These are the recommendations that the NTSB made, following the accident of Delta Air Lines Flight 1086, on March 5, 2015. The final report was adopted on September 13, 2016.

New Recommendations

As a result of this investigation, the National Transportation Safety Board makes the following new safety recommendations:

To 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. (A-16-20)

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. (A-16-21)

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. (A-16-22)

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. (A-16-23)

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. (A-16-24)

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. (A-16-25)

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. (A-16-26)

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. (A-16-27)

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. (A-16-28)

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. (A-16-29)

To Boeing:

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. (A-16-30)

Explore the possibility of incorporating an alert in MD-80 series airplanes to aid pilots in preventing engine pressure ratio exceedances. (A-16-31)

To US operators of MD-80 series airplanes:

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. (A-16-32)

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. (A-16-33)

Previously Issued Recommendation Reiterated in This Report

The National Transportation Safety Board reiterates the following recommendation to the Federal Aviation Administration:

Revise Advisory Circular 120-48, “Communication and Coordination Between Flight Crewmembers and Flight Attendants,” to update guidance and training provided to flight and cabin crews regarding communications during emergency and unusual situations to reflect current industry knowledge based on research and lessons learned from relevant accidents and incidents over the last 20 years. (A-09-27)

You can read the NTSB’s final report in its entirety (170 pages) HERE