Volume 3 GENERAL TECHNICAL ADMINISTRATION
CHAPTER 10 OPERATIONAL EMPHASIS ITEMS
Section 1 Operational Emphasis Items
3-261 GENERAL. This section includes information
that is not task‑specific, but is of importance to inspectors performing inspections
and other contacts with airmen and operators.
3-262 HAZARDS ASSOCIATED WITH IMPROPER SECURITY OF
NOSE SECTION EXTERIOR CARGO DOORS. Investigation of a fatal accident revealed
that the nose baggage door of a twin‑engine aircraft opened in flight shortly
after takeoff. Eight people died in the ensuing accident. Further investigation
revealed a bypass of the safety interlock feature on the nose baggage door sometime
before the accident. Therefore, the pilot received no warning that the door
A. Continued Occurrences. The continued occurrence
of unwanted nose baggage door openings on small twin‑engine aircraft indicates
a safety problem still exists with small aircraft that use the nose section
as a baggage area.
1) The nose baggage doors of these aircraft may
have door warning lights located in the cockpit. The warning lights illuminate
to indicate an open or unsecured baggage door.
2) Some models have a safety interlock feature
designed to prevent an engine start if the nose baggage compartment door is
not properly latched.
3) The warning light system and the safety interlock
may become inoperative or one may intentionally bypass the system. When the
pilot is not aware of an open or improperly latched nose baggage door, door
opening and release of cargo can occur with catastrophic results.
B. Federal Aviation Administration (FAA) Responsibilities.
In all contacts with operators of twin‑engine aircraft with nose section cargo
storage areas, inspectors should inform operators and pilots of the hazards
associated with improper security of nose section exterior cargo doors.
1) Inspectors should suggest that the operators
establish and use a procedure to ensure the security of all exterior cargo doors
before flight. The inspector should also recommend installation of secondary
locking devices or cargo restraint systems.
2) During inspection of this type of aircraft,
an Airworthiness inspector should determine if an installed safety interlock
feature is functioning properly or if it has been bypassed. Properly repair
malfunctioning warning or safety interlock systems before flight.
3-263 AIR TRAFFIC CONTROL (ATC) CLEARANCE READBACK.
Over the past several years, accidents and incidents have occurred because of
misunderstandings between pilots and controllers. As a result of National Transportation
Safety Board (NTSB) investigations and recommendations, the ATC Handbook has
been amended to require a readback of any altitude assignment or a vectoring
A. Adherence to Communications Procedures. In all
contacts with pilots, instructors, examiners, and pilot schools, inspectors
should emphasize the need for strict adherence to communications procedural
B. ATC Readbacks. During contact with pilots, inspectors
should stress the possible hazards associated with pilot and controller misunderstandings.
Clear readback of ATC altitude or heading clearances helps to avoid such misunderstandings.
3-264 PASSENGER EMERGENCY BRIEFINGS. After the
crash of a corporate jet, the passengers had difficulty evacuating the airplane
because of insufficient knowledge of emergency procedures. No one briefed the
passengers as required by Title 14 of the Code of Federal Regulations (14 CFR)
91.519. Furthermore, no one posted the placarded instructions for opening
the main cabin door or the overhead emergency exits as required by 14 CFR part
25.811. In addition, a small carpet became wedged underneath the door separating
the passenger cabin from the main entrance area, adding to the problems in evacuating
A. Responsibilities of Corporate Operators. Operators
of corporate aircraft should:
1) Ensure that passengers are made aware of emergency
procedures before takeoff.
2) Ensure compliance with placard requirements.
3) Ensure that procedures to stow all loose items
in the aircraft before takeoff and landing are in effect.
4) Periodically review the accuracy and appropriateness
of the passenger briefing cards.
B. FAA Responsibilities. During surveillance or
other contact with corporate aircraft operators, inspectors must stress the
importance of briefing passengers on emergency procedures before flight.
3-265 USE OF MANUFACTURER CHECKLISTS. Investigation
of an accident involving a jet aircraft operated under part
91 subpart D revealed that the flightcrew members failed to check the emergency/park
brake handle position before takeoff.
A. Takeoff Crash. In this accident, an aircraft
crashed when the pilot was unable to rotate the aircraft to the proper pitch
attitude during an attempted takeoff. Examination of the emergency/park brake
lever indicated that the lever was in the "park" position during the takeoff
B. Manufacturer Checklists. Comparison of the manufacturer's
suggested checklist with the company's checklist indicated that the manufacturer's
suggested checklist recommended that the status of the emergency/park brake
and associated warning light be checked on three separate occasions before takeoff.
None of these checks appeared on the company checklist.
C. FAA Responsibilities. Aviation safety inspectors
(ASI) must review the checklists of high‑performance jet aircraft to ensure
that any information or procedures in the manufacturer's suggested checklist
are included in the checklist used by the flightcrew.
3-266 ALTERNATE AIRPORTS FOR HIGH‑ALTITUDE INSTRUMENT
FLIGHT RULES (IFR) OPERATIONS.
A. High‑Altitude Airports. There are several high‑altitude
airports in the United States with approved instrument approach procedures (IAP)
where the minimum descent altitudes (MDA) are greater than 2,000 feet (ft) above
ground level (AGL) and/or the landing visibility minimums are greater than 3
miles. This could result in a critical situation if the weather is marginal
and a pilot has failed to plan for a suitable alternate airport.
91.167(b) permits a pilot to avoid the alternate airport fuel requirement.
This provision is dependent upon the ceiling at the estimated time of arrival
(ETA) over the airport of intended landing being forecast, for at least 1 hour
before and after landing, to be at least 2,000 ft above the airport elevation
and the visibility being at least 3 miles.
C. FAA Responsibilities. During surveillance or
other contacts with pilot groups, especially in high‑altitude areas, inspectors
should stress the need for a careful review of the instrument approaches to
airports located in mountainous terrain with respect to minimum altitudes and
aircraft avionic equipment capability. Inspectors should recommend that pilots
consider the need for enough fuel to divert to an alternate airport even when
the weather forecasts are at or above the minimums for waiving this requirement.
1) A number of airports have minimum altitudes
below 2,000 ft and 3 miles for some IAPs that require special equipment such
as a glideslope (GS) or distance measuring equipment (DME). All other IAPs at
these airports have MDAs above the required minimum ceiling for foregoing the
necessary fuel to reach an alternate. If there is no special equipment installed
or it becomes inoperative, and the ceiling is, as forecast, about 2,000 ft AGL,
the situation may necessitate that the pilot declare an emergency under instrument
conditions at the destination airport.
2) A number of airports have MDAs that are slightly
(100 to 200 ft) below 2,000 ft AGL. In situations when the weather is forecast
to be 2,000 ft ceiling and/or 3 miles visibility, a pilot may find upon arrival
that the weather is somewhat less than forecast. If a missed approach was necessary
and the prospects of the weather improving were slim, the pilot who had not
included enough fuel to get to a suitable alternate might become involved in
3-267 HAZARDS ASSOCIATED WITH CARRIAGE OF CARGO PACKED
IN CARBON DIOXIDE. An incident involved a Falcon Jet's flightcrew members
who experienced dizziness and shortness of breath while awaiting takeoff clearance.
The cargo on board the aircraft included items packed in solid carbon dioxide,
also known as dry ice. The crew was confined in an unventilated cabin for approximately
10 minutes. The flight returned to the ramp, and the crew recovered after exiting
the aircraft. The dry ice was offloaded, and the flight departed without further
incident. Subsequent investigation revealed that crewmembers on other flights
had also experienced these symptoms when carrying dry ice.
A. Dry Ice as a Hazardous Material (Hazmat). Dry
ice, usually in a snow‑like consistency, refrigerates food, medicine, and other
perishable items. Dry ice is a solid under the hazmat regulations of Title 49
of the Code of Federal Regulations (49 CFR).
1) When transported by aircraft, contain solid
carbon dioxide, a hazmat, in packaging designed and constructed to permit the
release of carbon dioxide gas.
2) One of the factors affecting the sublimation
rate of this gas is the surface area of the solid carbon dioxide. The snow‑type
consistency of dry ice causes gas to sublimate at a much higher rate than carbon
dioxide in blocks. The rate of carbon dioxide release varies with the degree
of insulation used in packaging, crushed or solid form of carbon dioxide, temperature,
and atmospheric pressure.
3) Carbon dioxide is a simple asphyxiate. When
conditions are high enough that there is insufficient oxygen in the atmosphere
to support life, symptoms of asphyxiation may result. The signs and symptoms
are those that precede asphyxia: headache, dizziness, shortness of breath, muscular
weakness, drowsiness, and ringing in the ears. Immediate removal from exposure
generally results in rapid recovery.
B. Hazards of Dry Ice On Board Aircraft. The hazard
associated with the carriage of dry ice aboard all aircraft is minimal under
most cabin ventilation conditions. However, the concentration of carbon dioxide
in an unventilated cabin area the size of a Falcon Jet or smaller can be significant.
The cabin air rate of change per hour should be positive to prevent unwanted
carbon dioxide concentrations when carrying dry ice. While this hazard is greater
during ground operations, it is possible to have a carbon dioxide buildup in
the cockpit/cabin area during flight. The buildup could be greater during periods
requiring less ventilation, such as cool weather operations with the vents closed
and only a small amount of heat applied.
C. FAA Responsibilities. Inspectors should contact
pilots and certificate holders who they know carry cargo packed with dry ice
and discuss this issue. At present, the extent of the problem is unknown. Forward
any reports of crewmembers having symptoms that possibly relate to carriage
of dry ice to the Commercial Operations Branch (AFS‑820).
1) The FAA recommends that pilots operating aircraft
with a cabin volume the size of the Falcon Jet or smaller, which are not capable
of forced ventilation while on the ground, be aware of this hazard and initiate
procedures to ensure there is no impairment to their ability to function. One
positive solution is the use of 100 percent oxygen by the crew while taxiing
and holding the aircraft before takeoff.
2) Pilots of unpressurized small aircraft carrying
dry ice should be aware of the possibility of carbon dioxide buildup during
en route operations. If pilots suspect any carbon dioxide asphyxiation symptoms,
they should increase the cabin ventilation. Pilots should also consider landing
as soon as practical if the symptoms continue.
3) Operators who need to carry large quantities
of dry ice over long distances may wish to evaluate or monitor cockpit conditions.
There are many types of carbon dioxide detection devices available.
3-268 FLAP OPERATION ON HS‑125 AIRCRAFT. Two recent
incidents involving flap spar damage caused by flap contact with snow and/or
slush during landing have prompted a need to reemphasize compliance with the
applicable instructions contained in the Hawker Siddeley Crew Flight Manual.
A. Lift‑Dump Position. In each incident, the stress
and resulting overloads were imposed when the flaps were deployed to the 75
degree or "lift‑dump" position. In one case, damage to the flaps and flap spars
created an additional hazard by the lateral movement outboard of the damaged
flap, which in turn damaged the adjacent aileron.
B. Crew Manual Changes. The Hawker Siddeley Company
has incorporated the following instructions in the crew flight manuals of HS‑125
Models 3AR, 3ARA, 400, 600, and 700 when operating on a runway with deep puddles,
slush, snow, or ice.
1) Ensure as far as possible that the landing does
not result in a go‑around after touchdown.
2) After every such landing or aborted takeoff,
avoid retracting the flaps, if practicable. Examine the top and bottom surfaces
of the flaps and adjacent structures for damage, preferably with the flaps in
the lift‑dump position. Also, ensure that there is no packed slush, snow, or
ice between the flap and wing structures.
3) If the flaps are confirmed as damaged after
examination, report the fact to the person responsible for the aircraft's maintenance
at the first convenient opportunity but not later than the next Service A inspection.
Examine each flap inboard hinge bolt for signs of overloading.
C. FAA Responsibilities. Principal operations inspectors
(POI) should contact all known operators of the HS‑125 models indicated above
and advise them of the hazards associated with operations onto snow‑ or slush‑covered
runways with this type of aircraft. Request that operators review the specific
instructions in the crew flight manual regarding this hazard with their flightcrews.
3-269 LANDING ON WET OR SLIPPERY RUNWAYS. Water,
ice, or snow on a runway can seriously affect aircraft ground controllability
and braking efficiency. In the case of standing water, as the speed of the aircraft
and the depth of the water increase, the water layer builds up an increasing
resistance to displacement, resulting in the formation of a wedge of water beneath
the tire. The vertical component of this resistance progressively lifts the
tire, decreasing the area in contact with the runway until, with certain aircraft
configurations and water depths, the tire is completely out of contact with
the runway surface and starts hydroplaning on a film of water. In this condition,
the tires no longer contribute to directional control, and braking action is
A. Types of Hydroplaning.
1) Dynamic hydroplaning can occur when there is
standing water on the runway surface. Water about one‑tenth inch deep acts to
lift the tire off the runway as explained above.
2) Viscous hydroplaning occurs because of the viscous
properties of water. The tire cannot penetrate a thin film of fluid more than
one-thousandth inch deep and the tire rolls on top of the film. Viscous hydroplaning
can occur at a much lower speed than dynamic hydroplaning, but it requires a
3) Reverted rubber hydroplaning requires a prolonged,
locked wheel skid, reverted rubber, and a wet runway surface. Rubber that has
reverted to the surface during previous landings contaminates most runways.
This reverted rubber acts as a seal between the tire and the runway and delays
water exit from the tire footprint area. The water heats from friction becoming
steam, and the steam supports the tire off the pavement.
B. Hydroplaning Tests. From the data obtained during
hydroplaning tests, the minimum dynamic hydroplaning speed of a tire has been
determined to be 8.6 times the square root of the tire pressure in pounds per
square inch (psi). For example, the Learjet main tire has a pressure of 115
psi, and its calculated hydroplaning speed is 92 knots (kts). It is important
to note that the calculated speed is for the start of the dynamic hydroplaning.
Once hydroplaning has started, it may persist to a significantly slower
speed, depending on the type of hydroplaning.
1) A joint FAA/National Aeronautics and Space Administration
(NASA)/United States Air Force (USAF) Runway Research Program was conducted
to establish the degree of stopping distance correlation between jet aircraft
and ground friction measurement vehicles.
2) Although the aircrafts used for the program
were transport category aircraft (B‑727 and DC‑9), because of these tests, the
following general procedures are suggested when landing any aircraft on slippery
or wet runways:
a) Fly a stabilized approach without excessive airspeed.
Touch down at the proper point and avoid holding the airplane off.
b) If it is not possible to establish a zero drift condition
before touchdown, execute a missed approach.
c) If available, activate the spoilers as soon as possible
after main gear touchdown. With automatic spoiler systems, be prepared to deploy
the spoilers manually.
d) Immediately lower the nosewheel to the surface and
maintain wheel loading by forward pressure on the control column.
e) If available, apply reverse thrust on all engines.
f) Maintain directional control, primarily with rudder
and nosewheel steering. Use differential braking as needed.
g) Apply light to moderate brake pedal pressure.
h) If directional control becomes a problem while in reverse
thrust, reduce reverse thrust on all engines and, if necessary, return them
to forward thrust.
i) Do not attempt to turn off a slippery runway until
reducing speed sufficiently to turn without skidding.
C. FAA Responsibilities. Inspectors with program
responsibility for airman certification and testing should review the adequacy
of pilot training and competence with respect to landing on slippery runways
and the phenomenon of hydroplaning. Pilot training programs should cover these
subject areas with emphasis on the operational procedures that are essential
to a successful landing (i.e., speed control (stabilized approach), touchdown
point, and the use of spoilers/speed brakes, wheel brakes (including use of
antiskid limitations), and reverse thrust).
3-270 COMPUTING RUNWAY LANDING AND DECELERATION REQUIREMENTS.
A. Accident History. In an accident several years
ago, a Learjet overran the end of a runway, traveled off a 90‑ft bluff, and
was destroyed by impact and fire. The accident killed four passengers and two
crewmembers. The runway was 3,240 ft long and 100 ft wide with 120‑ft displaced
thresholds. The FAA‑approved flight manual for the Learjet indicated a requirement
of 3,100 ft for landing distance based on airport elevation, runway gradient,
temperature, and wind at the time of the accident.
B. FAA Responsibilities. Inspectors should contact
operators of transport category aircraft in General Aviation Operations (GAOP)
and discuss the use of minimum landing runway lengths that will provide the
safety margin required by 14 CFR part
135. If it is not possible for General Aviation (GA) operators to use these
safety margins, the inspector should encourage the operator to establish the
use of safety margins consistent with the performance of the emergency braking
system of the aircraft.
1) It is important for pilots to preplan for brake
failures, including decisions to abort a landing after touchdown.
2) Review the use of emergency brakes and other
deceleration devices during preflight planning.
3) Many transport category aircraft have performance
charts included in the Aircraft Flight Manual (AFM). These performance charts
depict minimum landing distance with the margins required by parts
135 already calculated. Encourage the use of these charts, since use of
the more conservative values when flight planning will result in crews choosing
runways with a greater margin of safety.
3-271 ALTIMETER SETTINGS FOR BAROMETRIC PRESSURE ABOVE
31.00 inHG. There is no need to test altimeters for barometric pressures
exceeding 31.00 inHg; most are not capable of an adjustment to exceed this value.
A. Characteristics of High Barometric Pressure.
The Air Traffic Procedures Advisory Committee (ATPAC) identified a need to ensure
common pilot/controller understanding of aircraft operations in areas where
the barometric pressure exceeds 31.00 inHg. The committee, with consultation
from the Flight Standards Service (AFS) and the Air Traffic Organization (ATO),
recommended that the FAA advise the aviation community of the effects of high
barometric pressure on aircraft operations.
1) The atmospheric conditions that produce barometric
pressure in excess of 31.00 inHg are a cold, dry air mass. The associated ceiling
and visibility are essentially unlimited except for local conditions such as
smoke or ice fog.
2) When the actual barometric pressure is greater
than the altimeter setting, the indicated altitude will be lower than the actual
altitude. The effect of cold temperature is in the opposite direction. The two
variables, pressure and temperature, tend to nullify each other.
3) A paragraph was incorporated into the Aeronautical
Information Manual (AIM) advising that ATC will announce an altimeter setting
of 31.00 inHg ("Three One Zero Zero") any time the barometric pressure equals
or exceeds that value. The actual barometric pressure will be provided upon
B. FAA Responsibilities. Inspectors should ensure
that the aviation community is aware of the AIM material and the effects it
has on their operations. Place special emphasis on advising operators at remote
airports that it may not be possible to set field elevation before departure
when these atmospheric conditions exist.
3-272 OPERATION ON CLOSED RUNWAYS/TAXIWAYS. Reports
of aircraft operating on closed runways/taxiways indicate a need for increased
emphasis on the potential problems associated with this type of operation.
A. Notification of Conditions Affecting Safety.
Airport operators are responsible for establishing and using procedures for
the immediate notification of airport users and the FAA of any conditions adversely
affecting operational safety.
1) Airport operators have the authority to close
an airport, or any of its runways, when they determine an area to be unusable
or unsafe for aircraft operations. Airport operators are the primary authority
for originating, by Notices to Airmen (NOTAM) or other means, information to
airmen concerning unsafe conditions or other operational limitations on their
2) In the case of airports certificated under 14
139, the regulation requires dissemination of information concerning airport
conditions affecting safe aircraft operations to air carrier users of the airport.
B. Operations During Closure. Airport operators
have reported instances of aircraft operations on their airports contrary to
the notices of closure or other restrictions because of unusable or unsafe conditions.
The airports involved have been both certificated and noncertificated airports.
The aircraft involved have been both air carrier and GA aircraft.
C. Accident History. Analyses of past accidents
and incidents have identified the following situations that have contributed
to hazardous operational conditions on airport areas:
1) Holes, obstacles, loose pavement, or debris
on or near operations areas.
2) Heavy equipment, stationary or mobile, operating
near airport operations areas or in safety areas.
3) Relatively low visibility units such as cranes,
drills, and the like in critical areas such as approach zones.
4) Crews of workers, who may not be highly visible,
near runways or taxiways.
5) Mounds of earth, construction material, temporary
structures, and other obstacles in proximity to operations areas and approach
6) Safety area encroachments, improper ground vehicle
operations, and unmarked or uncovered holes and trenches near aircraft operating
D. Permanent Runway/Taxiway Closings. When an airport
operator permanently closes a runway or a taxiway, the lighting circuits are
1) On a closed runway, obliterate the threshold
markings, runway designation marking, and touchdown zone (TDZ) markings, and
place crosses at each end and at 1,000‑ft intervals.
2) Place a cross at each entrance of the closed
E. Temporarily Closed Runways/Taxiways.
1) Treat temporarily closed runways in the same
manner as permanently closed runways, but do not obliterate markings. Place
temporary crosses only at the runway ends on top of the runway numbers.
2) The use of barricades with alternate orange
and white markings, supplemented with flags, indicates temporarily closed taxiways.
For night operations, use flashing yellow lights.
3) During night operations, an airport with a closed/obstructed
runway may still have the airport rotating beacon in operation.
4) Identification of temporary runway threshold
displacements should be located outboard of the runway surface. This could include
outboard lights, runway end identification lights (REIL), and markings.
F. Pilot Expectations. If a NOTAM has not been
issued advising that a runway is closed, and if there is no information to the
contrary, a pilot should be able to expect that the runway is free of unusual
conditions of a hazardous nature. However, if a NOTAM has been issued advising
that the runway is undergoing maintenance and the entire surface is unusable
or unsafe, the pilot has no way of knowing what hidden defects the pavement
may contain or what sort of activity may suddenly occur on a previously unoccupied
portion of the surface.
G. Closed Runway Information. When a runway or
other area will close, the airport operator provides information to the local
ATC facility so that one may issue a NOTAM.
1) Inspectors should review the NOTAM system detailed
in the AIM and particularly note the NOTAM information that one distributes
locally. Do not attach NOTAM information to the hourly sequence reports.
2) Maintain a separate file of NOTAMs at each Flight
Service Station (FSS) for facilities in its area only.
3) Specifically request NOTAM information for other
FSS areas directly from the FSS that has responsibility for the airport concerned.
The responsibility for obtaining this information rests with the pilot in command
(PIC) during preflight planning. Operation on any closed and NOTAM‑listed airport
area that results in an accident, incident, or other hazardous occurrence, is
grounds for enforcement action.
H. FAA Responsibilities. When a report of, or a
complaint about, an aircraft operating on a closed runway or other airport surface
is received, the inspector should make a record of the complaint in detail (see
Volume 7, Chapter 5).
1) The inspector should record as many specific
details as possible in order to determine if a hazardous operation took place
(see Volume 7, Chapter 6).
2) The followup investigation should be conducted
with an emphasis on the competency of the airman involved (e.g., recognition
of hazardous situations, awareness of conditions affecting the operation, and
ability to obtain information necessary for conduct of safe operations). If
necessary, the inspector should begin an enforcement investigation (see Volume
7, Chapter 7).
3) During routine contact with airmen (participation
in safety seminars, pilot counseling, flight instructor seminars, discussions
with pilot schools, etc.), inspectors should disseminate this information and
offer appropriate cautions, while emphasizing that the safety of any flight
is ultimately the responsibility of the PIC.
3-273 SIMULATED RUNAWAY PITCH TRIM TRAINING.
A. Training Accidents. Accidents involving transport
category aircraft indicate that a simulated runaway pitch trim training exercise
may have been a factor. Concern centers around the methods and technique used
to conduct the training.
1) At high airspeeds, it is less desirable to hold
a simulated runaway nose‑down trim condition for a length of time that would
allow the trim drive unit to reach the design limits.
2) At low airspeeds or high‑drag configurations,
such as landing or climb, it would be undesirable to continue trimming to the
nose‑up trim limit.
3) In either configuration, the activation of lift‑dump
devices would deteriorate the aircraft's handling qualities.
4) Technique and judgment are the key elements
when conducting this type of training.
B. Inspectors' Actions. Inspectors, whose duties
include conducting pilot certification and pilot proficiency flight checks,
should review operators' techniques and procedures for simulated runaway pitch
trim training. Trim impulse should not exceed 3 seconds' (sec) duration, nor
should any simulated runaway pitch trim exercise be introduced at a speed above
250 kts or below an altitude of 12,000 ft AGL. Inspectors should also inform
pilot examiners, Pilot Proficiency Examiners (PPE), and operators of transport
category aircraft of the precautions they must employ associated with simulated
runaway pitch trim training, with emphasis on the parameters discussed in this
3-274 USE OF ATC SERVICES DURING NIGHT/MARGINAL VISUAL
FLIGHT RULES (MVFR) CONDITIONS. The use of ATC services may reduce the potential
for in‑flight, terrain‑type accidents and in turn greatly enhance safety. An
NTSB analysis of aircraft accidents in night and MVFR conditions indicated that
the use of available ATC services by pilots operating in these conditions would
greatly enhance safety.
3-275 PROPER IDENTIFICATION AND PROCEDURES DURING IN-FLIGHT
A. Incident History. Incidents where the flightcrews
improperly identified and reacted to cockpit light indications stressed the
need for this guidance. One event occurred during an approach when an engine
ignition light came on. Without further verification, the flightcrew assumed
that the engine had failed and continued the approach. During the attempted
single‑engine missed approach, the flightcrew lost aircraft control and crashed.
Communications between the pilots during this accident indicated lack of situational
awareness as well as misidentification of the problem. It would have been possible
to avoid this accident if the flightcrew correctly analyzed the situation and
took proper corrective action. Once they incorrectly assumed the engine had
failed, the crew then complicated the situation by failing to accomplish the
correct engine shutdown procedures and plan for a single-engine approach. The
investigation revealed that during training the only time the crew experienced
an illuminated ignition light was in conjunction with an engine failure. Flightcrews
received no exposure to circumstances that may cause the ignition light to illuminate,
other than an engine failure, during training. This may have conditioned the
crew to regard the light only as an engine failure event.
B. Following the Emergency Checklist. In a separate
event, the crew was confronted with an illuminated start valve light, followed
by fire indication lights, shortly after takeoff. The crew only completed the
first two steps of the emergency procedure checklist (autothrottle: off and
throttle: idle), before stopping to brief the flight attendants (F/A). Failure
to complete the engine fire shutdown procedure in a timely manner led to additional
problems during the subsequent approach and landing. Although a captain may
do whatever he or she judges most important to mitigate an emergency situation,
given the information available to the flightcrew at the time, it is important
to stress that interrupting an emergency checklist should be strongly discouraged
as a matter of safety policy unless a greater emergency exists.
C. FAA Responsibilities. Inspectors responsible
for approving and reviewing training programs are encouraged to review their
operator's training curriculums for emphasis of the following points:
1) Initial and recurrent training programs should
provide a broad range of engine failure scenarios, including failures that one
may misinterpret as an engine failure.
2) Once the flightcrew verifies an engine failure,
they should take action to accomplish the correct shutdown checklist and properly
plan for an engine-out approach and possible go-around.
3) Emphasize the importance of the emergency/abnormal
checklist. Completion of its checklist should be deliberate and methodical;
it should not be rushed or interrupted for routine events until it has been
3-276 TRAINING PROGRAM CONSIDERATIONS FOR FLIGHT ENVELOPE‑PROTECTED
A. Description. Flight envelope protection varies
by aircraft type and, in some instances, by series. These systems typically
employ automated interventions in an attempt to prevent the aircraft from exceeding
predetermined limitations. They include, but are not limited to:
1) Fully Integrated Envelope Protection. Fully
integrated envelope protection typically employs protection algorithms as part
of a larger set of flight control laws found on fly‑by‑wire aircraft. In these
aircraft the flight control system actively limits flight control position downstream
of pilot input in order to keep the aircraft from exceeding predetermined envelope
limits. This type of envelope protection may have high speed/low speed, bank
angle and load factor protections in addition to angle of attack (AOA) protection.
2) Deterrent Envelope Protection. Deterrent (or
force feedback) envelope protection typically employs protection indirectly
by applying force feedback cues, such as force gradients or steps, to the pilot
in an effort to deter the Pilot Flying (PF) from continuing a control input
that would cause the aircraft to exceed the normal flight envelope.
3) Stick Pusher. Stick pusher typically employs
mechanical means to lower the aircraft's AOA if a predetermined value is exceeded.
B. FAA Responsibilities. Comprehensive information
regarding envelope protection is available from the aircraft manufacturer. Air
carriers, program managers, and operators must adequately train pilots on the
varied effects of envelope protection during normal, abnormal and emergency
situations. For part
121 operations, the requirements are listed under part
121 appendix E, appendix F, and §
121.913 for Advanced Qualification Programs (AQP). For part
135 operations, the training requirements are listed under part
135.345(b)(5) and checking under §
135.293. For 14 CFR part
125 operations, the initial and recurrent pilot testing requirements are
listed under part
125.287(a)(2). For part
91 subpart K (part
91K) operations, the training requirements are listed under §§
91.1103(a); the pilot testing requirements are listed under §
91.1065(a)(2). Consideration of the Flight Standardization Board (FSB) Report
is recommended. This report may contain additional training requirements specific
to aircraft type, not contained in the CFRs or manufacturer documentation. Accordingly,
when reviewing and approving operator pilot training programs or curriculums,
POIs and Training Center Program Managers (TCPM) must ensure the effects of
envelope protection during normal, abnormal and emergency operations are adequately
covered in both ground and flight training.
3-277 MISSED APPROACH/GO-AROUND POLICY, PROCEDURES,
A. Accident History. Studies conducted by the Flight Safety
Foundation (FSF) and published in June 2013 have shown the majority of accidents
over the last 10 years occurred during the approach, landing, and go-around
flight phases. In 2011, 68 percent (63) of accidents in commercial aviation
occurred during these phases of flight. Approach and landing accidents remain
the highest ranked categories of air carrier fatal accidents. The NTSB found
that pilots unwilling to execute a required go-around and/or missed approach
when necessary was a cause in some approach and landing accidents. The FSF studies
found that the lack of a go-around decision is the leading risk factor in approach
and landing accidents and is the primary cause of runway excursions during landing;
in fact, less than 5 percent of unstabilized approaches lead to a go‑around.
They concluded that no other single decision (go-around decision) could have
as great an impact on the overall aviation industry accident rate.
B. Policy and Procedures. Inspectors of parts
135 operators responsible for approving/accepting manuals/procedures must
require operators to publish or reinforce written policies and procedures emphasizing:
1) That the PF, the pilot monitoring (PM), or Flight Engineer
(FE), as applicable, should be able to assess the approach and call for a "go-around"
if a stable approach cannot be continued to a safe touchdown in the TDZ for
the intended landing runway. If either pilot or the FE believes that the parameters
for stabilized approach criteria as stated in their approved/accepted manual/procedure
are not met during the approach, a flightcrew member must call for a "go-around."
2) The PF's immediate response to a "go-around" callout
is the execution of a go‑around maneuver and/or missed approach, as applicable.
Also note that depending on the phase of flight, a Crew Resource Management
(CRM) discussion on the go-around/missed approach decision may not be possible.
3) No punitive measures for flightcrew members who make
a go-around call for the sake of safety.
C. Training Programs. Inspectors responsible for approving/accepting
flightcrew training programs must require operators to incorporate go-around/missed
approach policies and procedures during ground and flight training for all training
RESERVED. Paragraphs 3‑278 through 3‑279.