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NTSB Safety Recommendations A-09-113 through -128

Title: NTSB Safety Recommendations A-09-113 through -128




National Transportation Safety Board

Washington, DC 20594

October 27, 2009


NTSB Safety Recommendations A-09-113 through -128


The National Transportation Safety Board recommends that the

Federal Aviation Administration:

Require all 14 Code of Federal Regulations Part 91K and Part

135 operators to incorporate upset recovery training

(similar to that described in the airplane upset recovery

training aid used by many Part 121 operators) and related

checklists and procedures into their training programs. (A-


Require Cessna to redesign and retrofit the yaw damper and

autopilot switches on the autopilot control panel in

Citation series airplanes to make them easily

distinguishable and to guard against unintentional pilot

activation. (A-09-114)

Identify airplanes other than the Cessna Citation with

autopilot control panel designs that may lead to inadvertent

activation of the autopilot and require manufacturers to

redesign and retrofit the autopilot control panels to make

the buttons easily distinguishable and to guard against

unintentional activation. (A-09-115)

Issue an airworthiness directive mandating compliance with

Cessna Service Bulletin 550-24-14, "Control Wheel Electrical

Cable Replacement," which was issued on January 17, 1992.


Require Cessna to modify all Citation series airplanes by

incorporating an aural pitch trim-in-motion warning and

contrasting color bands on the pitch trim wheel to help

pilots recognize a runaway pitch trim condition before

control forces become unmanageable. (A-09-117) (This

recommendation supersedes Safety Recommendation A-07-52 and

is classified "Open-Unacceptable Response.")

Require Cessna to replace all Citation series airplane pitch

trim, autopilot, and any other circuit breakers for critical

systems that a pilot might need to access during an

emergency situation with easily identifiable and collared

circuit breakers to aid a pilot in quickly identifying and

easily pulling those circuit breakers if necessary. (A-09-

118) (This recommendation supersedes Safety Recommendation

A-07-54 and is classified "Open-Unacceptable Response.")

Require airplane manufacturers to develop guidance on the

identification of circuit breakers that pilots need to

identify quickly and pull easily during abnormal or

emergency situations and to provide such guidance, once

developed, to operators of those airplanes. (A-09-119)

Require operators to implement the manufacturers' guidance

asked for in Safety Recommendation A-09-119 regarding which

circuit breakers pilots need to identify quickly and pull

easily during abnormal or emergency situations in their

airplanes. (A-09-120)

Require Cessna to evaluate and limit the maximum aileron

trim deflection on Citation series airplanes to that

required to meet the certification control requirements for

powered trim tabs, unless there is a design justification to

exceed those requirements. (A-09-121)

Require Cessna to reduce the aileron trim sensitivity (the

unexpectedly significant aileron trim deflection that

results from a relatively small amount of trim knob input)

on Citation series airplanes to avoid sudden and excessive

aileron trim deflections. (A-09-122)

As an interim measure (pending an available aileron trim

system retrofit), notify Citation pilots and operators of

the potential hazards related to the sensitivity and

responsiveness of the airplane's aileron trim system. (A-09-


Revise check airman approval and oversight procedures to

incorporate heightened surveillance during a probationary

period and at other times, as warranted, for check airmen

whose background evaluation uncovers a history of criminal

convictions, certificate revocations, checkride failures, or

other performance-related deficiencies. (A-09-124)

Conduct a detailed review of the oversight provided to

Marlin Air to determine why the oversight system failed to

detect (before and after the accident) and correct Marlin

Air's operational deficiencies, particularly in the areas of

pilot hiring, training, and adherence to procedures. (A-09-


Based on the review described in Safety Recommendation A-09-

125, revise the oversight system and Federal Aviation

Administration Order 8900.1 as needed. (A-09-126)

Require all 14 Code of Federal Regulations Part 135 and Part

91K operators to provide their customers, when a business

agreement or contract is finalized, with Federal Aviation

Administration (FAA) contact information identified as

specifically for use in expressing concerns about flight

safety, thus providing customers with a clear means of

communicating any safety concerns to the FAA. (A-09-127)

Require all 14 Code of Federal Regulations Part 91K and Part

135 operators to notify the assigned principal operations

inspectors of specific adverse financial events, such as

bankruptcy, court judgments related to nonpayment of

recurring expenses, or termination of a credit agreement or

contract by a vendor for reasons of late payment or

nonpayment. Upon receipt of such information, inspectors

should increase their oversight of operators who appear to

be in financial distress. (A-09-128)

The National Transportation Safety Board reiterates the

following safety recommendation to the Federal Aviation


Amend the advisory materials associated with 14 Code of

Federal Regulations 25.1309 to include consideration of

structural failures and human/airplane system interaction

failures in the assessment of safety-critical systems. (A-


Adopt Society of Automotive Engineers [Aerospace Recommended

Practice] 5150 into 14 Code of Federal Regulations Parts 21,

25, 33, and 121 to require a program for the monitoring and

ongoing assessment of safety-critical systems throughout the

life cycle of the airplane. Safety-critical systems will be

identified as a result of [Safety Recommendation] A-06-36.

Once in place, use this program to validate that the

underlying assumptions made during design and type

certification about safety-critical systems are consistent

with operational experience, lessons learned, and new

knowledge. (A-06-38)




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



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enclosures; however, related publications, accident

briefs, and aviation accident synopses may be found

on the NTSB website.


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