Communication and Coordination Between Flight Crewmembers and Flight Attendants,” to update guidance and training provided to flight and cabin crews regarding communications during emergency and unusual situations to reflect current industry knowledge based on research and lessons learned from relevant accidents and incidents over the last 20 years. On August 28, 2012, the FAA stated that its supplemental notice of proposed rulemaking (SNPRM), “Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers,” addressed this recommendation by requiring that initial and recurrent flight and cabin crew training include communication during emergency situations (NARA 2011). The FAA also stated that it was revising AC 120-48 to update the guidance regarding communications during emergency and unusual situations to reflect current industry knowledge based on lessons learned. The FAA indicated that it anticipated issuing the revised AC in 2013. On March 18, 2014, the NTSB stated that the final rule resulting from the SNPRM did not contain the action addressed in this recommendation but noted that the recommended action could be accomplished outside of the final rule (NARA 2013). The NTSB also stated that, according to its conversations with the FAA, the issuance of revised AC 120-48 was delayed by work associated with the final rule, but the FAA indicated that it still intended to issue the revised AC 120-48. As a result, Safety Recommendation A-09-27 remained classified “Open— Acceptable Response” pending completion of that action. In addition, as discussed in section 1.10.3.3, the NTSB issued Safety Recommendation A-09-27 in response to its findings from the American Airlines flight 1400 accident. The recommendation asked the FAA to update the guidance and training provided to flight and cabin crews regarding communication and coordination during emergency and unusual situations. On August 28, 2012, the FAA stated that a revision to AC 120-48, which was expected in 2013, would provide updated guidance regarding communications during emergency and unusual situations to reflect the latest industry knowledge based on lessons learned. However, as of September 1, 2016, the FAA had not issued the revised AC. Given the inadequate communication and coordination among the Delta flight 1086 flight and cabin crewmembers, the NTSB reiterates Safety Recommendation A-09-27 and reclassifies it OPEN—UNACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 3/18/2014
Response: In your August 28, 2012, letter, you stated that the SNPRM addressed this recommendation by requiring that initial and recurrent flight and cabin crew training include communication during emergency situations. In our comments on the SNPRM, we said that, if that language were retained in the final rule, the rule’s publication would satisfy Safety Recommendation A-09-27. You also stated that a revision to AC 120-48 had been drafted, and was being internally reviewed. Although the November 12, 2013, final rule did not contain the provisions relevant to this recommendation, the action called for in this recommendation is not dependent on the final rule. From conversations between FAA and NTSB staff, we have learned that issuance of the revised AC was delayed by work associated with issuing the final rule. Now that the rule has been issued, we are encouraged that you intend to finish revising AC 120 48 and issue the document soon. Pending completion of that action, Safety Recommendation A-09-27 remains classified OPEN—ACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 11/20/2012
Response: The NTSB notes that the FAA is currently reviewing the comments received in response to the “Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers” supplemental notice of proposed rulemaking (SNPRM). The SNPRM requires that initial and recurrent flight and cabin crew training include communication during emergency situations. We note that the FAA has also started revising AC 120-47, “Communication and Coordination Between Flight Crewmembers and Flight Attendants,” as recommended. Pending the publication of the revised AC 120-48, Safety Recommendation A-09-27 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/28/2012
Response: -From Michael P. Huerta, Acting Administrator: As noted in our October 29, 2011 , letter, the Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers Supplemental Notice of Proposed Rulemaking (SNPRM) addresses this recommendation. The Federal Aviation Administration (FAA) published the SNI'RM on May 20, 20 11. Specifically, the SNRPM addresses this recommendation by requiring that initial and recurrent flight and cabin crew training include communication during emergency situations. Specifically, these requirements include: (1) identifying the actions needed for each emergency situation; (2) determining the importance of notification ; (3) establishing who needs to be notified; (4) planning alternate actions when notification of personnel is impossible; and (5) preparing for a planned emergency evacuation by communicating such information as time available, type of emergency signals to brace, and other special instructions. The comment period to the SNPRM closed on July 19, 2011, and we are currently reviewing comments received to the docket. We anticipate publishing a final rule in 2013. The FAA has also begun to draft a change to AC I20A7, Communication and Coordination between Flight Crewmembers and Flight Attendants. The draft revision is currently being reviewed by subject matter experts to determine if additional revisions arc necessary. The AC is being revised to update guidance regarding communications during emergency and unusual situations to reflect current industry knowledge based on lessons learned. We anticipate issuing a revised AC, also in 2013. I will keep the Board informed of the FAA's progress on this safety recommendation and will provide an update by September 30, 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 regarding communications during emergency and unusual situations to reflect current industry knowledge. If this language is retained in the resulting final rule, this likely will be an acceptable response to this recommendation and it will be closed.

From: NTSB
To: FAA
Date: 6/16/2011
Response: The FAA stated that it would revise AC 120-48 after publication of the final rule “Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers.” The FAA has published the Supplemental Notice of Proposed Rulemaking (SNPRM); the NTSB will comment on that document in a separate letter. The SNPRM addresses Safety Recommendation A-09-27 by requiring that initial and recurrent flight and cabin crew training include communication during emergency situations. Specifically, these requirements include (1) identifying the actions needed for each emergency situation, (2) determining the importance of notification, (3) establishing who needs to be notified, (4) planning alternate actions when notification of personnel is impossible, and (5) preparing for a planned emergency evacuation by communicating such information as time available, type of emergency signals to brace, and other special instructions. Pending the publication of the revised AC 120-48, Safety Recommendation A-09-27 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/29/2010
Response: - From J. Randolph Babbitt, Administrator: The Federal Aviation Administration finished drafting Qualification, Service, and use of Crewmembers and Aircraft Dispatchers Supplemental Notice of Proposed Rulemaking (SNPRM), which will appropriately address this recommendation. We expect to publish the SNPRM later this year. We plan to revise Advisory Circular 120-48, Communication and Coordination between Flight Crewmembers and Flight Attendants, after publication of the final rule. We look forward to the Board's comments on the SNPRM. We believe that these actions will address the issues that the Board stated in its May 19, 2009, letter to the FAA. I will keep the Board informed of the FAA's progress on this safety recommendation, and I will provide an updated response by October 2011.

From: NTSB
To: FAA
Date: 4/2/2010
Response: The FAA replied that, after publication of the final rule proposed in the January 12, 2009, NPRM, it will revise AC 120-48 as recommended. Pending publication of the revised AC, Safety Recommendation A-09-27 is classified OPEN -- ACCEPTABLE RESPONE.

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: As indicated in our response to recommendation A-09-26, the comment period for the NPRM Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers, closed on August 10, 2009. The proposed curriculum includes crewmember and flight attendant communication and coordination in emergency and unusual situations. We plan to revise Advisory Circular 120-48, Communication and Coordination Between Flight Crewmembers and Flight Attendants, after publication of the final rule. We anticipate publication of the final rule in January 2010.