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Safety Recommendation Details

Safety Recommendation A-82-082
Details
Synopsis: ON JANUARY 13, 1982, AIR FLORIDA FLIGHT 90, A BOEING 737-222 (N62AF) STRUCK THE NORTHBOUND SPAN OF THE 14TH STREET BRIDGE WHICH CONNECTS THE DISTRICT OF COLUMBIA WITH ARLINGTON, COUNTY, VIRGINIA, AND PLUNGED INTO THE ICE-COVERED POTOMAC RIVER JUST AFTER TAKING OFF FROM WASHINGTON NATIONAL AIRPORT. SEVENTY OF THE 74 PASSENGERS, 4 OF THE 5 CREWMEMBERS, AND 4 PERSONS IN VEHICLES ON THE BRIDGE WERE FATALLY INJURED. THE WEATHER CONDITIONS WHICH HAD PREVAILED BEFORE AND AT THE TIME OF THE ACCIDENT CONSISTED OF SUBFREEZING TEMPERATURES AND ALMOST STEADY MODERATE TO HEAVY SNOWFALL WITH OBSCURED VISIBILITY.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REQUIRE REVISION OF THE B-737 APPROVED FLIGHT MANUAL TO ADD "ANTI-ICE" TO THE NORMAL TAXI AND TAKEOFF CHECKLIST. REVIEW THE CHECKLISTS FOR ALL AIR CARRIER AIRCRAFT TO ENSURE THAT ALL ACTION ITEMS REQUIRED FOR A SUCCESSFUL TAKEOFF ARE INCLUDED ON THE APPROPRIATE CHECKLIST. SPECIAL CONSIDERATION SOULD BE GIVEN TO ITEMS WHOSE FUNCTIONS MAY BE AFFECTED BY ENVIRONMENTAL CONDITIONS SUBJECT TO CHANGE DURING GROUND DELAY PERIODS.
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: 1/1/1982
Date Closed: 1/6/1984
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Checklist, Icing, Weather

Safety Recommendation History
From: NTSB
To: FAA
Date: 1/6/1984
Response: We note that the FAA has completed the review of checklists for all air carrier aircraft. As a result of the review, ten air carriers and ten Part 91 operators implemented some form of corrective action to revise their aircraft checklists. The completion of the comprehensive aircraft checklist review fulfills the objectives of Safety Recommendation A-82-82, which has been classified as "Closed-- Acceptable Action." We appreciate your efforts to respond to our safety recommendations.

From: FAA
To: NTSB
Date: 9/28/1983
Response: FAA LETTER: THE FAA CONCURRED WITH THIS RECOMMENDATION AND ON JANUARY 13, 1983, DIRECTED THAT ALL PRINCIPAL OPERATIONS INSPECTORS REVIEW AIRCRAFT CHECKLISTS USED BY THEIR FLIGHT CREWS TO ENSURE THAT ALL ACTION ITEMS REQUIRED FOR A SUCCESSFUL TAKEOFF ARE INCLUDED ON THE APPROPRIATE CHECKLIST.

From: NTSB
To: FAA
Date: 6/1/1983
Response: In the FAA's earlier response of November 15, 1982, we were informed of two changes in the Boeing-737 Approved Flight Manual (AFM) to alert flightcrews to the criticality of using "anti-ice" during subfreezing weather conditions. We now note that the FAA has transmitted a letter to all regional division managers directing that a review of checklists for all air carrier aircraft be accomplished. The FAA's responsive action satisfies the intent of this recommendation which is now classified in an "Open--Acceptable Action" status awaiting the FAA's further response.

From: FAA
To: NTSB
Date: 3/4/1983
Response: FAA LETTER: WE CONCUR THAT A REVIEW OF THE CHECKLISTS FOR ALL AIR CARRIER AIRCRAFT, IN ACCORDANCE WITH THE RECOMMENDATION, IS A BENEFICIAL ENDEAVOR. THEREFORE, WE HAVE TRANSMITTED A LETTER TO ALL REGIONAL DIVISION MANAGERS DIRECTING THAT SUCH A REVIEW BE ACCOMPLISHED.

From: NTSB
To: FAA
Date: 1/12/1983
Response: We note that the FAA does not agree with the necessity to add "anti-ice" to the Boeing-737 taxi and takeoff checklists. The FAA believes that the existing provision of "anti-ice" on the after-start checklist is adequate to ensure operational safety. This recommendation was issued because of our concern regarding the not uncommon situation in which an airplane may experience lengthy ground delays between completion of the after-start checklist and the start of the takeoff. In such a case there could be substantial changes in the environment and ambient conditions which would require a reassessment of the use of anti-ice. In view of our concern regarding a potential problem associated with long ground delays, we are pleased to note two changes to the Boeing-737 Approved Flight Manual (AFM) which will serve to alert flightcrews to the criticality of using "anti-ice" during subfreezing weather conditions. These additions to the AFM are titled, Engine Anti-Ice System and Operation in Icing Conditions, and include specific emphasis and guidance concerning the use and limitations of engine "anti-ice." We believe these additions to the Boeing-737 AFM provide an acceptable alternate to the recommended changes to the taxi and takeoff checklists. Therefore, the portion of Safety Recommendation A-82-82 pertaining to revisions to the Boeing-737 checklists has been classified as "Closed--Acceptable Alternate Action." In addition, we note that the FAA agrees that a review of the checklists of all air carrier aircraft, as described in this recommendation, would be useful. The FAA will publish a letter to all regional division managers to implement this review. We will classify this part of Safety Recommendation A-82-82 as "Open--Acceptable Action" awaiting the completion and results of this review.

From: FAA
To: NTSB
Date: 11/15/1982
Response: FAA LTR: THE FAA DISAGREES WITH THE NEED TO ADD "ANTI-ICE" TO THE B-737 TAXI AND TAKEOFF CHECKLISTS. THE FAA BELIEVES THAT HAVING "ANTI-ICE" ON THE AFTER START CHECKLIST IS SUFFICIENT TO ENSURE OPERATIONAL SAFETY. HOWEVER, TWO CHANGES TO THE B-737 APPROVED FLIGHT MANUAL (AFM) WILL SERVE TO ALERT FLIGHTCREWS TO THE NEED OF USING "ANTI-ICE" DURING SUBFREEZING WEATHER CONDITIONS. THESE ADDITIONS TO THE AFM ARE CALLED, ENGINE ANTI-ICE SYSTEM AND OPERATION IN ICING CONDITIONS AND INCLUDE SPECIFIC EMPHASIS AND GUIDANCE CONCERNING THE USE AND LIMITATIONS OF ENGINE "ANTI-ICE." THE FAA AGREES THAT A REVIEW OF THE CHECKLISTS FOR ALL AIR CARRIER AIRCRAFT, AS DESCRIBED IN THIS RECOMMENDATION, WOULD BE USEFUL. THE FAA PLANS TO PUBLISH A LETTER TO ALL REGIONAL DIVISION MANAGERS TO IMPLEMENT THIS REVIEW.