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Safety Recommendation Details

Safety Recommendation A-07-086
Details
Synopsis: On April 25, 2006, about 0350 mountain standard time, a Predator B, a UA manufactured by General Atomics Aeronautical Systems, Inc. (GA-ASI), crashed approximately 10 nautical miles northwest of Nogales International Airport, Nogales, Arizona, within 100 yards of a house that was located in a sparsely populated residential area. There were no injuries to persons on the ground. The UA, which was unregistered and owned by the CBP and operated under contract with GA-ASI, sustained substantial damage. The public-use flight was operating in night visual meteorological conditions. An instrument flight rules flight plan had been filed and activated for the flight, which originated from the Libby Army Airfield (FHU), Sierra Vista, Arizona.
Recommendation: TO UNITED STATES CUSTOMS AND BORDER PROTECTION: Develop a safety plan, which ensures that hazards to the National Airspace System and persons on the ground introduced by the U.S. Customs and Border Protection’s (CBP) unmanned aircraft system (UAS) operation are identified and that necessary actions are taken to mitigate the corresponding safety risks to the public over the life of the program. The plan should include, as a minimum, design requirements, emergency procedures, and maintenance program requirements to minimize the safety impact of UAS malfunctions in flight, continuous monitoring of the CBP’s unmanned aircraft operation, analysis of malfunctions and incidents, and lessons learned from other operators of similar UAS designs.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Nogales, AZ, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: CHI06MA121
Accident Reports:
Report #: None
Accident Date: 4/25/2006
Issue Date: 10/24/2007
Date Closed: 5/23/2013
Addressee(s) and Addressee Status: United States Department of Homeland Security, United States Customs and Border Protection (Closed - Acceptable Action)
Keyword(s): Federal Civilian Operations,

Safety Recommendation History
From: NTSB
To: United States Department of Homeland Security, United States Customs and Border Protection
Date: 4/17/2015
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) notice of proposed rulemaking (NPRM) titled “Operation and Certification of Small Unmanned Aircraft Systems,” which was published in 80 Federal Register 9544 on February 23, 2015. The proposed rule will allow the operation of small unmanned aircraft systems (sUAS) in the National Airspace System (NAS). Proposed new Part 107 in Title 14 Code of Federal Regulations (CFR) would establish operating requirements to allow sUAS (defined as weighing less than 55 pounds) to operate for non-hobby or non-recreational purposes. To mitigate risk, the proposed rule would limit sUAS to daylight only operations, confined areas of operation, and visual-line-of-sight operations. The proposed rule also addresses aircraft registration and marking, NAS operations, operator certification, visual observer requirements, and operational limits to maintain the safety of the NAS and ensure that sUAS do not pose a threat to national security. Following an April 2006 accident involving a US Customs and Border Protection (CBP) MQ-9 unmanned aircraft, the NTSB issued 5 safety recommendations (A-07-65 through -69) to the FAA and 17 safety recommendations (A-07-70 through -86) to the CBP regarding the configuration, operation, and maintenance of the MQ-9. We acknowledge that these recommendations are not directly applicable to the proposed rule because the unmanned aircraft involved in the accident that prompted them is much larger and operates at much higher altitudes and greater distances than sUAS as defined in the proposed rule. In addition, Safety Recommendation A-07-69, concerning accident and incident reporting and notification and which the NTSB closed in 2008, is no longer relevant because the NTSB revised 49 CFR Part 830, “Notification and Reporting of Aircraft Accidents or Incidents; and Overdue Aircraft, and Preservation of Aircraft Wreckage, Mail, Cargo, and Records,” in 2010 to include UAS in accident and incident reporting requirements. Although our 2006 UAS safety recommendations are not directly applicable to the NPRM, we note that the proposed limitations are intended to mitigate some of the risks identified in our investigation of the CBP accident. Additionally, we note that many sUAS are powered by lithium battery technology and that we have examined the risks associated with the transport and use of that technology. We therefore encourage the FAA to review our recommendations and supporting information for potential lessons learned when developing guidance material and specific content for the written knowledge tests outlined in proposed new Part 107. For example, test content should include awareness of lost-link failsafe procedures, operator development and use of maintenance and inspections steps and guides, and the characteristics and proper handling of lithium batteries. The NTSB concurs with the FAA’s incremental, risk-based approach to sUAS regulation. In a similar manner, historically, the NTSB also concurred with a simpler regulatory approach toward ultralight aircraft as outlined in 14 CFR 103. The NTSB accident and incident criteria included in 49 CFR Part 830, reflect a similar approach. For example, UAS events involving smaller aircraft that do not result in serious injuries or fatalities are not defined as an accident, and the other required notifications included in section 830.5 do not necessarily lead to a full investigation. Section III.I.2, “Oversight, Accident Reporting,” of the NPRM preamble (p. 9576) invites comments regarding a reporting threshold for sUAS events that cause damage to other property. We note that section 830.5(a)(6) requires that events resulting in damage in excess of $25,000 be reported to the NTSB. The FAA may wish to take this, and the other criteria included in 49 CFR Part 830, into account as it continues to develop sUAS regulations. The NTSB also notes that 49 CFR Part 830, as in many other applicable regulations, makes a distinction between the term “operator,” as in a commercial entity, and “pilot,” as in the manipulator of the controls. Although the NTSB recognizes the FAA’s reasons for not using the term “pilot,” we believe the dual meanings of the term “operator” could cause confusion over responsibilities in the case of a company that owns a number of sUAS and employs a number of sUAS “operators.” The NTSB appreciates the opportunity to comment on this NPRM.

From: NTSB
To: United States Department of Homeland Security, United States Customs and Border Protection
Date: 5/23/2013
Response: We reconsidered the CBP’s safety oversight system, including the reporting and review of all incidents involving the UAS and a trend analysis of these events, which the CBP described in its April 22, 2008, letter. In the recent meeting, we learned that the CBP continues to use this system and, as stated above, the CBP’s UA activities are overseen by the same organization that manages CBP manned aircraft operations. Accordingly, Safety Recommendation A-07-86 is classified CLOSED—ACCEPTABLE ACTION.

From: United States Department of Homeland Security, United States Customs and Border Protection
To: NTSB
Date: 7/30/2009
Response: Letter Mail Controlled 8/31/2009 12:47:52 PM MC# 2090394 - From Jayson P. Ahern, Commissioner: Thank you for your June 22, 2009 letter wherein you outlined the review of U.S. Customs and Border Protection's (CBP), Office of Air and Marine's responses to the National Transportation Safety Board's investigation and recommendations surrounding the April 25, 2006, accident involving a CBP-operated General Atomics Predator B unmanned aircraft that lost power and crashed near Nogales, Arizona. CBP acknowledges your acceptance for 15 of the 17 actions carried out by the Office of Air and Marine. CBP will continue to review its current practices and make adjustments as deemed necessary to ensure public safety the safety of its officers and agents. I appreciate your interest in U.S. Customs and Border Protection. If you have any questions or concerns, please contact me.

From: NTSB
To: United States Department of Homeland Security, United States Customs and Border Protection
Date: 6/22/2009
Response: The CBP described its safety oversight system, which includes the reporting and review of all incidents involving the UAS and a trend analysis of these events. Reports in this system include a detailed narrative of the event, including analysis and lessons learned. As part of a launch briefing before every flight, CDOs together with maintenance personnel, pilots, and ground support crew review any potential risk and appropriate measures that will be taken to mitigate the risk before the flight is dispatched. Proposed changes to the UAS undergo a thorough review by a panel of individuals representing safety, maintenance, operations, contracting, and General Atomics. This panel must agree that the recommended change is both necessary and safe before the modification can occur. The CBP’s actions to implement an incident tracking and trending program, pre-launch briefings, and a design change review process are commendable and partially responsive to this recommendation; however, they do not fully meet the intent of this recommendation. To do so, the CBP needs to conduct a full systems safety analysis and take appropriate actions to mitigate any safety risks identified by such an analysis. Descriptions of the types of analysis needed may be found in the FAA’s Systems Safety Handbook (http://www.faa.gov/library/manuals/aviation/risk_management/ss_handbook/), United States Department of Defense military standard MIL-STD-882, Standard Practice for Systems Safety, and in the Society of Automotive Engineers Aviation Recommended Practice (SAE ARP) 4761,Guidelines and Methods for Conducting the Safety Assessment Process on Civil Airborne Systems and Equipment. The NTSB also requests that the CBP describe any specific criteria that exist for which an incident must be reported. Pending the CBP’s conducting a full systems safety analysis of its UAS, a description of appropriation mitigations of safety risks identified by such an analysis, and a description of any specific criteria for reporting and reviewing incidents involving the CBP’s UAS, Safety Recommendation A-07-86 is classified OPEN -- ACCEPTABLE RESPONSE.

From: United States Department of Homeland Security, United States Customs and Border Protection
To: NTSB
Date: 4/22/2008
Response: Letter Mail Controlled 4/22/2008 2:33:19 PM MC# 2080213: - From Michael C. Kostelnik, Assistant Commissioner: Recommendation previously adopted by CBP Safety oversight is provided via a robust system and the National Air Safety Program Manager. All incidents involving the UAS are accounted for via an internal safety system that is reviewed for trend analysis. Reports inputted into the system include a detailed narrative of the event to include analysis and lessons learned. As part of launch briefing before every flight, Command Duty Officers in concert with maintenance personnel, pilots and ground support crew review any potential risk. If any adverse risk is determined to exist, appropriate measures are taken mitigate the risk to an acceptable level before the flight is dispatched. Proposed changes to the UAS must undergo a thorough review by a panel comprised of individuals representing safety, maintenance, operations, contracting, and General Atomics. This panel must agree that the recommended change is both necessary and safe before the modification can occur. Once completed, the UA system is then tested to ensure compatibility and appropriate installation. Additionally, CBP has instituted a UAS Working Group that meets quarterly. Members not only include CBP personnel, but other agencies that use similar technology to ensure cross-communications and the sharing of corporate knowledge. Additional participants include the FAA and GSA's ICAP.