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NTSB SAFETY RECOMMENDATION
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National Transportation Safety Board
Washington, DC 20594
May 19, 2009
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NTSB Safety Recommendations A-09-21 through A-09-28
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The National Transportation Safety Board makes the following
recommendations to the Federal Aviation Administration:
Evaluate the history of uncommanded air turbine starter
valve (ATSV)-Open events in the MD-80 fleet and the
effectiveness of coupling the ATSV-Open light to the Master
Caution system to determine whether all MD-80 airplanes need
to be modified to couple the ATSV-Open light to the Master
Caution system. Once the evaluation is completed, require
any necessary modifications. (A-09-21)
Require principal operations inspectors to review their
Operators’ pilot guidance and training on task allocation
and workload management during emergency situations to
verify that they state that, to the extent practicable, the
pilot running the checklists should not engage in additional
nonessential operational tasks, such as radio
communications. (A-09-22)
Require MD-80 series airplane operators to incorporate
information about the relationship between the pneumatic
crossfeed valve and the engine fire handle into their
training programs and written guidance. (A-09-23)
Establish best practices for conducting both single and
multiple emergency and abnormal situations training. (A-09-
24)
Once the best practices for both single and multiple
emergency and abnormal situations training asked for in
Safety Recommendation A-09-24 have been established, require
that these best practices be incorporated into all
operators’ approved training programs. (A-09-25)
Require that operators provide pilots with guidance
requiring that pilots and flight attendants actively monitor
exit availability and configure the airplane and cabin for
an evacuation when the airplane is stopped away from the
gate after a significant event to help expedite an emergency
evacuation if one becomes necessary. (A-09-26)
Revise Advisory Circular 120-48, “Communication and
Coordination Between Flight Crewmembers and Flight
Attendants,” to update guidance and training provided to
flight and cabin crews regarding communications during
emergency and unusual situations to reflect current industry
knowledge based on research and lessons learned from
relevant accidents and incidents over the last 20 years. (A-
09-27)
Require Boeing to establish an appropriate replacement
interval for air turbine starter valve air filters installed
on all MD-80 series aircraft. (A-09-28)
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http://www.ntsb.gov/recs/letters/2009/A09_21_28.pdf
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The complete recommendation letter is available on the Web
at the URL indicated above.
The letter is in the Portable Document Format (PDF) and can
be read using the Acrobat Reader 5.0 or later from Adobe
(http://www.adobe.com/prodindex/acrobat/readstep.html).
An archive of recommendation letters is available at
http://www.ntsb.gov/recs/letters/letters.htm.
Electronic versions of letters may or may not include
enclosures; however, related publications, accident
briefs, and aviation accident synopses may be found
on the NTSB website.
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