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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.
TO THE FEDERAL AVIATION ADMINISTRATION: Require Boeing to establish guidance for pilots of all relevant airplanes to follow when an unintended thrust reverser lockout occurs and to provide that guidance to all operators of those airplanes.
Original recommendation transmittal letter:
Open - Unacceptable Response
Jackson Hole, WY, United States
Runway Overrun of American Airlines Flight 2253, Boeing 757-200, N668AA
Addressee(s) and Addressee Status:
FAA (Open - Unacceptable Response)
Safety Recommendation History
The FAA’s only letter concerning Safety Recommendation A-12-46, dated August 29, 2012, stated that Boeing published supporting guidance in its flight crew training manuals indicating that pilots should monitor approaching or exceeded engine operational limits, thrust reverser failure, and any other abnormalities. Our November 20, 2012, reply pointed out that the problem in the Jackson Hole incident was that, after the pilots observed that the thrust reversers had not deployed, they did not know they needed to move the reverse thrust levers to the stowed position during the landing roll before attempting to deploy them again. Because Boeing’s revisions did not address this follow-up technique, Safety Recommendation A-12-46 was classified “Open?Unacceptable Response.” Although Safety Recommendation A-12-46 is now 4 years old, we are not aware of any guidance that has been issued since your August 2012 letter that address the concerns it discusses. Accordingly, we request an update on any actions that you have taken or plan to take to address this recommendation. In the meantime, Safety Recommendation A-12-46 remains classified OPEN—UNACCEPTABLE RESPONSE.
We issued this recommendation because our investigation of the December 29, 2010, incident revealed that an unforeseen mechanical/hydraulic interaction that occurred during the accident had locked the thrust reversers in transit during the landing. To resolve this problem, the pilots should have moved the reverse thrust lever to the stowed position in order to unlock the system before attempting to redeploy the thrust reversers; however, postincident interviews with American Airlines pilots indicated that they were not aware of this technique, and moving the reverse thrust levers to the stowed position during the landing roll was not an intuitive action. We concluded that, if the incident pilots had known that when the thrust reversers locked in transit, they needed to move the reverse thrust levers to the stowed position before attempting to deploy them again, the deployment of the thrust reversers could have occurred much earlier in the landing roll. This recommendation was issued to ensure that pilots of airplanes on which such a lock is possible will have the knowledge needed to follow the required procedure in a timely manner. The FAA replied that Boeing has already published supporting guidance in the company’s Flight Crew Training Manuals (FCTM) that provides the recommended procedure for pilots in the event of an unintended thrust reverser lockout. The FCTM guidance indicates that the pilot monitoring should monitor engine operational limits being approached or exceeded, any thrust reverser failure, and any other abnormalities. The FAA also indicated that Boeing is expanding these revisions and has incorporated language into the Boeing 757 Flight Crew Operations Manual Landing Roll Procedure to call out if there is no REV indication(s) or the indication(s) stays amber. These revisions do not satisfy the recommendation. The problem in the Jackson Hole incident was not that the pilots failed to notice the thrust reversers had not deployed, but that, after they had observed the failure of the thrust reversers to deploy, they did not know they needed to move the reverse thrust levers to the stowed position before attempting to deploy them again. Boeing’s revisions do not address this need. Accordingly, pending the FAA’s taking the recommended action, Safety Recommendation A-12-46 is classified OPEN—UNACCEPTABLE RESPONSE.
-From Michael P. Huerta, Acting Administrator: Boeing has already published supporting guidance in their Flight Crew Training Manuals (FCTM) that provides the necessary guidance for pilots in the event of an unintended thrust reverser lockout (enclosed). This guidance indicates the pilot monitoring should monitor engine operational limits being approached or exceeded, any thrust reverser failure or other abnormalities. Boeing is expanding these revisions and has incorporated the following language into the 757 Flight Crew Operations Manual (FCOM) Landing Roll Procedure (enclosed): If there is no REV indication(s) or the indication(s) stays amber. call "NO REVERSER LEFT ENGINE", or "NO REVERSER RIGHT ENGINE', or "NO REVERSERS". Similar call outs are being published in the FCOM's for the Boeing 737, 747, 767, 777, and 787 fleets with slight variations in wording based on technical differences from model to model. We believe this implementation is adequate from both an operational perspective and as guidance for a principal operations inspector's required evaluation, acceptance and approval of their operator's procedures and manuals. We will continue to review and validate these changes as they are published. To satisfy part 121 operations and pilot training requirements, operators may use either the FAA approved Airplane Flight Manual (AFM) or they may develop, obtain approval for, and use a Company Flight Manual (CFM). Typically, aircraft manufacturers publish supporting information or manuals such as the FCOM and FCTM to aid operators during the development of operator specific manuals such as the CFM. During aircraft certification, section 25.125 prescribes the airworthiness standards for landing during aircraft certification. The results of flight test certification and night testing related to landing performance is published in the AFM as necessary for the safe operation of the aircraft. In the case of the Boeing 757 and other turbojet aircraft, reverse thrust is not used when testing/calculating landing performance. Consequently, procedures for thrust reverser anomalies are typically not included in the AFM. I will provide an update on the status of the Boeing FCOM procedures by November 30, 2013.
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