NTSB Aircraft Incident Report
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decelerates. However, in this case, CVR data showed that about 0.8 second after the first officer
stated ―no reverse,‖ the captain was taking command of the thrust reverser levers. By assuming
control of the thrust reversers before the first officer could attempt to resolve the situation, the
captain deviated from normal company procedures regarding the pilot flying/pilot monitoring
responsibilities during the landing roll. Specifically, if the captain had adhered to his monitoring
responsibilities during the landing roll, it is more likely that he would have recognized that the
speedbrakes had not automatically deployed and corrected the situation by manually deploying
them, increasing the airplane‘s braking effectiveness significantly.
The NTSB has previously issued safety recommendations related to pilot workload
management and monitoring skills, including Safety Recommendation A-07-13,
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which asked
the FAA to do the following:
Require that all pilot training programs be modified to contain modules that teach and
emphasize monitoring skills and workload management and include opportunities to
practice and demonstrate proficiency in these areas.
On January 12, 2009, the FAA published an NPRM titled ―Qualifications, Service and
Use of Crewmembers and Aircraft Dispatchers.‖ Based on comments that the FAA received on
this NPRM, on May 20, 2011, the FAA published a supplemental notice of proposed rulemaking
(SNPRM) that proposed additional training requirements for flight crewmembers, including the
use of flight simulators for training of flight crewmembers.
On July 15, 2011, the NTSB submitted comments to the FAA on the SNPRM and noted
its general support for the requirements proposed in the SNPRM. In its comments, the NTSB
noted that proposed section 121.1213 partially addressed Safety Recommendation A-07-13 by
requiring that pilot training include opportunities to practice and demonstrate proficiency in
monitoring skills and workload management. However, the SNPRM did not propose a
requirement for modules that teach and emphasize these subjects. The NTSB indicated that the
FAA would need to require pilot training programs to include appropriate training modules on
these subjects during which crews would be required to practice and demonstrate proficiency.
On November 7, 2011, the FAA published Safety Alert for Operators (SAFO) 11011,
―Runway Excursions at Jackson Hole Airport (JAC),‖ which ―emphasizes the importance of
implementing and following SOPs and training for flightcrews.‖
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The related supplement
provided best practices and mitigation strategies that include emphasis on pilot monitoring
responsibilities and the manual deployment of speedbrakes if they do not automatically deploy.
However, the information in the SAFO is only guidance, and this incident demonstrates the need
for the changes proposed in the SNPRM.
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For additional information, see Crash During Approach to Landing, Circuit City Stores, Inc., Cessna
Citation 560, N500AT, Pueblo, Colorado, February 16, 2005, Aircraft Accident Report NTSB/AAR-07/02
(Washington, D.C.: National Transportation Safety Board, 2007), which is available at <http://www.ntsb.gov>.
Also, see Northwest Airlines, Inc., [Flight 255], McDonnell Douglas DC-9-82, N312RC, Detroit Metropolitan
Wayne County Airport, Romulus, Michigan, August 16, 1987, Aircraft Accident Report NTSB/AAR-88/05
(Washington, D.C.: National Transportation Safety Board, 1988) and Delta Air Lines, Inc., [Flight 1141],
Boeing 727-232, N473DA, Dallas-Fort Worth International Airport, Dallas, Texas, August 31, 1988, Aircraft
Accident Report NTSB/AAR-89/04 (Washington, D.C.: National Transportation Safety Board, 1989).
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American Airlines provides its pilots with 757 Special Landing Analysis charts for JAC.