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Safety Recommendation Details

Safety Recommendation A-19-001
Details
Synopsis: This report discusses the March 8, 2017, accident involving Ameristar Air Cargo, Inc., dba Ameristar Charters, flight 9363, a Boeing MD-83 airplane, which overran the departure end of runway 23L at Willow Run Airport, Ypsilanti, Michigan, after the captain executed a rejected takeoff. The 110 passengers and 6 flight crewmembers evacuated the airplane via emergency escape slides; however, one slide failed to inflate and could not be used. One passenger received a minor injury, and the airplane sustained substantial damage. Safety issues identified in this report include the lack of a means to enable flight crews of Boeing DC-9/MD-80 series and 717 model airplanes to verify before takeoff that the elevators are not jammed, the need for improved in-service inspection techniques for critical rotating parts of all engines, the need for lower ground gust criteria for elevator physical inspections and operational checks by maintenance personnel for Boeing DC 9/MD-80 series and 717 model airplanes, the potential inadequacy of ground gust limit loads for the certification of transport-category airplanes, the lack of procedures for operators of Boeing DC-9/MD-80 series and 717 model airplanes to monitor the wind that affects parked airplanes, the lack of procedures for weather observers related to sign off and backup augmentation responsibilities during a facility evacuation, and evacuation slide malfunction. As a result of this investigation, the National Transportation Safety Board makes three safety recommendations to the Federal Aviation Administration and three recommendations to The Boeing Company.
Recommendation: TO THE BOEING COMPANY: Complete the development of a modification for Boeing DC-9/MD-80 series and 717 model airplanes that will prevent the possibility of elevator jamming due to ground wind exposure.
Original recommendation transmittal letter: PDF
Overall Status: Open - Initial Response Received
Mode: Aviation
Location: Ypsilanti, MI, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA17FA076
Accident Reports: Runway Overrun During Rejected Takeoff Ameristar Air Cargo, Inc., dba Ameristar Charters, flight 9363 Boeing MD-83, N786TW Ypsilanti, Michigan, March 8, 2017
Report #: AAR-19-01
Accident Date: 3/8/2017
Issue Date: 3/8/2019
Date Closed:
Addressee(s) and Addressee Status: Boeing Company (Open - Initial Response Received)
Keyword(s):

Safety Recommendation History
From: Boeing Company
To: NTSB
Date: 6/6/2019
Response: -From Dan Marcotte, Boeing Air Safety Investigations: As we discussed, Boeing has discovered structural limitations that have made impractical our previously planned modification to mitigate the potential of DC-9/MD-80 elevator jamming due to ground wind exposure. We are exploring other alternatives to mitigate the potential for flight crews initiating a takeoff with an elevator jammed due to ground wind exposure. The 717 differs from the DC-9/MD-80 series airplanes, as an elevator position indicator is provided on the CONFIG synoptic page. To mitigate the potential of takeoff initiation with a jammed elevator on 717 airplanes, Boeing has revised the Flight Control Check performed in the Taxi Procedure section of Boeing’s 717 Flight Crew Operating Manual, to direct flight crews confirm elevators are not stuck down on the CONFIG synoptic page’s elevator position indicator. The procedure includes a note informing flight crews that if the correct elevator indication is not confirmed during the check, maintenance is required prior to takeoff. The revised Flight Crew Operating Manual was published on October 18, 2018.

From: NTSB
To: Boeing Company
Date: 3/8/2019
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters. We are providing the following information to urge your organization to act on the safety recommendations in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. On February 14, 2019, the NTSB adopted its report, Runway Overrun During Rejected Takeoff, Ameristar Air Cargo, Inc., dba Ameristar Charters, flight 9363, Boeing MD-83, N786TW, Ypsilanti, Michigan, March 8, 2017, NTSB AAR-19/01. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. As a result of this investigation, the NTSB identified the following safety issues: • Lack of a means to enable flight crews of Boeing DC-9/MD-80 series and 717 model airplanes to verify before takeoff that the elevators are not jammed. • Need for lower ground gust criteria for elevator physical inspections and operational checks by maintenance personnel for Boeing DC 9/MD-80 series and 717 model airplanes. • Potential inadequacy of ground gust limit loads for the certification of transport category airplanes. • Lack of procedures for operators of Boeing DC-9/MD-80 series and 717 model airplanes to monitor the wind that affects parked airplanes. • Lack of procedures for weather observers related to sign off and backup augmentation responsibilities during a facility evacuation. • Evacuation slide malfunction. Accordingly, the NTSB makes the following safety recommendations to The Boeing Company. Additional information regarding these recommendations can be found in section 2.4.2 of the report. • Complete the development of a modification for Boeing DC-9/MD-80 series and 717 model airplanes that will prevent the possibility of elevator jamming due to ground wind exposure. (A-19-1) • Develop new preflight procedures or other mitigations for Boeing DC-9/MD-80 series and 717 model airplanes that will enable a flight crew to verify before takeoff that the elevators are not jammed. (A-19-2) • Until the actions in Safety Recommendations A-19-1 and -2 are completed, revise the Aircraft Operating Manual and Aircraft Maintenance Manual for Boeing DC-9/MD-80 series and 717 model airplanes to lower the ground gust criteria that will require physical inspections and operational checks of the elevators by maintenance personnel. (A-19-3) The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (for example, A-19-1). We encourage you to submit your response to correspondence@ntsb.gov. If your reply exceeds 20 megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.