How accidents become rules.

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TO THE FEDERAL AVIATION ADMINISTRATION: Develop abuse tests that subject a single cell within a permanently installed, rechargeable lithium-ion battery to thermal runaway and demonstrate that the battery installation mitigates all hazardous effects of propagation to other cells and the release of electrolyte, fire, or explosive debris outside the battery case. The tests should replicate the battery installation on the aircraft and be conducted under conditions that produce the most severe outcome.

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TO THE UNITED STATES COAST GUARD: Establish, with assistance from experts on the effects of pharmacological agents on human performance and alertness, procedures or criteria by which vessel operating personnel who medically require substances not on the U.S. Dept. of Transportation's list of approved medications may be allowed, when appropriate, to use those medications when performing their duties.

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TO THE UNITED STATES COAST GUARD: Develop, then periodically publish, an easy-to-understand source of information for vessel operating personnel on the hazards of using specific medications when performing their duties.

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THE NTSB RECOMMENDS THAT THE FAA: AMEND, BY 12/31/95, 14 CFR 121.343, 125.225, & 135.152 TO REQUIRE THAT ALL AIRPLANES OPERATED UNDER 14 CFR PARTS 121, 125, OR 135 (10 SEATS OR LARGER), FOR WHICH AN ORIGINAL AIRWORTHINESS CERTIFICATE IS RECEIVED AFTER 12/31/96, RECORD THE PARAMETERS LISTED IN "PROPOSED FDR ENHANCEMENTS FOR NEWLY MANUFACTURED AIRPLANES" ON A FLIGHT DATA RECORDER HAVING AT LEAST A 25-HOUR RECORDING CAPACITY.

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THE NTSB RECOMMENDS THAT THE FAA: AMEND, BY 12/31/95, 14 CFR 121.343, 125.225, & 135.152 TO REQUIRE THAT BOEING 727 ARIPLANES, LOCKHEED L-1011 AIRPLANES, & ALL TRANSPORT CATERGORY AIRPLANES OPERATED UNDER 14 CFR PARTS 121,125, OR 135 WHOSE TYPE CERTIFICATE APPLIES TO AIRPLANES STILL IN PRODUCTION, BE EQUIPPED TO RECORD ON A FLIGHT DATA RECORDER SYSTEM, AS A MINIMUM, THE PARAMETERS LISTED IN "PROPOSED MINIMUM FDR PARAMETER REQUIREMENTS FOR AIRPLANES IN SERVICE" PLUS ANY OTHER PARAMETERS REQUIRED BY CURRENT REGULATIONS APPLICABLE TO EACH INDIVIDUAL AIRPLANE. SPECIFY THAT AIRPLANES BE SO EQUIPP…

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TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 CFR Part 121 and 135 operators to provide training to flightcrews in the recognition of and recovery from unusual attitudes and upset maneuvers, including upsets that occur while the aircraft is being controlled by automatic flight control systems, and unusual attitudes that result from flight control malfunctions and uncommanded flight control surface movements. (Supersedes Safety Recommendation A-96-066)

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THE NTSB RECOMMENDS THAT ALL PART 121 AIR CARRIERS: REVIEW INITIAL AND RECURRENT FLIGHTCREW TRAINING PROGRAMS TO ENSURE THAT THEY INCLUDE SIMULATOR OR AIRCRAFT TRAINING EXERCISES WHICH INVOLVE COCKPIT RESOURCE MANAGEMENT AND ACTIVE COORDINATION OF ALL CREWMEMBER TRAINEES AND WHICH WILL PERMIT EVALUATION OF CREW PERFORMANCE AND ADHERENCE TO THOSE CREW COORDINATION PROCEDURES.

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THE NTSB RECOMMENDS THAT THE FAA: REQUIRE THAT EACH BOEING 737 AIRPLANE OPERATED UNDER 14 CFR PARTS 121 OR 125 BE EQUIPPED, BY 12/31/95, WITH A FLIGHT DATA RECORDER SYSTEM THAT RECORDS, AS A MINIMUM, THE PARAMETERS REQUIRED BY CURRENT REGULATIONS APPLICABLE TO THAT AIRPLANE PLUS THE FOLLOWING PARAMETERS (RECORDED AT THE SAMPLING RATES SPECIFIED IN "PROPOSED MINIMUM FDR PARAMETER REQUIREMENTS FOR AIRPLANES IN SERVICE"): LATERAL ACCELERATION; FLIGHT CONTROL INPUTS FOR PITCH, ROLL & YAW; & PRIMARY FLIGHT CONTROL SURFACE POSITIONS FOR PITCH, ROLL, AND YAW. (URGENT)

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TO THE FEDERAL AVIATION ADMINISTRATION: Revise the icing certification testing regulation to ensure that airplanes are properly tested for all conditions in which they are authorized to operate, or are otherwise shown to be capable of safe flight into such conditions. If safe operations cannot be demonstrated by the manufacturer, operational limitation should be imposed to prohibit flight in such conditions and flightcrews should be provided with the means to positively determine when they are in icing conditions that exceed the limits for aircraft certification.

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TO THE FEDERAL AVIATION ADMINISTRATION: Require all 14 Code of Federal Regulations Part 121, 135, and 91K operators of stick pusher-equipped aircraft to provide their pilots with pusher familiarization simulator training. (A-10-23) (Supersedes Safety Recommendation A-07-4)

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THE NTSB RECOMMENDS THAT THE SECRETARY OF THE CALIFORNIA DEPARTMENT OF TRANSPORTATION: BAN THE MOVEMENT OF HAZARDOUS MATERIALS THROUGH VEHICULAR TUNNELS WHERE THE RELATIVE RISKS OF THE TUNNEL ROUTE ARE HIGHER THAN ALTERNATE ROUTES.

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TO THE FEDERAL AVIATION ADMINISTRATION: Revise the icing criteria published in 14 Code of Federal Regulations (CFR), Part 23 and 25, in light of both recent research into aircraft ice accretion under varying conditions of liquid water content, drop size distribution, and temperature, and recent development in both the design and use of aircraft. Also, expand the appendix C icing certification envelop to include freezing drizzle/freezing rain and mixed water/ice crystal conditions, as necessary. A-96-54 supersedes recommendations A-81-116 and 118.

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TO THE FEDERAL AVIATION ADMINISTRATION: Require manufacturers and operators of pneumatic deice boot-equipped airplanes to revise the guidance contained in their manuals and training programs to emphasize that leading edge deice boots should be activated as soon as the airplane enters icing conditions. (A-07-14) (This safety recommendation supersedes Safety Recommendation A-98-91)

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TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to incorporate the realistic, gusty crosswind profiles developed as a result of Safety Recommendation A-10-110 into their pilot simulator training programs.

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AMEND 14 CFR 33.77 TO INCREASE THE MAXIMUM NUMBER OF BIRDS IN THE VARIOUS SIZE CATEGORIES REQUIRED TO BE INGESTED INTO TURBINE ENGINES WITH LARGE INLETS. THESE INCREASED NUMBERS AND SIZES SHOULD BE CONSISTENT WITH THE BIRDS INGESTED DURING SERVICE EXPERIENCE OF THESE ENGINES.

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TO THE FEDERAL AVIATION ADMINISTRATION: Require that all Boeing 737 airplanes operated under 14 Code of Federal Regulations parts 121 or 125 that currently have a flight data acquisition unit be equipped, by July 31, 2000, with a flight data recorder system that records, at a minimum, the parameters required by FAA final rules 121.344 and 125.226, dated 7/17/97, applicable to that airplane plus the following parameters: pitch trim; trailing edge and leading edge flaps; thrust reverser position (each engine); yaw damper command; yaw damper on/off discrete; standby rudder on/off discrete; and c…

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TO THE FEDERAL AVIATION ADMINISTRATION: Require that all Boeing 737 airplanes operated under 14 Code of Federal Regulations parts 121 or 125 that are not equipped with a flight data acquisition unit be equipped, at the earliest time practicable but no later than August 1, 2001, with a flight data recorder system that records, at a minimum, the parameters required by FAA final rules 121.344 and 125.226, dated 7/17/97, applicable to that airplane plus the following parameters: pitch trim; trailing edge and leading edge flaps; thrust reverser position (each engine); yaw damper command; yaw damp…

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THE NTSB RECOMMENDS THAT THE FAA: REQUIRE THAT ALL NEWLY MANUFACTURED COCKPIT VOICE RECORDERS INTENDED FOR USE ON AIRPLANES HAVE A MINIMUM RECORDING DURATION OF 2 HOURS. (Supersedes Safety Recommendation A-95-023)

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TO THE FEDERAL AVIATION ADMINISTRATION: Require that all existing transport aircraft that are required to carry a flight data recorder be retrofitted with a flight data recorder system capable of recording values that meet the accuracy requirements through the full dynamic range of each parameter at a frequency sufficient to determine a complete, accurate, and unambiguous time history of parameter activity, with emphasis on capturing each parameter's dynamic motion at the maximum rate possible, including reversals of direction at the maximum rate expected.

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TO THE FEDERAL AVIATION ADMINISTRATION: Require that within 2 years, all Airbus A300-600/A310 and Boeing 747-400 airplanes and any other aircraft that may be identified as recording filtered data be retrofitted with a flight data recorder system capable of recording values that meet the accuracy requirements through the full dynamic range of each parameter at a frequency sufficient to determine a complete, accurate, and unambiguous time history of parameter activity, with emphasis on capturing each parameter's dynamic motion at the maximum rate possible, including reversals of direction at th…

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THE NTSB RECOMMENDS THAT THE STATE OF ARKANSAS: DEVELOP A COORDINATED PROGRAM WITH THE RAILROAD COMPANIES THAT OPERATE WITHIN THE STATE, TO EXTEND THE OPERATION LIFESAVER PROGRAM TO THE RURAL COMMUNITIES WHERE THE MAJORITY OF TRACKAGE AND UNPROTECTED GRADE CROSSINGS ARE LOCATED BY WORKING DIRECTLY WITH LOCAL OFFICIALS, FARM BUREAUS, AND FARMING COOPERATIVE ASSOCIATIONS TO PROMOTE GRADE CROSSING SAFETY WITHIN RURAL COMMUNITIES.

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TO THE FEDERAL AVIATION ADMINISTRATION: Require Honeywell to modify its flight management system (FMS) software either to inhibit manual entries in the gross weight field or to allow the takeoff gross weight to be uplinked directly into the FMS, and require operators of airplanes with Honeywell FMSs to incorporate this software modification.

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THE NTSB REITERATES SAFETY RECOMMENDATION H-75-9 OF MAY 30, 1975, AND FURTHER RECOMMENDS THAT THE BUREAU OF MOTOR CARRIER SAFETY: UPON COMPLETION OF THE TESTING OF THE TRACTOR-TRAILER DRIVER TRAINING STANDARDS, THE SAMPLE MODEL CURRICULUM, AND FINAL EXAMINATION CRITERIA, AMEND PART 391, "QUALIFICATIONS OF DRIVERS," OF THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS TO INCLUDE CRITERIA AND STANDARDS FOR THE TRAINING OF TRACTOR-TRAILER DRIVERS.

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TO THE FEDERAL AVIATION ADMINISTRATION: Require that all 14 Code of Federal Regulations Part 121 operators establish Safety Management System programs.

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TO THE FEDERAL AVIATION ADMINISTRATION: Require that 14 Code of Federal Regulations (CFR) Part 135 on-demand charter operators that conduct dual-pilot operations establish and implement a Federal Aviation Administration-approved crew resource management training program for their flight crews in accordance with 14 CFR Part 121, subparts N and O. (Supersedes Safety Recommendation A-02-012)

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TO THE FEDERAL AVIATION ADMINISTRATION: Issue a regulation, similar to 14 Code of Federal Regulations 119.39, that applies to applicants for a Part 145 repair station certificate, so the FAA can prevent individuals who have been associated with a previously revoked repair station from continuing to operate through a new repair station.

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TO THE FEDERAL AVIATION ADMINISTRATION: Require that all 14 Code of Federal Regulations Part 91K, 121, and 135 operators establish procedures requiring all crewmembers on the flight deck to positively confirm and cross-check the airplane’s location at the assigned departure runway before crossing the hold short line for takeoff. This required guidance should be consistent with the guidance in Advisory Circular 120-74A and Safety Alert for Operators 06013 and 07003. (Supersedes Safety Recommendation A-06-083)

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TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to review their standard operating procedures to verify that they are consistent with the flight crew monitoring techniques described in Advisory Circular (AC) 120-71A, "Standard Operating Procedures for Flight Deck Crewmembers"; if the procedures are found not to be consistent, revise the procedures according to the AC guidance to promote effective monitoring.

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TO THE FEDERAL AVIATION ADMINISTRATION: Develop, and distribute to all pilots, multimedia guidance materials on professionalism in aircraft operations that contain standards of performance for professionalism; best practices for sterile cockpit adherence; techniques for assessing and correcting pilot deviations; examples and scenarios; and a detailed review of accidents involving breakdowns in sterile cockpit and other procedures, including this accident. Obtain the input of operators and air carrier and general aviation pilot groups in the development and distribution of these guidance materi…

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TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations (CFR) Part 121, 135, and 91K operators and 14 CFR Part 142 training centers to develop and conduct training that incorporates stalls that are fully developed; are unexpected; involve autopilot disengagement; and include airplane-specific features, such as a reference speeds switch.

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TO THE FEDERAL AVIATION ADMINISTRATION: Modify 14 Code of Federal Regulations Part 25 to include a certification standard that will ensure safe handling qualities in the yaw axis throughout the flight envelope, including limits for rudder pedal sensitivity.

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TO THE FEDERAL AVIATION ADMINISTRATION: Require that air carriers provide their pilots with opportunities to practice high altitude stall recovery techniques in the simulator during which time the pilots demonstrate their ability to identify and execute the appropriate recovery technique.

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TO THE FEDERAL AVIATION ADMINISTRATION: Gather data on surface winds at a sample of major U.S. airports (including Denver International Airport) when high wind conditions and significant gusts are present and use these data to develop realistic, gusty crosswind profiles for use in pilot simulator training programs.

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TO THE UNITED STATES COAST GUARD: Incorporate additional training that emphasizes realistic vessel traffic service (VTS) simulation exercises, including detecting and responding to unsafe traffic situations, in your initial training and proficiency requirements for all VTS watchstanders in the US Coast Guard VTS system.

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TO THE FEDERAL AVIATION ADMINISTRATION: Require that all turbofan engine and turbofan-powered aircraft manufacturers, working with operators of such aircraft, develop effective operational strategies and related guidance materials to minimize the chance of a dual-engine power loss; the FAA should then verify that these strategies and guidance materials are incorporated into operating manuals and training programs in a timely fashion.

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INSTALL STEEL FLIGHT CONTROL PUSH RODS IN THE ELECTRICAL COMPARTMENT AREA.

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TO THE FEDERAL AVIATION ADMINISTRATION: Revise the Federal Aviation Regulations such that: all scheduled passenger service conducted in aircraft with 20 or more passenger seats be conducted in accordance with the provisions of 14 CFR Part 121.

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TO THE FEDERAL AVIATION ADMINISTRATION: Require within 2 years that all turbojet-powered airplanes equipped with six or more passenger seats have an operating ground proximity warning system installed. (Superseded by A-99-036)

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TO THE FEDERAL AVIATION ADMINISTRATION: Require the development of and implementation of design or operational changes that will preclude the operation of transport-category airplanes with explosive fuel-air mixtures in the fuel tank: (a) significant consideration should be given to the development of airplane design modifications, such as nitrogen-inerting systems & the addition of insulation between heat-generating equipment & fuel tanks. Appropriate modifications should apply to newly certificated airplanes &, where feasible to existing airplanes.

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TO THE FEDERAL AVIATION ADMINISTRATION: Require in Boeing 747 airplanes, and in other airplanes with fuel quantity indication system (FQIS) wire installations that are corouted with wires that may be powered, the physical separation and electrical shielding of FQIS wires to the maximum extent possible.

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TO THE FEDERAL AVIATION ADMINISTRATION: Require, in all applicable transport airplane fuel tanks, surge protection systems to prevent electrical power surges from entering fuel tanks' fuel quantity indication system wires.

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THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: AMEND 14 CFR 139.49 TO PRESCRIBE A MINIMUM LIST OF RESCUE/SUPPORT EQUIPMENT TO BE CARRIED ON EACH CRASH/FIRE/ RESCUE VEHICLE WHICH IS COMMENSURATE WITH THE AIRPORT'S INDEX OF FIREFIGHTING AND RESCUE SERVICE.