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industry best practices and are designed to avoid inaccurate or negative training wouldlead to
improvement and standardization of industry training programs.
17.
The use of lower levels of automation, such as simulators without motion or simple computer screen
displays, may be more appropriate to provide the necessary awareness training with less danger of
introducing incorrect information.
18.
PROBABLE CAUSE
The National Transportation Safety Board determines that the probable cause of this accident was the
in-flight separation of the vertical stabilizer as a result of the loads beyond ultimate design that were created
by the first officer’s unnecessary and excessive rudder pedal inputs. Contributing to these rudder pedal
inputs were characteristics of the A300-600 rudder system design and elements of the American Airlines
Advanced Aircraft Maneuvering Program.
SAFETY RECOMMENDATIONS
NEW RECOMMENDATIONS
As a result of the investigation of this accident, the National Transportation Safety Board makes the
following recommendations:
To the Federal Aviation Administration:
Modify 14 Code of Federal Regulations Part 25 standards to include a certification standard that will
ensure safe handling qualities in the yaw axis throughout the flight envelope, including limits for
rudder pedal sensitivity. (A-04-XX)
1.
After the yaw axis certification standard recommended in safety recommendation number 1 has been
established, review the designs of existing airplanes to determine if they meet the standard. For
existing airplanes designs that do not meet the standard, the FAA should determine if the airplanes
would be adequately protected from the adverse effects of a potential aircraft-pilot coupling (APC)
after rudder inputs at all airspeeds. If adequate protection does not exist, the FAA should require
modifications, as necessary, to provide the airplanes with increased protection from the adverse effects
of a potential APC after rudder inputs at high airspeeds. (A-04-XX)
2.
Review the options for modifying the A300-600 and the A310 to provide increased protection from
potentially hazardous rudder pedal inputs at high airspeeds and, on the basis of this review, require
modifications to the A300‑600 and A310 to provide increased protection from potentially hazardous
rudder pedal inputs at high airspeeds. (A-04-XX)
3.
Develop and disseminate guidance to transport-category pilots that emphasizes that multiple full
deflection, alternating flight control inputs should not be necessary to control a transport-category
4.
Executive Summary http://www.ntsb.gov/publictn/2004/AAR0404.htm
4 of 5 10/27/2004 8:39 AM
airplane and that such inputs might be indicative of an adverse aircraft-pilot coupling event and thus
should be avoided. (A-04-XX)
Amend all relevant regulatory and advisory materials to clarify that operating at or below maneuvering
speed does not provide structural protection against multiple full control inputs in one axis or full
control inputs in more than one axis at the same time. (A-04-XX)
5.
Adopt and disseminate written guidance for use in developing and accepting upset recovery programs;
such guidance could take the form of an advisory circular and should reflect the industry’s best
practices and be designed to avoid inaccurate or negative training. (A-04-XX)
6.
Along with developing the guidance recommended in safety recommendation number 6, evaluate
issues concerning the level of automation appropriate to teaching upset training, and develop and
disseminate guidance that will promote standardization and minimize the danger of inappropriate
simulator training. (A-04-XX)
7.
To the Direction Général de l’Aviation Civile :
Review the options for modifying the A300-600 and the A310 to provide increased protection from
potentially hazardous rudder pedal inputs at high airspeeds and, on the basis of this review, require
modifications to the A300‑600 and A310 to provide increased protection from potentially hazardous
rudder pedal inputs at high airspeeds. (A-04-XX)
8.
Previously Issued Recommendations Resulting From This Accident Investigation:
To the Federal Aviation Administration:
Require the manufacturers and operators of transport-category airplanes to establish and implement
pilot training programs that: (1) explain the structural certification requirements for the rudder and
vertical stabilizer on transport-category airplanes; (2) explain that a full or nearly full rudder deflection
in one direction followed by a full or nearly full rudder deflection in the opposite direction, or certain
combinations of sideslip angle and opposite rudder deflection can result in potentially dangerous loads
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