Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation A-87-009
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 SIMULATOR TRAINING PROGRAMS TO VERIFY THAT ENGINE FAILURES IN THE POST TAKEOFF CLIMB ARE FREQUENTLY GIVEN WITH PARTICULAR EMPHASIS ON THE USE OF ENGINE AND FLIGHT INSTRUMENTS AS THE PRIMARY SOURCE OF INFORMATION FOR AIRPLANE CONTROL AND ON THE NEED FOR DELIBERATE ACTIONS BASED ON FLIGHT AND ENGINE INSTRUMENT ANALYSIS RATHER THAN HASTY ACTION BASED ON KINESTHETIC CUES.
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): Flightcrew, Simulator, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/28/1988
Response: We are pleased to note that the FAA has issued ACOB 8-88-3, directing principal operations inspectors to review their assigned carriers' approved simulator training programs to ensure they include engine failures in the post takeoff climb, with emphasis on the use of engine and flight instruments as the primary source of information for airplane control, and on the need for deliberate actions based on flight and engine instruments analysis rather than hasty action based on kinesthetic cues. This recommendation is also classified as "Closed--Acceptable Action."

From: FAA
To: NTSB
Date: 4/13/1988
Response: THE FAA HAS ISSUED ACOB 8-88-3, VERIFY AIR CARRIER SIMULATOR TRAINING PROGRAMS INCLUDE ENGINE FAILURES IN THE POST TAKEOFF CLIMB SEGMENT. THIS ACOB DIRECTS PRINCIPAL OPERATIONS INSPECTORS TO REVIEW THEIR RESPECTIVE AIR CARRIER'S SIMULATOR TRAINING PROGRAMS WITH EMPHASIS ON THE USE OF ENGINE AND FLIGHT INSTRUMENTS AS THE PRIMARY SOURCE OF INFORMATION FOR AIRPLANE CONTROL. 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 WITH THIS RECOMMENDATION AND WILL ISSUE AN ACOB DIRECTING PRINCIPAL OPERATIONS INSPECTORS TO REVIEW THEIR RESPECTIVE AIR CARRIER'S SIMULATOR TRAINING PROGRAMS WITH EMPHASIS ON THE ISSUE OF ENGINE AND FLIGHT INSTRUMENTS AS THE PRIMARY SOURCE OF INFORMATION FOR AIRPLANE CONTROL. IT IS ANTICIPATED THAT THIS ACOB WILL BE ISSED IN LATE SEPTEMBER.