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Safety Recommendation Details

Safety Recommendation A-82-007
Details
Synopsis: AS A RESULT OF ITS CONTINUING INVESTIGATION OF THE CRASH OF AIR FLORIDA FLIGHT 90, A BOEING 737-222 (N62AF) ON JANUARY 13, 1982, THE NATIONAL TRANSPORTATION SAFETY BOARD BELIEVES THAT IMMEDIATE CORRECTIVE ACTION IS NEEDED IN THE AREA OF COLD-WEATHER OPERATIONS PROCEDURES. THE AIRCRAFT HAD DEPARTED FROM RUNWAY 36 AT WASHINGTON NATIONAL AIRPORT IN MODERATE TO HEAVY SNOWFALL AND LOW VISIBILITY. THE AIRCRAFT FAILED TO ACHIEVE A SUFFICIENT RATE OF CLIMB, STRUCK THE 14TH STREET BRIDGE ABOUT 4,500 FEET FROM THE DEPARTURE END OF THE RUNWAY, AND CRASHED INTO OF THE POTOMAC RIVER. SEVENTY-FOUR OF THE 79 PERSONS ABOARD THE AIRCRAFT WERE KILLED EITHER ON IMPACT OR BY DROWNING, AND 4 PERSONS IN AUTOMOBILES ON THE BRIDGE WERE KILLED WHEN THE VEHICLES WERE STRUCK BY THE DESCENDING AIRCRAFT.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: IMMEDIATELY REVIEW THE PREDEPARTURE DEICING PROCEDURES USED BY ALL AIR CARRIER OPERATORS ENGAGED IN COLD WEATHER OPERATIONS AND THE INFORMATION PROVIDED TO FLIGHTCREWS TO EMPHASIZE THE INABILITY OF DEICING FLUID TO PROTECT AGAINST REICING RESULTING FROM PRECIPITATION FOLLOWING DEICING. (URGENT)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Washington, DC, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA82AA011
Accident Reports: Air Florida, Inc., Boeing 737-222, N62AF, Collision with 14th Street Bridge
Report #: AAR-82-08
Accident Date: 1/13/1982
Issue Date: 1/28/1982
Date Closed: 8/3/1982
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Icing,Weather

Safety Recommendation History
From: NTSB
To: FAA
Date: 8/3/1982
Response: In our April 19, 1982, correspondence we requested that the FAA provide us with more detail concerning the methods and standards used to review the predeparture deicing procedures (A-82-7) and the information provided to flightcrews (A-82-8) by all carrier operators engaged in cold weather operations. We note that the FAA required each principal operations inspector or appropriate aviation safety inspector to actively review each air carrier's manuals and guidance on cold weather operations. We also note that the standards or benchmarks used to determine the adequacy of an air carrier's deicing procedures and information provided to flightcrews included pertinent Federal Aviation Regulations, advisory circulars and air carrier operation and maintenance bulletins. This additional information describing FAA's review of each air carrier's predeparture deicing procedures and dissemination of information to flightcrews engaged in cold weather operations satisfies the intent of Safety Recommendations A-82-7 and -8 which have been classified as "Closed--Acceptable Action."

From: FAA
To: NTSB
Date: 6/7/1982
Response: FAA LTR: THE FAA REQUESTED EACH PRINCIPAL OPERATIONS INSPECTOR OR APPROPRIATE AVIATION SAFETY INSPECTOR TO ACTIVELY REVIEW EACH AIR CARRIER'S MANUALS AND GUIDANCE ON COLD WEATHER OPERATIONS. THE STANDARDS OR BENCHMARKS USED TO DETERMINE THE ADEQUACY OF AN AIR CARRIER'S DEICING PROCEDURES INCLUDED PERTINENT FEDERAL AVIATION REGULATIONS, ADVISORY CIRCULARS AND AIR CARRIER OPERATION AND MAINTENANCE BULLETINS.

From: NTSB
To: FAA
Date: 4/19/1982
Response: We note that the FAA has reviewed this recommendation with all air carriers with emphasis on predeparture deicing procedures including the inability of deicing fluid to protect against subsequent reicing. While this complies with this recommendation, we would like to receive summary documentation detailing methods used by the FAA to complete this review. For example, did FAA staff personally review each operator's predeparture deicing procedures or was the review conducted by telephone? In addition, what benchmark was used to determine the adequacy of an individual air carrier's deicing procedures? We remain concerned because the Safety Board issued a similar recommendation, A-80-112, to the FAA on November 14, 1980, in which we recommended that the FAA ". . . advise operators of the potential hazard of an accumulation of wet snow on airfoil surfaces after deicing with a diluted ethylene glycol solution." In response the FAA issued ACOB 7-81-1 which advised principal inspectors to request operators to review their deicing and anti-icing procedures and to ensure that these procedures are adequate and are included in their operations manual. The Safety Board believes this review was not effective, Data Source: NTSB Recommendations to FAA and FAA Responses and therefore, in A-82-7 recommends that the FAA play a more active role in reviewing the operator's deicing procedures and manuals. It is in this context that we request an explanation of how this review was conducted and the criteria used to measure the adequacy of an operator's deicing procedures. This recommendation, A- 82-7, will be classified as "Open--Acceptable Action" awaiting a response to our request for documentation.

From: FAA
To: NTSB
Date: 2/22/1982
Response: FAA LTR: A TELEGRAPHIC MESSAGE OF JANUARY 28, 1982, CONTAINING THE VERBATIM CONTENTS OF THE SAFETY BOARD'S RECOMMENDATION LETTER, WAS TRANSMITTED TO ALL AIR CARRIERS. IN ADDITION, FAA FLIGHT STANDARDS PERSONNEL CONTACTED ALL AIR CARRIERS AND REVIEWED THIS RECOMMENDATION.