MCDONNELL DOUGLAS AIRCRAFT CO MD 88Delta Air Lines
New York, NY, USA · 2015-03-05·N909DL
What happened
NTSB summary, verbatimNTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report. The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-16/02. On March 5, 2015, at 1102 eastern standard time, Delta Air Lines flight 1086, a Boeing MD-88, N909DL, was landing on runway 13 at LaGuardia Airport, New York, New York, when it departed the left side of the runway, contacted the airport perimeter fence, and came to rest with the airplane's nose on an embankment next to Flushing Bay. The 2 pilots, 3 flight attendants, and 98 of the 127 passengers were not injured; the other 29 passengers received minor injuries. The airplane was substantially damaged. Flight 1086 was a regularly scheduled passenger flight from Hartsfield-Jackson Atlanta International Airport, Atlanta, Georgia, operating under the provisions of 14 Code of Federal Regulations Part 121. An instrument flight rules flight plan had been filed. Instrument meteorological conditions prevailed at the time of the accident.
Photographs
6the aircraft, and what the investigators foundPhotographs are NTSB docket attachments — works of the US government, in the public domain. Captions are the Board’s own.
Probable cause
the Board's determinationthe captain's inability to maintain directional control of the airplane due to his application of excessive reverse thrust, which degraded the effectiveness of the rudder in controlling the airplane's heading. Contributing to the accident were the captain's (1) situational stress resulting from his concerns about stopping performance and (2) attentional limitations due to the high workload during the landing, which prevented him from immediately recognizing the use of excessive reverse thrust.
Occurrence sequence
3 stepsNTSB coding · CICTT taxonomy- 1 · Landing-landing rollLoss of control on grounddefining event
- 2 · Landing-landing rollRunway excursion
- 3 · Landing-landing rollCollision with terr/obj (non-CFIT)
Findings
4 causal · 4 contributing- CAUSEAircraft › Aircraft oper/perf/capability › Performance/control parameters › Powerplant parameters — Incorrect use/operation
- CAUSEAircraft › Aircraft oper/perf/capability › Aircraft capability — Capability exceeded
- CAUSEPersonnel issues › Psychological › Perception/orientation/illusion › Perception — Pilot
- CAUSEPersonnel issues › Task performance › Workload management › Task overload — Pilot
- FACTOROrganizational issues › Management › Policy/procedure — Operator
- FACTORPersonnel issues › Task performance › (general) — Cabin crew
- FACTOREnvironmental issues › Physical environment › Runway/land/takeoff/taxi surface › Snow/slush/ice covered surface — Availability of related info
- FACTOROrganizational issues › Management › Policy/procedure — Manufacturer
Safety recommendations
14 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Collaborate with Boeing and US operators of MD-80 series airplanes to (1) conduct a study to examine reverse thrust engine pressure ratio (EPR)-related operational data, procedures, and training and (2) identify industry-wide best practices that have been shown to be effective in reliably preventing EPR exceedances to mitigate the risks associated with rudder blanking.
TO THE FEDERAL AVIATION ADMINISTRATION: Encourage US operators of MD-80 series airplanes to (1) implement the best practices identified in Safety Recommendation A-16-20 and (2) participate in an industry-wide monitoring program to verify the continued effectiveness of those solutions over time.
TO THE FEDERAL AVIATION ADMINISTRATION: Require operators of MD-80 series airplanes to revise operational procedures to include a callout when reverse thrust power exceeds 1.3 engine pressure ratio during landings on a contaminated runway.
TO THE FEDERAL AVIATION ADMINISTRATION: Continue to work with industry to develop the technology to outfit transport-category airplanes with equipment and procedures to routinely calculate, record, and convey the airplane braking ability required and/or available to slow or stop the airplane during the landing roll. (Safety Recommendations A-16-023 and A-16-024 supersede Safety Recommendation A-07-064)
TO THE FEDERAL AVIATION ADMINISTRATION: If the systems described in Safety Recommendation A-16-23 are shown to be technically and operationally feasible, work with operators and the system manufacturers to develop procedures that ensure that airplane-based braking ability results can be readily conveyed to, and easily interpreted by, arriving flight crews, airport operators, air traffic control personnel, and others with a safety need for this information. (Safety Recommendations A-16-023 and A-16-024 supersede Safety Recommendation A-07-064)
TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121 operators to provide (1) guidance that instructs flight attendants to remain at their assigned exits and actively monitor exit availability in all non-normal situations in case an evacuation is necessary and (2) flight attendant training programs that include scenarios requiring crew coordination regarding active monitoring of exit availability and evacuating after a significant event that involves a loss of communications.
TO THE FEDERAL AVIATION ADMINISTRATION: Develop best practices related to evacuation communication, coordination, and decision-making during emergencies through the establishment of an industry working group and then issue guidance for 14 Code of Federal Regulations Part 121 air carriers to use to improve flight and cabin crew performance during evacuations.
TO THE FEDERAL AVIATION ADMINISTRATION: Clarify guidance to all 14 Code of Federal Regulations Part 121 air carriers to reinforce the importance of (1) having precise information about the number of passengers aboard an airplane, including lap-held children, and (2) making this information immediately available to emergency responders after an accident to facilitate timely search and rescue operations.
TO THE FEDERAL AVIATION ADMINISTRATION: For airports certificated under 14 Code of Federal Regulations Part 139, direct airport certification safety inspectors to ensure, before or during the airports’ next scheduled annual inspection, that policies and procedures for friction measurement during winter operations are accurately and adequately described in the airports’ Airport Certification Manual and Snow and Ice Control Plan.
TO THE FEDERAL AVIATION ADMINISTRATION: Revise Advisory Circular 150/5200-30D, “Airport Field Condition Assessments and Winter Operations Safety,” to provide more precise guidance regarding (1) the need to issue notices to airmen (NOTAM) in a timely manner and (2) the specific changes to runway surface conditions that would prompt the issuance of updated NOTAMs.
TO THE BOEING COMPANY: Collaborate with the Federal Aviation Administration and US operators of MD-80 series airplanes to (1) conduct a study to examine reverse thrust engine pressure ratio (EPR)-related operational data, procedures, and training and (2) identify industry-wide best practices that have been shown to be effective in reliably preventing EPR exceedances to mitigate the risks associated with rudder blanking.
TO THE BOEING COMPANY: Explore the possibility of incorporating an alert in MD-80 series airplanes to aid pilots in preventing engine pressure ratio exceedances.
TO US OPERATORS OF MD-80 SERIES AIRPLANES(AMERICAN AIRLINES, DELTA AIRLINES, AND ALLEGIANT AIR): Collaborate with the Federal Aviation Administration and Boeing to (1) conduct a study to examine reverse thrust engine pressure ratio (EPR)-related operational data, procedures, and training and (2) identify industry-wide best practices that have been shown to be effective in reliably preventing EPR exceedances to mitigate the risks associated with rudder blanking.
TO THE PORT AUTHORITY OF NEW YORK AND NEW JERSEY: After consultation with the Federal Aviation Administration, clarify your policies regarding continuous friction measuring equipment use during winter operations and ensure that this information is included in the Airport Certification Manual and Snow and Ice Control Plan for each airport operated by the Port Authority.
Sequence of events
3 timed eventsfrom the FDR factual report · claude-sonnet-5- 85,175 SRNFinal approachp.3Start of plotted final approach data at radio altitude of 1,025 ft
- 85,240 SRN to 85,295 SRNLanding/Rolloutp.5Expanded scale plot of deceleration aids and forces around time of landing (55 seconds of data)
- 85,305 SRNLandingp.4End of plotted approach/landing data for basic parameters and flight controls
NTSB analysis
from the final reportNTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report. The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-16/02. On March 5, 2015, at 1102 eastern standard time, Delta Air Lines flight 1086, a Boeing MD-88, N909DL, was landing on runway 13 at LaGuardia Airport, New York, New York, when it departed the left side of the runway, contacted the airport perimeter fence, and came to rest with the airplane's nose on an embankment next to Flushing Bay. The 2 pilots, 3 flight attendants, and 98 of the 127 passengers were not injured; the other 29 passengers received minor injuries. The airplane was substantially damaged. Flight 1086 was a regularly scheduled passenger flight from Hartsfield-Jackson Atlanta International Airport, Atlanta, Georgia, operating under the provisions of 14 Code of Federal Regulations Part 121. An instrument flight rules flight plan had been filed. Instrument meteorological conditions prevailed at the time of the accident.