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Safety Recommendation Details

Safety Recommendation A-88-072
Details
Synopsis: ON MAY 26, 1987, AT 4:45 P.M., AIR NEW ORLEANS, DOING BUSINESS AS CONTINENTAL EXPRESS FLIGHT 962, DEPARTED RUNWAY 19 AT NEW ORLEANS INTERNATIONAL AIRPORT ON A SCHEDULED COMMUTER FLIGHT TO EGLIN AIR FORCE BASE, FLORIDA. THERE WERE TWO PILOTS AND NINE PASSENGERS ONBOARD AT THE TIME. AS THE AIRPLANE REACHED AN ALTITUDE OF 150 TO 200 FEET ABOVE GROUND LEVEL, THE CREW FELT A SEVERE YAWING MOTION AND OBSERVED THE ENGINE TORQUE FLUCTUATE ERRATICALLY. THE CAPTAIN PROCEEDED TO MAKE AN EMERGENCY LANDING IN THE DEPARTURE OVERRUN OF RUNWAY 19. FOLLOWING ONE BOUNCE AND FINAL TOUCHDOWN, MAXIMUM BRAKING AND FULL REVERSE THRUST WERE APPLIED. THE AIRPLANE THEN ROLLED OFF THE OVERRUN, ACROSS AN AIRPORT ACCESS ROAD, THROUGH AN AIRPORT SECURITY FENCE, THROUGH A CONCRETE HIGHWAY BARRIER, AND ACROSS A HIGHWAY. THE AIRPLANE STRUCK SEVERAL VEHICLES ON THE ROADWAY DURING THE ACCIDENT SEQUENCE. THE MAIN WRECKAGE CAME TO REST IN A PARKING LOT ON THE OTHER SIDE OF THE HIGHWAY. THE CREW AND PASSENGERS EVACUATED SAFELY AND THERE WAS NO FIRE. TWO PASSENGERS ABOARD THE AIRPLANE SUFFERED SERIOUS INJURIES. IN ADDITION, BOTH PILOTS, SEVEN PASSENGERS, AND TWO OCCUPANTS OF GROUND VEHICLES RECEIVED MINOR INJURIES. THE AIRPLANE WAS DESTROYED.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: ISSUE AN ADVISORY CIRCULAR TO COMMERCIAL OPERATORS RECOMMENDING THE USE OF A PROCEDURAL CHECKLIST THAT INCORPORATES HUMAN ENGINEERING DESIGN CRITERIA FOR SIZE AND STYLE OF PRINT.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: KENNER, LA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA87MA033
Accident Reports: Air New Orleans, DBA Continental Express Flight 962, British Aerospace 3101 (Jetstream 31) N331CY
Report #: AAR-88-06
Accident Date: 5/26/1987
Issue Date: 6/28/1988
Date Closed: 5/28/1992
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 5/28/1992
Response: In May 1990, NASA published a study that was conducted by the Ames Research Center and was prompted in part by the Safety Board's investigations of these accidents and its subsequent recommendations to the FAA. The study examined the human factors involved in a paper checklist. It found that this was " . . . only the outer shell of the problem. The core of the problem emerged as the design concepts and the social issues surrounding the use of the checklist that have led some pilots to misuse it or not use it at all." The study concluded: The question that aviation industry and governmental regulators must now confront is whether the current checklists are in themselves resident pathogens. The authors conclude that the traditional flight-deck checklist design and some of the checklist concepts in the industry do contain resident pathogens. Evidently, the extraction of these pathogens is difficult. The authors, however, hope that this report and guidelines listed . . . will aid those individuals who are responsible for extracting these pathogens from their systems. The unique interaction between checklists, humans, machines, and the operational environment, makes the checklist problem a true human factors issue. Nevertheless, the human factors aspect of this device and procedure is still ignored by many. But the price of this ignorance is much too often tragically established. The NASA study proposed 16 guidelines for the design and use of flight-deck checklists. Following issuance of the Safety Board's recommendations, the FAA contracted with the Volpe National Transportation Systems Center (TSC) to conduct a study to identify conditions that interfere with cockpit crews executing or verifying normal and abnormal cockpit procedures through the use of checklists, to determine the need and nature of FAA action to promote good checklist practices, and to determine requirements for research on the design and use of cockpit checklists. The study was published in April 1991. It reported that air carriers were operating with poorly designed checklists and manuals, that flightcrews were not well trained in the use of these aids, and that they did not use the aids when they were expected to do so. The study included 11 recommendations to the FAA to conduct research in a number of areas, including checklist presentation methods, checklist format, typography, readability, and user behavior. It recommended the development of prototypes using human factors principles, standard terminology, and the application of new technology. The FAA used information from the TSC study to revise the Air Transportation Operations Inspector's Handbook to provide guidance to principal operations inspectors (POIs) for evaluating the legibility of checklists, including size and style of print. Although the Safety Board agrees with the intent of the revisions, the Board believes that the POIs, without human factors expertise and specific checklist design guidelines, cannot be expected to adequately address this complex problem. The Safety Board believes that this action alone is not responsive to its recommendations, and we are not aware of any additional action taken by the FAA in response to the recommendations contained in the TSC and NASA studies. The Safety Board notes that the FAA does not plan to issue an AC as requested in Safety Recommendation A-88-72. The TSC and NASA studies developed data that could serve as the foundation for a comprehensive human factors examination and evaluation by experts. The Safety Board believes that such an examination would result in the improved understanding of checklist-induced errors and checklist misuse, the development of checklist design improvements, and enhanced flight operations and safety. Based on the FAA's resolute position on this matter, Safety Recommendations A-88-68 and A-88-72 are classified "Closed--Unacceptable Action."

From: FAA
To: NTSB
Date: 9/10/1991
Response: THE FAA DOES NOT PLAN TO ISSUE AN ADVISORY CIRCULAR AS REQUESTED IN THIS SAFETY RECOMMENDATION. THE REVISIONS TO THE INSPECTOR'S HANDBOOK PROVIDE GUIDANCE TO PRINCIPAL OPERATIONS INSPECTORS FOR EVALUATING THE LEGIBILITY OF CHECKLISTS, INCLUDING SIZE AND STYLE OF PRINT. THE PRINCIPAL OPERATIONS INSPECTORS USE THIS GUIDANCE WHEN WORKING WITH THE OPERATOR AS THE CHECKLIST IS BEING DEVELOPED.

From: NTSB
To: FAA
Date: 3/10/1989
Response: This is to acknowledge the FAA's further response to Safety Recommendation A-88-72, enclosing Action Notice 8400.2. We are pleased to note that this action notice provides guidance to principal operations inspectors on checklist contents and checklist procedures. Pending the FAA's further response, this recommendation remains in an "Open--Acceptable Action" status.

From: FAA
To: NTSB
Date: 2/3/1989
Response: "THE FAA IS CONTINUING ITS EFFORTS TO DETERMINE THE PRESENT CHECKLIST PROCEDURES, THE USE OF CHECKLIST DEVICES, AND THE OPERATING ENVIRONMENT AS A DETERMINANT IN THE SELECTION OF CHECKLIST MANAGEMENT TECHNIQUES. IN JANUARY 1989, THE FAA CONDUCTED ITS FIRST OF A SERIES OF MEETINGS WITH VARIOUS INDUSTRY GROUPS TO DEVELOP STANDARDIZED GUIDANCE MATERIAL ON THIS SUBJECT. IN THE INTERIM, THE FAA ISSUED ACTION NOTICE 8400.2 - TO PROVIDE GUIDANCE TO ITS PRINCIPAL OPERATIONS INSPECTORS ON CHECKLIST CONTENTS AND CHECKLIST PROCEDURES."

From: NTSB
To: FAA
Date: 10/12/1988
Response: The Safety Board is pleased that the FAA will study checklist procedures and checklist management devices prior to issuing an AC as recommended. We look forward to its expeditious completion. Also, we are pleased to note that the FAA issued Air Carrier Operations Bulletin No. 88-5, Flightcrew Checklists, for principal operations inspectors to ensure that checklists are designed in a clear, concise, and legible form. Pending issuance of an AC, this recommendation is classified as "Open--Acceptable Action." In further support of this recommendation, we would like to draw your attention to a recent investigation conducted by the Safety Board involving a Horizon Air DHC-8 airplane at Seattle, Washington, on April 15, 1988. Our investigation disclosed a problem concerning the design and legibility of the "Emergency and Abnormal Checklist" aboard the plane. Coincidentally, the size of print used in the checklist is 57 percent smaller than that recommended, identical to that experienced in the Kenner, Louisiana, accident. This suggests that checklist design deficiencies may be more widespread.

From: FAA
To: NTSB
Date: 9/14/1988
Response: Before issuing an advisory circular to commercial operators on the use of a procedural checklist that incorporates human engineering design criteria, the FAA is conducting a study to determine the present checklist procedures, the use of checklist devices, and the operating environment as a determinant in the selection of checklist management techniques. This study will be a contracted effort, and the FAA is in the process of identifying adequate funding. I will keep the Board apprised of the FAA's progress on this action. In the interim, the FAA issued Air Carrier Operations Bulletin No. 88-5, Flightcrew Checklists, to all principal operations inspectors requesting verification that aircraft checklists are designed in a clear, concise, and legible form. I have enclosed a copy of the bulletin for the Board's information.