Issued: 15-NOV-1996 | To: FAA | A-96-141 |
IMMEDIATELY REVIEW & AMEND, AS NECESSARY, ALL AIRPLANE MAINTENANCE MANUALS TO REQUIRE OPERATORS TO USE ONLY STANDARDIZED, HIGHLY CONSPICUOUS COVERS WITH WARNING FLAGS ATTACHED IN ANY SITUATION IN WHICH STATIC PORTS WOULD NEED TO BE COVERED. (Closed - Acceptable Action) |
Issued: 01-DEC-1996 | To: AeroPeru | N52AW (1) |
Familiarise crews with specific emergencies involving erroneous speed indications and design a procedure for flying with erroneous or no altitude indications. |
Issued: 01-DEC-1996 | To: AeroPeru Maintenance Service | N52AW (10) |
Select higher quality technical staff, with continuing training and the creation of incentives for staff to perform more effectively in the interests of operational safety. |
Issued: 01-DEC-1996 | To: AeroPeru Maintenance Service | N52AW (11) |
Monitor the manufacturer\'s standards and recommendations, and comply strictly with the future recommendations issued as a consequence of this accident. |
Issued: 01-DEC-1996 | To: AeroPeru Maintenance Service | N52AW (12) |
Implement regulations for flights after maintenance in relation to polishing, painting or other similar work. |
Issued: 01-DEC-1996 | To: CORPAC | N52AW (13) |
Raise the level of operational technical knowledge in practical terms for controllers, putting them in situations in which they play the role of the pilot, so that they can analyse the type of information which could cause confusion, since the pilot relies on the controller\'s correct information. |
Issued: 01-DEC-1996 | To: CORPAC | N52AW (14) |
Assess controllers with a view to effective selection, rejecting staff with insufficient English and aeronautical culture. |
Issued: 01-DEC-1996 | To: CORPAC | N52AW (15) |
Retrain the rejected staff for a second practical operational assessment. |
Issued: 01-DEC-1996 | To: CORPAC | N52AW (16) |
Carry out coordination exercises (simulations) with SEI staff. Work with the SEI staff and evaluate the minimum reaction time needed to resolve the emergency. Make resolution and implementation plans for all types of emergency. |
Issued: 01-DEC-1996 | To: CORPAC | N52AW (17) |
Give controller resource management (CRM) courses so that controllers have better situation awareness and decision-making abilities in emergency cases, training controllers in human factors and problem-solving. |
Issued: 01-DEC-1996 | To: CORPAC | N52AW (18) |
Recommend team integration work, and advice and support for the recognition of emergency situations in radio communications, with the use of English and the correct application of phraseology as soon as the emergency is declared. |
Issued: 01-DEC-1996 | To: CORPAC | N52AW (19) |
Implement the international airport\'s terminal and area radar system as a matter of urgency and priority for practical, safe and expeditious air traffic operations. |
Issued: 01-DEC-1996 | To: AeroPeru | N52AW (2) |
Conduct practical sessions in a specific simulator, and also refresher courses including simulated flight with the erroneous speed indication failures, using the specific tables for the procedure in the various flight phases, and follow United Airlines\' advanced manoeuvre programme. |
Issued: 01-DEC-1996 | To: CORPAC | N52AW (20) |
Implement an automatic terminal information service (ATIS) in accordance with the importance of the workstations |
Issued: 01-DEC-1996 | To: DGTA Peru | N52AW (21) |
Create a communication system through the publication of technical bulletins, safety circulars, flyers and specific documents on operational matters, in conjunction with the airlines\' representatives on topics related to safe operations and accident prevention programmes. |
Issued: 01-DEC-1996 | To: DGTA Peru | N52AW (22) |
Plan seminars, workshops and conferences relating to operational safety, human factors, accident prevention and specific matters such as operational integration through CRM or similar programmes. |
Issued: 01-DEC-1996 | To: DGTA Peru | N52AW (23) |
Be more demanding and drastic in the penalties against operators with a view to their complying with the established operations and airworthiness procedures. |
Issued: 01-DEC-1996 | To: FAA | N52AW (24) |
Immediately release and communicate technical information issued by the NTSB, such as FSIBs (flight standards information bulletins). Such information is not always accepted by the FAA but is very important for the operator as essential information obtained from accident investigations. It must be circulated given the importance of the safety elements it involves, which are useful to the operator and manufacturer, without prejudice to the FAA\'s opinion. |
Issued: 01-DEC-1996 | To: FAA | N52AW (25) |
Work with manufacturers on the improvement of procedures relating to the interfaces between crews and automated cockpits and the reliability limit to produce a guide on how to investigate the factors contributing to an error involving contradictory alarms. |
Issued: 01-DEC-1996 | To: FAA | N52AW (26) |
Determine the contributing factors regardless of their origin, whether they result from errors associated with the pilot, mechanic, dispatcher, air traffic controller or any other participant in the operational system. |
Issued: 01-DEC-1996 | To: FAA | N52AW (27) |
In order to obtain positive results, the conclusions must be communicated immediately to all staff who were a contributing factor, so that appropriate and effective measures can be taken in accordance with the recommendations. |
Issued: 01-DEC-1996 | To: Boeing | N52AW (28) |
Give more importance to flight training based on attitude and power in the various operational phases, which are not adequately covered in the training programmes or in the manufacturer\'s specific manuals. |
Issued: 01-DEC-1996 | To: Boeing | N52AW (29) |
Implement systems which avoid conflicting or contradictory alarms, such as overspeed and stick shaker being activated at the same time. |
Issued: 01-DEC-1996 | To: AeroPeru | N52AW (3) |
Design eye-catching covers for protecting the static ports when maintenance and polishing work is done on an aircraft. |
Issued: 01-DEC-1996 | To: Boeing | N52AW (30) |
Introduce a "caution" alert when the speed and altitude are not reliable on the EICAS screen. |
Issued: 01-DEC-1996 | To: Boeing | N52AW (31) |
Design a procedure with all the steps and actions to be followed in the event of a total failure of the dynamic and static instruments (to be included in the QRH). |
Issued: 01-DEC-1996 | To: Boeing | N52AW (32) |
Advise airlines for the establishment of specific guides to the problem of static port blockages. |
Issued: 01-DEC-1996 | To: SAR Coordination Ops | N52AW (33) |
Reorganise the search and rescue system in accordance with the norms and methods recommended in ICAO Annex 12, "Search and Rescue", incorporating it into the COSPAS-SARSAT system. |
Issued: 01-DEC-1996 | To: SAR Coordination Ops | N52AW (34) |
Develop a specific manual for our situation, tailored to the Peruvian geosystem and topography, using as a basis ICAO Doc. 7333-AN/859, "Search and Rescue Manual", and ICAO Circular 185, "Satellite-aided Search and Rescue". |
Issued: 01-DEC-1996 | To: AeroPeru | N52AW (4) |
Make the crew aware that it is mandatory to follow the evasive procedures in response to GPWS terrain alarms and conduct practical sessions in flight simulators. |
Issued: 01-DEC-1996 | To: AeroPeru | N52AW (5) |
There must be better use and observation of, and reliance on, the radio altimeter. |
Issued: 01-DEC-1996 | To: AeroPeru | N52AW (6) |
Establish special regulations and procedures for flights experiencing problems with the indications of instruments receiving information from the ADCs, and for the interpretation and appropriate use of alternative means. |
Issued: 01-DEC-1996 | To: AeroPeru | N52AW (7) |
Comply strictly with the procedure designed by the Flight Safety Directorate for the documentation of an aircraft\'s release from when it leaves maintenance to its acceptance by the crew assigned to the flight, in order to inculcate safer and more efficient operational discipline. |
Issued: 01-DEC-1996 | To: AeroPeru Maintenance Service | N52AW (8) |
Implement a better quality control system. |
Issued: 01-DEC-1996 | To: AeroPeru Maintenance Service | N52AW (9) |
Carry out better documented pre-flight checks (at present the static ports are not specifically mentioned). |