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American Airlines Flight 331 Likely a Preventable Accident

The December 22 American Airlines Flight 331 accident that injured more than 90 passengers has left numerous questions unanswered. However, even before the National Transportation Safety Board determines a probable cause for this accident, two things are clear from the initial reports: we are fortunate that, in light of the circumstances, the injuries sustained were not catastrophic; and, more troubling, this scenario was likely entirely preventable.

2009 has proven an interesting year for airline pilots and the flying public. In January, we witnessed the heroism of Captain Sullenberger averting disaster and gracefully landing US Airways Flight 1545 in the Hudson River. Cockpit voice recordings reveal a calm and measured reaction to a bird strike, as well as a calculated decision to land the plane in the Hudson. His professionalism, training, experience and judgment prepared him to successfully and artfully land a plane under trying circumstances.

A mere month later, Continental Air Flight 3407, operated by Colgan Air, crashed into a house during approach near Buffalo, NY, killing all 49 passengers and crew as well as one person the ground. Unlike Captain Sully, the pilots operating this regional flight were sleep deprived, sick, distracted and flying in inclement weather. They lacked sufficient training and resources, and were thus unqualified to be flying a plane under those circumstances.

In October, two Northwest pilots missed their destination by over 150 miles and failed to respond to air traffic controller attempts to reach them. The pilots claimed they “lost situational awareness” because they were distracted, reviewing a new company policy on a laptop. Speculation surrounding this incident has focused heavily on the theory that the pilots were in fact sleeping, again highlighting the issue of pilot fatigue.

Which brings me to the events of Tuesday night in Jamaica. The facts as they unfold have many similarities – both from an operational standpoint, as well as the aircraft type and runway environment – to Southwest Flight 1248 overran its runway in December 2005. In the Southwest accident investigation, the NTSB looked at factors such as decision to land, calculation of landing distance on a contaminated runway, company braking procedures, as well as pilot training.

Reports indicate that Tuesday’s flight in Jamaica had sufficient fuel to return to Miami, yet decided to land on the contaminated runway rather than turn around. The pilots were near timing out for their flight hours for the day, which raises the possibility of pilot fatigue impacting their decision-making process and their operation of the aircraft. Was the decision to land made based on the safety of the passengers or – considering the pressure of holiday travel, passenger frustration, pilot fatigue and cost – did the pilots decide that the safety risk was worth it?

The numerous accidents and incidents of 2009 raise serious questions about what is going on in the cockpit. The over arching question is a serious one: during these economic times, is aviation industry creating a culture of undervaluing risk to save money?

Make no mistake, there are numerous technical issues that may have contributed to the scenario that unfolded on Tuesday night, as well as the lack of preventative measures that could have mitigated damages. Moreover, the risk of human error is everpresent, and for that reason we must advocate also for additional safety measure that minimize the impact of such errors. Nonetheless, the events and mistakes outlined above are not discrete individual incidents; rather, they are evidence of a deteriorating safety culture. We are entrusting the safety of passengers to tired, overworked, and often under paid pilots who have insufficient training and distractions in the cockpit. Congress must act to ensure that the business interests of airlines do not outweigh the safety of our passengers. In 2009, Captain Sullenberger’s “Miracle on the Hudson” was an exception in a year fraught with serious safety hazards. But the reality is, he was not lucky – he was prepared. In 2010, let’s make his example the rule.

Kingston weather poor at time of American 737 overrun

While details on the American Airlines Boeing 737-800 overrun at Kingston remain sketchy, meteorological data shows poor weather conditions during arrival.

American’s timetable shows flight AA331’s scheduled arrival time is 21:10, but the carrier says the aircraft landed at 21:22CST, equating to 22:22 local.

Meteorological information from Norman Manley International Airport indicated heavy rain and possible thunderstorm activity at this time.

The airport has a single runway, designated 12/30, which has a length of 2,716m (8,910ft) but its virtually-offshore location – on a thin strip of land south of Jamaica – leaves little overrun margin at either end.

There is no confirmation of which runway the aircraft was using. While there is an instrument landing system for runway 12, the weather data indicates that this would have required landing with a tail wind.

NOTAM information, dated today, shows that the airport has restated the runway distances available to aircraft, and introduced a displaced threshold on runway 30.

American states that two of the 148 passengers were admitted to hospital for observation, but all others have been released. The jet, arriving from Miami, was also carrying a crew of six.

Damage to the 737 is substantial. Its fuselage has fractured aft of the wing, its right-hand CFM International CFM56 engine has separated and the left wing-tip has snapped.

By David Kaminski-Morrow

Plane overshoots Jamaica runway; more than 40 hurt

KINGSTON, Jamaica – An American Airlines flight carrying 154 people skidded across a Jamaican runway in heavy rain, bouncing across the tarmac and injuring more than 40 people before it stopped just short of the Caribbean Sea, officials and witnesses said.

Jamaica Flight Overshoots Runway

Workers sift through debris surrounding the fuselage of American Airlines flight AA331 which crash landed overnight on a flight from Miami to Jamaica, just beyond the runway of Norman Manley International Airport, in Kingston Jamaica, Wednesday, Dec. 23, 2009. More than 40 people were injured, at least 4 seriously, and there were no fatalities, according to officials, after the plane overshot the runway in Jamaica when it landed in heavy rain

Panicked passengers screamed and baggage burst from overhead bins as Flight 331 from Miami careened down the runway in the capital, Kingston, on Tuesday night, one passenger said.

The impact cracked the fuselage, crushed the left landing gear and separated both engines from the Boeing 737-800, airline spokesman Tim Smith said.

Crews evacuated dazed and bloodied passengers onto a beach from a cabin that smelled of smoke and jet fuel, passengers said. Rain poured through the plane’s broken roof, one said.

Some 44 people were taken to hospitals with broken bones and back pains and four were seriously hurt, airport and Jamaican government officials said. American Airlines said two people were admitted to the hospital and nobody suffered life-threatening injuries.

Heavy turbulence on the way to Jamaica had forced the crew to halt the beverage service three times before giving up, Pilar Abaurrea of Keene, New Hampshire, told The Associated Press by phone. The pilot warned of more turbulence just before landing but said it likely wouldn’t be much worse, she said.

“All of a sudden, when it hit the ground, the plane was kind of bouncing. Someone said the plane was skidding and there was panic,” she said.

U.S. investigators will analyze whether the plane should have been landing in such bad weather, Smith said, adding that other planes had landed safely in the heavy rain.

Passenger Natalie Morales Hendricks told NBC’s “Today” that the plane began to skid upon landing and “before I knew it, everything was black and we were crashing.”

“Everybody’s overhead baggage started to fall. Literally, it was like being in a car accident. People were screaming, I was screaming,” she said.

“There was smoke and debris everywhere,” after the plane halted, she said. “It was a mess. Everybody could smell jet fuel.”

Passenger Robert Mais told The Gleaner newspaper of Jamaica that he had heard the engine’s reverse throttle but that the plane didn’t seem to slow as it skittered down the runway.

The plane came to a halt about 10 to 15 feet (3 to 5 meters) from the Caribbean Sea and passengers walked along the beach to be picked up by a bus, Mais said. Rain came through the roof of the darkened jet and baggage from the overhead compartments was strewn about the cabin, he said.

The plane originated at Reagan National Airport in Washington and took off from Miami International Airport at 8:52 p.m. and arrived in Kingston at 10:22 p.m. It was carrying 148 passengers and a crew of six, American said. The majority of those aboard were Jamaicans coming home for Christmas, Jamaican Information Minister Daryl Vaz said.

Smith said there were two “significant” cracks in the fuselage, and the engines are designed to separate from the wings during an accident as a safety measure.

A team of six investigators from the National Transportation Safety Board was traveling to Jamaica from Washington on Wednesday morning to assist a probe led by the island’s government, agency spokesman Keith Holloway said.

The airport reopened early Wednesday after officials had delayed flights because of concerns that the plane’s tail might be hindering visibility.

Four hundred passengers waited for their flights to be cleared for takeoff, Security Minister Dwight Nelson told Radio Jamaica.

Heavy rains that have pelted Jamaica’s eastern region for four days are expected to dissipate by Thursday. Authorities said the rains washed away a 7-year-old girl on Tuesday and led to a bus crash in which two people died.

By KIRK WRIGHT, Associated Press

Associated Press Writers Danica Coto and Ben Fox in San Juan, Puerto Rico; Howard Campbell in Kingston, Jamaica; Carol Druga in Atlanta, Georgia; and Sofia Mannos in Washington contributed to this report.

The Legacy of Flight 4184

(CHICAGO) (WLS) — Saturday marks 15 years since the crash of American Eagle Flight 4184 near Roselawn, Indiana.

The disaster claimed 68 lives and changed the aviation landscape.

In the aftermath of 4184, we learned a great deal about the science of freezing rain and an entire fleet of aircraft not well suited to fly in it. We learned about warnings that went unheeded, and air traffic control procedures that would forever change. That was the technical stuff. Now we look back at the human factor.

On a quiet county road just south of Roselawn stand 68 crosses. Each bears the name of a life lost when Flight 4184 crashed into a soybean field a stone’s throw away.

The Super ATR aircraft had been in a holding pattern for O’Hare. The pilots were unaware of a deadly ice build-up that would cause the plane to roll and plunge to earth. There was little left of the plane and passengers.

Victims’ relatives- deep in grief and hungry for information could get little – from the airline or the government.

“Flight 4184 exemplified not only the tragic nature, but the utter confusion that existed during that time period,” said Don Nolan, aviation law attorney.

The pilot’s wife waited days for her husband’s employer just to call her. Airline care teams visited victims’ families and asked about their dead relatives medical histories.

Some of the unidentifiable human remains were laid to rest in a nearby cemetery. The airline conducted a service, but didn’t tell the families.

“I was angry, I was upset,” said Terri Severin.

Terri Severin lost her sister and her four year old nephew – the only child on the flight. Four months after the crash, Terri summoned the courage to go to the site. She was numbed by what she found.

“I actually walked away with bags full of plane wreckage, personal effects and human remains that were still just scattered at the site,” said Severin.

Those discoveries – plane parts, body parts four months later – became, for the relatives, the ultimate indignity.

“There were unspeakable things that occurred,” said Jim Hall.

Fifteen years ago, Hall was the chairman of the National Transportation Safety Board. The NTSB’s singular mission then was to find out what went wrong, and to make recommendations so it doesn’t happen again. But the families? That’s for somebody else.

“I was told this isn’t your business, and I said, ‘well my goodness. If I’m being paid by the taxpayers and we’re the agency that responds to these tragedies, it has to be our business,'” said Hall.

Hall wanted change. The families of 4184 demanded it, and in concert with families from other airline crashes, they pushed for it.

Two years later, the Aviation Disaster Family Assistance Act was signed into law.

Today when there is a disaster, the NTSB immediately takes the lead in dealing with the needs of families from information to crash site access.

“Today, the airlines are obligated to have a disaster plan in place. Those types of plans didn’t exist 15 years ago,” said Hall.

There are now protocols for airline employee training, grief counseling, the handling of remains and the return of personal effects.

“I am still healing and it will probably be a life long journey,” said Severin.

Terry Severin has written a book and lectures on what happened after 4184. She says she learned long ago that corporations and government are not fail-safe resources in the wake of disaster.

“But I have learned that the average citizen can make a difference in turning a negative response into a positive outcome,” said Severin.

This Saturday, Terri and other 4184 relatives will return to the memorial, as they do every year, to remember, to celebrate 68 lives and, perhaps, to contemplate what’s changed since that tragic miserable night 15 years ago in a bean field just outside Roselawn, Indiana.

The NTSB’s family response model is now used internationally. But responses to disaster will always be imperfect.

Terri Severin one day opened a letter saying that the airline had some unclaimed personal effects from 4184. It turned out that a couple of her nephew’s toys were among them. Terri received that letter eight years after the crash.

For more information on Severin’s book, visit www.inthewakeofthestorm.com.

By Paul Meincke

El Tribunal De Apelación De Illinois Confirma La Solicitud De Declinatoria Del Tribunal De Primera Instancia En Relación Con El Accidente Aéreo De Tans Perú De 2005

CHICAGO, Illinois (15 de junio de 2009) – El día de hoy el Tribunal de Apelación de Illinois, Primer Distrito, ratificó una Orden dictada por el H. Juez William D. Maddux el pasado 5 de septiembre, la cual rechazó las solicitudes de declinatoria del demandado para desestimar los casos sobre la base de jurisdicción inadecuada.Las demandas originales fueron entabladas por Nolan Law Group en el Tribunal de Primera Instancia del Condado de Cook, Illinois, en representación del patrimonio de ciertos pasajeros que fueron víctimas de homicidio culposo, en contra de The Boeing Company y United Technologies Corporation, como resultado del accidente ocurrido el 23 de agosto de 2005 en el que un Boeing 737-200 operado por Transportes Aéreos Nacional de Selva (TANS) se estrelló en la selva a aproximadamente 5.5 km al sur del Aeropuerto de Pucallpa.

La aeronave transportaba a 98 pasajeros, de los cuales 40 perecieron y muchos otros resultaron gravemente heridos, lo que lo convirtió en uno de los peores desastres en la historia de la aviación peruana.

En respuesta a la apelación de la orden del H. Juez Maddux presentada por los demandados, el 29 de mayo de 2009 Nolan Law Group presentó alegatos y réplicas escritas al tribunal de apelación, que describían la incapacidad de los demandados para respaldar adecuadamente su argumento de que el Tribunal de Illinois era un foro inadecuado.

Durante los procedimientos, los abogados de Nolan Law Group adoptaron la posición de que los demandados no lograron demostrar circunstancias excepcionales que favorecieran la transferencia o sobreseimiento de los casos y que, debido a que la decisión de admitir o rechazar la solicitud de sobreseimiento basado en una jurisdicción inadecuada es a discreción del tribunal de primera instancia, un tribunal revisor tendría que confirmar dicha decisión, a menos que se demostrara un abuso de facultades discrecionales.

“Sin un abuso de facultades discrecionales, un desacuerdo entre las opiniones de los jueces no es comparable a demostrar la existencia de circunstancias excepcionales”, señaló Donald J. Nolan, abogado de Nolan Law Group.

Nolan Law Group argumentó que era correcto el equilibrio de factores en los intereses públicos y privados del tribunal de primera instancia para rechazar la solicitud de sobreseimiento de los demandados, y que no existía un abuso de facultades discrecionales. Asimismo, reiteró su argumento de que el contexto de responsabilidad derivada del producto requería tomar en cuenta todos los aspectos de la solicitud de jurisdicción inadecuada de los demandados.

Además, Nolan Law Group demostró por qué Perú no es un foro “disponible” para volver a presentar los casos señalando que ciertos principios jurisdiccionales existentes en países sudamericanos están en conflicto directo con la jurisprudencia de jurisdicción inadecuada de los Estados Unidos, incluyendo la aplicación inflexible del Código Bustamante.

Nolan Law Grup representa actualmente a clientes que han entablado demandas por homicidio culposo en contra de Boeing y United Technologies Corporation como resultado del accidente del 23 de agosto de 2005, y esta resolución favorable le permite proceder con los casos en su contra en el Tribunal de Primera Instancia del Condado de Cook, Illinois.

In English | En Espanól

Illinois Appellate Court Upholds Lower Court’s Denial Of Forum Non Conveniens Motion Arising Out Of The 2005 Tans Peru Plane Crash

CHICAGO, Illinois (June 15, 2009) – Today the Appellate Court of Illinois, First District affirmed a September 5, 2008 Order issued by Judge William D. Maddux which denied defendant’s motions to dismiss cases on the grounds of forum non conveniens.

The original lawsuits were filed by Nolan Law Group in the Circuit Court of Cook County, Illinois, on behalf of certain passenger’s estates who have filed wrongful death and survival actions against The Boeing Company and United Technologies Corporation as a result of the August 23, 2005 crash where a Boeing 737-200 operated by Transportes Aereos Nacional de Selva (TANS) crashed in the jungle about 5.5 km south of Pucallpa Airport.

The aircraft was carrying 98 passengers, of which 40 were killed and many others were seriously injured, making it one of the worst aviation disasters in Peruvian history.

On May 29, 2009 in response to the defendants’ appeal of Judge Maddux’s ruling, Nolan Law Group presented written and oral arguments to the appellate court which outlined the defendants’ failure to provide adequate support for their contention that the Illinois Court is an inconvenient forum.

During the proceedings, Nolan Law Group attorneys took the position that defendants failed to demonstrate exceptional circumstances favoring the transfer or dismissal of the cases and that since the decision to grant or deny a motion to dismiss based on forum non conveniens lies within the discretion of the trial court, a reviewing court would have to uphold the trial court’s decision unless abuse of discretion was demonstrated.

“Without an abuse of discretion, a disagreement between judges’ opinions is not tantamount to showing exceptional circumstances” said Nolan Law Group attorney Donald J. Nolan.

Nolan Law Group argued that the trial court’s balance of private and public interest factors to deny defendants’ motion to dismiss was correct and that there was no abuse of discretion. Nolan Law Group also reiterated its argument that the products liability context of the case guided consideration of all aspects of defendants’ forum non conveniens motion.

Additionally, Nolan Law Group demonstrated why Peru is not an “available” forum for re-filing the cases, citing that certain existing jurisdictional principals in South American countries are in direct conflict with American forum non conveniens jurisprudence, including Peru’s steadfast application of the Bustamente code.

Currently, Nolan Law Group represents clients who have filed wrongful death and survival actions against Boeing and United Technologies Corporation stemming from the August 23, 2005 accident. This favorable ruling allows Nolan Law Group to proceed with its cases against Boeing and United Technologies in the Circuit Court of Cook County, Illinois.

In English | En Espanól

Jerome Skinner: System should be tweaked to further empower families

Continental Flight 3407, just like every aviation disaster, is a terrible tragedy for all who lost loved ones and for the Buffalo community in general. And like other air disasters, including the US Air Flight 427 crash near Pittsburgh and the Pan American Flight 103 bombing over Lockerbie, Scotland – it has given the families affected an opportunity to change the system and make family information and input much more important than it previously was.

It was out of the Pan Am 103 disaster that families became more aggressive in formally organizing and seeking involvement in post-accident investigative and fact-sharing activities. It was the long causal uncertainty of the investigation of Flight 427 that stirred the families to lobby for the Family Assistance Office concept put in place by the National Transportation Safety Board after the accident.

My law partner, Jim Hall, was chairman of the NTSB at the time and is thought of as the “father” of the Family Assistance Act. He believes that the office should consistently update the families and provide them with as much assistance as possible in understanding the investigative process.

This is the ideal. In reality it does not always function this way. I have worked in aviation litigation for almost 30 years and I share his opinion. No matter what the differences from family to family or accident to accident, the families always want to know why and how. They also want a voice.

A Buffalo News article seemed to come to grips with the fringes of the argument by dealing with the extreme claims that the system is so flawed that it is “intellectually dishonest,” or that the system is perfect from the viewpoint of the aviation industry that it represents. Neither is true.

Hall and I have a more useful suggestion, and one that will take the considerable muscle of the Flight 3407 families to implement. The existing party system will not be replaced. There are not enough investigators, testing laboratories or dollars to eliminate industry participation and make the system a truly independent process.

But the Office of Family Assistance must be called upon to provide families with consistent and complete information as the investigation is ongoing. This is already supposed to happen, but it will not unless the families demand it. The families could also call for the designation of a technically educated liaison to provide them information.

With that technical person in place, all that is needed is to “tweak” the system to give the families an opportunity to give the board input, offer suggestions and ask questions before the investigation goes into its analysis phase.

If the families ask for full information, a technical head to talk to and an opportunity to speak through that person before the process closes, it will be a big step that benefits all and ultimately enhances aviation safety in the future.

Confidential Settlement Reached in Product Liability Lawsuit From Fatal Helicopter Crash Involving Petros VII Pope and Patriarch of the Greek Orthodox Church

On September 11, 2004, His Beatitude, Pope and Patriarch Petros VII, along with 16 others including his brother, clergy, lay members of the Orthodox Church, and the Greek Army crew perished when the helicopter they were aboard went out of control and crashed into the Aegean Sea approximately 15 nautical miles from the shoreline near Mt. Athos, Greece.


The helicopter used for the flight was a CH-47D, commonly known as the “Chinook” which was manufactured in 2001 by The Boeing Company and sold to the Greek Army as part of a U.S. Foreign Military Sales Agreement valued at over 300 million dollars.

The fateful flight departed the Pachi Megaron Army Airfield west of Athens at approximately 9:30 a.m. for a routine flight to the holy monasteries at Mt. Athos on the Chalkidiki peninsula. However, at approximately 10:53 a.m. local time, after the pilot requested clearance to an altitude of 4,500 feet, things began to go tragically wrong. The last six radar points beginning at 10:54 a.m. (see below) indicate that rather than continuing in a north northeast heading toward Mt. Athos, the helicopter began to take a slight left turn. This heading change was then followed by a loss of the transponder signal and a steep left turn and a final high-speed plunge into the ocean.

The recovery process was hampered by the sea’s depth and weather. Nevertheless, investigation into the accident revealed several anomalies with the helicopter which including illuminated caution lights on the maintenance panel without illumination of corresponding lights on the Master Caution Panel, significant damage to the aft rotor droop stops, DC power present in the aft section of the helicopter but absent in the cockpit, damage to gear teeth in the aft rotor drive system, and an over current in the A11 circuit card of the automatic flight control system (AFCS). Additionally, switch positions in the cockpit indicated the pilots were trying to isolate a hydraulic problem.

The diagram depicts the last six radar points recorded for the helicopter. The last three are from ground based radar following failure of the helicopter’s

The diagram depicts the last six radar points recorded for the helicopter. The last three are from ground based radar following failure of the helicopter’s transponder

This was to be the first official trip by Petros VII to the holy monasteries at Mt. Athos. He, a new-calendarist ecumenist, was reportedly traveling to the Monastery of Vatopedi to celebrate that Monday the Feast of the Deposition of the Precious Sash of the Mother of God according to the Old Calendar.

Nolan Law Group’s helicopter accident attorneys represented the estates of Patriarch Petros VII, his brother, Georgios Papapetrou, Metropolitan Chrysostomos of Carthage, and Hierodeacon Nektarios Kontogiorgis. The cases were settled during voluntary mediation conducted by Hon. Edward N. Cahn, retired Chief Judge of the Eastern District of Pennsylvania. Papapetrou v.The Boeing Company, et al., Case No. 07-cv-3768, E.D.Pa.

Jim Hall: Aircraft icing needs harder look

Thursday’s crash of a de Havilland Dash 8 Q400 in Clarence was deeply saddening. Fifty persons were killed in the tragedy, and the 2z-year period of fatality- free flying in commercial aviation was brought abruptly to an end.More tragic, this crash was foreseeable and likely preventable, if not for the preference of profit over safety in some of the aviation industry and for the lax oversight of the Federal Aviation Administration in its failure to adequately address known safety risks related to icing.

Initial reports strongly indicate that airframe icing played a major role in the crash of this turboprop aircraft. This type of occurrence is not without precedent. On Oct. 31, 1994, American Eagle Flight 4184 dropped from the sky when ice accumulated on its wings. It crashed into a soybean field in Roselawn, Ind., killing all 68 people onboard. On Jan. 9, 1997, Comair flight 3272 dropped from the sky over Monroe, Mich. when ice accumulated on its wings, killing all 29 people on board.

Like Thursday’s crash, both of these planes were turboprop-an Avions de Transport Regional 72 and an Embraer 120, respectively. Both aircraft were equipped with pneumatic deicing boots, a technology invented in the 1930s that has not changed much since.

As chairman of the National Transportation Safety Board, I oversaw the investigation into the Roselawn and Monroe crashes. It became apparent that, while deicing boots are more fuel efficient than the heated wing technology that larger jets use, they are not as effective at reducing the risk of an icing accident.

Furthermore, the FAA is charged with overseeing the certification process of each make and model of aircraft, yet we found in our investigation that the FAA failed to ensure that this certification adequately accounted for hazards that can result from all known icing conditions. After our extensive investigation at Roselawn concluded, I signed the NTSB’s recommendations to the FAA regarding these issues.

More than 10 years later, the FAA has not adequately addressed these concerns, and the NTSB has placed safe flight in icing conditions on its “Most Wanted” safety improvements list.

The aircraft model that crashed Thursday was certified by the FAA on Jan. 26, 2000, and the accident aircraft itself was not manufactured until 2008-well after the Roselawn recommendations were issued and with full knowledge of the dangers that turboprops and deicing boots face in freezing conditions.

There was no move to incorporate the more effective (but more expensive) heated wing technology. What’s more, an airworthiness directive published by the FAA in 1996 notes that the earlier, 40-seat model of DHC-8 aircraft had an unsafe condition which could result in loss of control of the aircraft when flaps were extended during icing conditions-as they were in Thursday’s crash-and further that the autopilot should not be engaged in “severe icing conditions,” a vaguely defined term.

But because the FAA basically ignored the NTSB’s recommendation to adequately test aircraft in these conditions before declaring them airworthy, the certification of this new version of the DHC-8 went along without a hitch. The most substantial change to the new model was not related to safety: the aircraft was stretched to allow 78 passengers to be carried by the aircraft. In short, even in light of the Roselawn and Monroe accidents, safety was compromised so that these aircraft would be allowed to fly more people at cheaper cost.

In this instance, the FAA and the airline industry clearly placed a higher value on profit than on their passengers’ safety. Well-known risks were overlooked, well-documented recommendations were ignored. That this plane was allowed to fly in dangerous conditions for which it was not thoroughly tested and prepared, and without recommended safety measures and devices in place, demonstrates this.

This attitude must change. The NTSB should move quickly to identify any deficiencies and FAA should take the requested action, such as prohibiting this aircraft from operating in icing conditions until remedies are established. I hope this accident will finally cause the FAA and the commercial aviation industry to take icing risks seriously so that a tragedy such as this will not happen again.

Jim Hall, an attorney with Nolan Law Group, was chairman of the National Transportation Safety Board from 1994 to 2001.

Timeline of NTSB Icing Recommendations

October 31, 1994:Crash of ATR 72-212 (turboprop) at Roselawn, ID. 68 people were killed. American subsequently moved operations of ATR 72 to the Caribbean and southern U.S.

July 9, 1996: NTSB Aircraft Accident Report regarding Roselawn accident released. Probable cause was a “loss of control, attributed to a sudden and unexpected aileron hinge moment reversal that occurred after a ridge of ice accreted beyond the deice boots.”

August 8, 1996: NTSB Issues Safety Recommendations A-96-48 through A-96-69. Among these are Recommendations A-96-54 and A-96-56 which read as follows:

  • Revise the icing criteria published in 14 Code of Federal Regulations (CFR), Parts 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 developments in both the design and use of aircraft. Also, expand the Appendix C icing certification envelope to include freezing drizzle/freezing rain and mixed water/ice crystal conditions, as necessary. (A-96-54


  • 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 limitations 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. (A-96-56)


August 20, 1997: NTSB classifies the FAA’s response to A-96-54 and A-96-56 as “Open-Acceptable” after FAA created an Aviation Rulemaking Advisory Committee (ARAC) to develop certification criteria for the safe operation of aircraft in icing conditions.

1999: De Havilland Dash 8 Series Q402 receives type certification.

January 27, 2003: NTSB writes letter to FAA regarding the work of the ARAC, saying it is concerned about the “slow pace of the [the ARAC’s work].” The NTSB stated, “Although the FAA, through its referral of this work to the ARAC, is responding to these recommendations, the Safety Board remains concerned that in the 6 years since these recommendations were issued, the work has not been completed. The Board would like the FAA to provide a schedule for completion of the recommended actions.”

May 19, 2003: FAA responds to NTSB’s concern, stating that “The FAA will publish a notice of proposed rulemaking based on these recommendations by June 2004.”

November 9, 2004: After an NTSB meeting regarding “Most Wanted Recommendations,” NTSB classifies Recommendations A-96-54 and A-96-56 as “Open-Unacceptable.”

February 15, 2005: Cessna Citation 560, owned by Circuit City Stores, Inc. crashed in Pueblo, CO 4 miles east of Pueblo Memorial Airport. 8 people were killed. NTSB stated probable causes as: “the flight crew’s failure to effectively monitor and maintain airspeed and comply with procedures for deice boot activation on the approach, which caused an aerodynamic stall from which they did not recover. Contributing to the accident was the Federal Aviation Administration’s failure to establish adequate certification requirements for flight into icing conditions, which led to the inadequate stall warning margin provided by the airplane’s stall warning system.” (Emphasis added)

May 10, 2006: Two years after the FAA’s own deadline for action, the NTSB issued a statement again lamenting the lack of action: “There does not appear to have been any progress since the FAA previously informed the Board of the status of this recommendation on September 15, 2003.”

February 27, 2007: From NTSB update on FAA action regarding the Recommendations: “[T]he FAA has still not received the recommendations from [its working group studying deicing certification], prepared regulatory analyses, issued the NPRM, analyzed comments, or completed the many other tasks involved in issuing new regulations.”

April 16, 2008: Aircraft involved in Buffalo crash issued certificate of airworthiness.

February 12, 2009: Crash of de Havilland Dash 8 Q-402 (turboprop) outside of Buffalo, NY killed 50 people. Cockpit Voice Recorder indicated that crew mentioned significant ice buildup on windshield and leading edge of wings.

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