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Safety Recommendation Details

Safety Recommendation A-87-008
Details
Synopsis: AT 1521 C.D.T. ON SEPTEMBER 6, 1985, MIDWEST EXPRESS AIR LINES, INC. (MIDWEST EXPRESS), FLIGHT 105, A MCDONNELL DOUGLAS DC-9-14 AIRPLANE, CRASHED INTO AN OPEN FIELD AT THE EDGE OF A WOODED AREA ABOUT 1,680 FEET SOUTHWEST OF THE DEPARTURE END OF RUNWAY 19R SHORTLY AFTER TAKING OFF FROM GENERAL BILLY MITCHELL FIELD, MILWAUKEE, WISCONSIN. THE WEATHER WAS CLEAR WITH VISIBILITY 10 MILES. DURING THE INITIAL CLIMB, ABOUT 450 FEET ABOVE GROUND LEVEL (A.G.L.), THERE WAS A LOUD NOISE AND A LOSS OF POWER ASSOCIATED WITH AN UNCONTAINED FAILURE OF THE 9TH TO 10TH STAGE HIGH PRESSURE COMPRESSOR SPACER OF THE RIGHT ENGINE. FLIGHT 105 CONTINUED TO CLIMB TO ABOUT 700 FEET A.G.L. AND THEN ROLLED TO THE RIGHT UNTIL THE WINGS WERE OBSERVED IN A NEAR VERTICAL, APPROXIMATELY RIGHT 90 DEGREE BANKED TURN. DURING THE ROLL, THE AIRPLANE ENTERED AN ACCELERATED STALL, CONTROL WAS LOST, AND THE AIRPLANE CRASHED. THE AIRCRAFT WAS DESTROYED BY IMPACT FORCES AND POSTCRASH FIRE. THE PILOT, THE FIRST OFFICER, BOTH FLIGHT ATTENDANTS, AND ALL 27 PASSENGERS WERE FATALLY INJURED.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: ISSUE AN AIR CARRIER OPERATIONS BULLETIN DIRECTING PRINCIPAL OPERATIONS INSPECTORS TO REVIEW THEIR RESPECTIVE AIR CARRIER'S FLIGHTCREW TRAINING PROGRAMS TO ENSURE THE EXISTENCE OF NEW COORDINATION PROCEDURES THAT, NOTWITHSTANDING A POLICY ENDORSING NONESSENTIAL CONVERSATION DURING AN EMERGENCY CONDITION, REQUIRE ANY CREWMEMBER WHO OBSERVES A POTENTIAL OR ACTUAL EMERGENCY SITUATION TO VERBALLY CALL IT TO THE CAPTAIN'S ATTENTION.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: MILWAUKEE, WI, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA85AA036
Accident Reports: Midwest Express Airlines, Inc., DC-9-14, N100ME
Report #: AAR-87-01
Accident Date: 9/6/1985
Issue Date: 3/19/1987
Date Closed: 6/28/1988
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Crew Resource Management, Flightcrew, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/28/1988
Response: We are pleased that the FAA has issued Air Carrier Operations Bulletin (ACOB) No. 8- 88-2, to require any crewmember who observes a potential or actual emergency situation to verbally call it to the captain's attention. This recommendation is classified as "Closed--Acceptable Action."

From: FAA
To: NTSB
Date: 4/13/1988
Response: THE FAA HAS ISSUED ACOB 8-88-2, REQUIRE ANY CREWMEMBER WHO OBSERVES A POTENTIAL OR ACTUAL EMERGENCY SITUATION TO VERBALLY CALL IT TO THE CAPTAIN'S ATTENTION. THIS ACOB DIRECTS PRINCIPAL OPERATIONS INSPECTORS TO ENSURE THAT THEIR ASSIGNED CARRIERS DO NOT TEACH THE CONCEPT OF "SILENT COCKPIT" IN THEIR PILOT TRAINING PROGRAMS. I HAVE ENCLOSED A COPY OF THE ACOB FOR THE BOARD'S INFORMATION.

From: NTSB
To: FAA
Date: 7/21/1987
Response: We are pleased that the FAA concurs in these recommendations and will, accordingly, issue air carrier operations bulletins by September 1987. Pending your further response, these recommendations are classified "Open--Acceptable Action."

From: FAA
To: NTSB
Date: 5/29/1987
Response: THE FAA CONCURS THAT THE FAILURE OF A CREWMEMBER TO CALL OUT VERBALLY A POTENTIAL OR ACTUAL EMERGENCY SITUATION COULD LEAD TO DISASTER AND BELIEVES THIS FACT SHOULD BE EMPHASIZED. THEREFORE, AN AIR CARRIER OPERATIONS BULLETIN (ACOB) WILL BE ISSUED ON THIS SUBJECT. THE ESTIMATED COMPLETION DATE FOR THIS ACOB IS SEPTEMBER, 1987.