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Safety Recommendation Details

Safety Recommendation A-02-002
Synopsis: This safety recommendation letter addresses an industry-wide safety issue involving ommissions in pilot training on transport-category airplanes. Specifically, the National Transportation Safety Board has learned that many pilot training programs do not include information about the structural certification requirements for the rudder and vertical stabilizer on transport-category airplanes. Further, the Safety Board has learned that sequential full opposite rudder inputs (sometimes colloquially referred to as "rudder reversals")--even at speeds below the design maneuvering speed--may result in structural loads that exceed those addressed by the requirements. In fact, pilots may have the impression that the rudder limiter systems installed on most transport-category airplanes, which limit rudder travel as airspeed increases to prevent a single full rudder input from overloading the structure, also prevent sequential full opposite rudder deflections from damaging the structure. However, the structural certification requirements for transport-category airplanes do not take such maneuvers into account; therefore, such sequential opposite rudder inputs, even when a rudder limiter is in effect, can produce loads higher than those required for certification and that may exceed the structural capabilities of the aircraft.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Carefully review all existing and proposed guidance and training provided to pilots of transport-category airplanes concerning special maneuvers intended to address unusual or emergency situations and, if necessary, require modifications to ensure that flight crews are not trained to use the rudder in a way that could result in dangerous combinations of sideslip angle and rudder position or other flight parameters.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Belle Harbor, NY, United States
Is Reiterated: No
Is Hazmat: No
Accident #: DCA02MA001
Accident Reports: In-Flight Separation of Vertical Stabilizer American Airlines Flight 587, Airbus Industrie A300-605R, N14053
Report #: AAR-04-04
Accident Date: 11/12/2001
Issue Date: 2/8/2002
Date Closed: 12/26/2013
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Flightcrew, Rudder, Training and Education

Safety Recommendation History
From: NTSB
Date: 5/12/2014
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) draft Advisory Circular (AC) 120-UPRT, “Upset Prevention and Recovery Training,” which was posted for comment on the FAA’s website on March 12, 2014. Draft AC 120-UPRT describes the philosophy and recommended training for airplane upset prevention and recovery. The purpose of the AC is to provide recommended practices and guidance regarding academic and flight simulation device training for pilots to prevent the development of airplane upset conditions and ensure correct and consistent recovery responses to upsets. The AC was created from recommended practices developed by major airplane manufacturers, labor organizations, air carriers, training organizations, simulator manufacturers, and industry representative organizations. Although this AC is directed to air carriers in implementing 14 Code of Federal Regulations (CFR) Part 121 regulations, the FAA encourages all airplane operators, pilot schools, and training centers to implement upset prevention and recovery training and to use the guidance contained in the AC, as applicable to the type of airplane in which training is conducted. We generally support the draft AC (with specific suggestions below). On November 12, 2013, the FAA published a final rule titled “Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers.” Draft AC 120 UPRT and draft revised AC 120-109A provide the guidance necessary for operators and FAA inspectors to implement the requirements in the final rule. In addition, we are pleased to note that draft AC 120-UPRT contains several prominent warnings against the use of excessive rudder inputs and recommends the use of the Airplane Upset Recovery Training Aid in developing upset recovery training programs. Safety Recommendations A-02-1 and -2 and A-04-59 and -61, which are all classified as “Closed?Acceptable Action,” addressed these issues.

From: NTSB
Date: 12/26/2013
Response: On November 12, 2013, the FAA published a final rule titled, “Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers” which contained a number of provisions that address these recommendations. Among these provisions are proposed requirements for training flight crews to avoid inappropriate rudder use to recover from adverse attitudes and authority for FAA principal operations inspectors to compel revisions to training programs when necessary, rather than their simply having to accept these programs. Accordingly, Safety Recommendations A 02 1 and 2 are classified CLOSED—ACCEPTABLE ACTION.

From: NTSB
Date: 4/30/2012
Response: Notation 8406: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) notice of proposed rulemaking (NPRM) titled “Pilot Certification and Qualification Requirements for Air Carrier Operations,” which was published at 77 Federal Register (FR) 12374 on February 29, 2012. The notice proposes to create new certification requirements for pilots in air carrier operations, including requiring that first officers in 14 Code of Federal Regulations (CFR) Part 121 operations hold an airline transport pilot (ATP) certificate and type rating for the aircraft to be flown; allowing pilots with an aviation degree or military pilot experience but fewer than 1,500 hours total time as a pilot to obtain an ATP certificate with restricted privileges; and requiring at least 1,000 flight hours in air carrier operations to serve as pilot in–command (PIC) in Part 121 air carrier operations. The notice also proposes to modify the requirements for obtaining an ATP certificate with an airplane category multiengine class rating or type rating to require 50 hours of multiengine flight experience and completion of a new FAA-approved ATP certificate training program that would include academic training and training in a flight simulation training device. According to the NPRM, these changes would help to ensure that pilots entering an air carrier environment have the training and aeronautical experience necessary to adapt to a complex, multicrew environment in a variety of operating conditions. The NPRM cites the 2009 Colgan Air accident near Buffalo, New York, as an event that focused public, congressional, and industry attention on flight crew experience requirements and training for conducting Part 121 air carrier operations. In February 2010, the FAA published an advance notice of proposed rulemaking (ANPRM), titled “New Pilot Certification Requirements for Air Carrier Operations” (75 FR 6164, February 8, 2010) that sought input on current Part 121 eligibility, training, and qualification requirements for seconds-in-command (SICs). The current NPRM is based on comments in response to the ANPRM, input received from an aviation rulemaking committee established in July 2010, and statutory requirements for modifying ATP certification outlined in the Airline Safety and Federal Aviation Administration Extension Act of 2010 (Public Law 111-216). Adding to that foundation, the NPRM states that the FAA conducted a study of 61 NTSB investigation reports from fiscal year (FY) 2001 through FY 2010 (31 Part 121 accidents and 30 Part 135 air carrier accidents, with 107 fatalities, 28 serious injuries, and 44 minor injuries). The study showed that the accidents examined involved pilot deficiencies in aircraft handling, including stall and upset recognition and recovery, high altitude training, active pilot monitoring skills, effective crew resource management (CRM), stabilized approaches, operations in icing conditions, and hypoxia training. The NPRM asserts that the changes to air carrier pilot qualification would address, in part, 21 NTSB safety recommendations in the following areas: Safety Issue Recommendations Training flight crews to respond to sudden, unusual, or unexpected aircraft upsets: A-96-120, A-04-62, A-07-3, and A-09-113 Developing and conducting stall recovery training and providing stickpusher familiarization training for pilots of stickpusher-equipped aircraft: A-10-22 and -23 Training in high altitude operations: A-07-1 and -2 Training and guidance for rudder use in transport-category aircraft: A-02-2 Airport situational awareness: A-07-44 Stabilized approach concept: A 01 69 and A-08-18 Landing performance calculations: A-07-59 and A-08-41 CRM training: A-03-52 Pilot monitoring duties: A-10-10 Requirements for flight crewmember academic training regarding leadership and professionalism: A-10-15 Training in icing conditions: A-07-14 Hypoxia awareness training: A 00 110 Training in landing and taking off in crosswinds with gusts: A 10-110 and -111 The NTSB is generally supportive of the proposed rule as it relates to many of the issues previously identified in our safety recommendations. Specific comments on several areas of the NPRM follow. Academic Credit To Reduce Flight Experience Requirements Although the NTSB has not made recommendations for flight hour minimums for air carrier pilots (instead focusing its recommendations on specific procedures and training, needed regulations, and needed guidance to crews and operators), we stated in our comments on the ANPRM that: Ensuring a high level of knowledge, skills, and professionalism for flight crewmembers is essential, but total flight hours or an airline transport pilot certificate does not necessarily equate to the level of knowledge, skills, and professionalism required for consistently safe flight operations. The comments went on to state that, “the NTSB recognizes the value of academic training for air carrier pilots, but the NTSB also believes that academic training is not a substitute for practical experience.” An important tenet in the recent NPRM is the concept that, “in certain circumstances, the combination of focused academic training and structured flight training can substitute for actual flight experience” (p. 12379). The NTSB concurs with the FAA’s acknowledgement that there may be multiple pathways to becoming a qualified air carrier pilot. However, there remain unresolved issues for how academic credit should be applied, including student performance within an accredited academic program and the type of degree conferred. These issues are not addressed in the NPRM and require more evaluation before this proposal is implemented. It is essential that the content and rigor involved in academic training be clearly defined and, most importantly, appropriate resources allocated to conduct evaluation and oversight of these alternative methods of qualification. ATP Certification Training Program The NPRM discusses the establishment of an FAA-approved ATP certificate training program for a multiengine class ATP or type rating. The proposed training program outlined under section 61.154 would include 24 hours of classroom training and 16 hours of simulator training (8 in a full flight simulator of at least Level C standards) and is intended to provide pilots with the core knowledge and understanding in areas critical to operating high performance aircraft in a complex and high altitude environment. The training would be provided by an authorized training provider and would be required to be completed before a pilot would be eligible to take the ATP knowledge test. Issued as part of the NPRM, draft Advisory Circular (AC) 61-ATP, “Airline Transport Pilot Certification Training Program for Airplane Category Multiengine Class Rating or Type Rating,” contains an outline of the curriculum topics and objectives for both the classroom and simulator training making up this training program. The AC is intended for use by training providers when developing the program and by the FAA when reviewing and approving the programs. Many of the topics contained in the draft AC address issues from NTSB safety recommendations; in fact, the FAA notes that most of the 21 recommendations cited in the NPRM are addressed, in part, by the proposed amendments and advisory material. Although the NTSB concurs with the FAA’s assessment that, in most cases, the topics addressed will serve to partially satisfy the action requested in existing recommendations, the amount of specificity provided in the proposed rule and AC does not allow a comprehensive review of the degree to which the FAA’s proposed actions would satisfy the intent of the NTSB’s recommendations. In some instances, neither document provides evidence that a recommendation topic is addressed. The NTSB notes that recent safety recommendations in this area have focused on attempts to improve crew response to in-flight emergencies, including task prioritization and training. While AC 61-ATP does include a classroom training objective named “differences between emergency and non-normal checklist procedures and checklists,” the guidance on emergency procedures should be made more explicit to incorporate the issues identified in these NTSB recommendations. CRM is another topic relevant to previous NTSB recommendations and outlined in AC 61-ATP. However, the list of proposed topics in the AC does not explicitly refer to the importance of first officer assertiveness, which is an issue addressed in Safety Recommendation A-11-39. This recommendation is not cited in the NPRM, but the NTSB believes that it is within the scope of the draft advisory material and suggests amending the AC to include information consistent with Safety Recommendation A-11-39 to help support this important aspect of CRM. The NTSB is encouraged that the NPRM proposes to centralize the process for approving ATP certification training programs. Specifically, the NPRM states that only authorized training providers can administer the training required under section 61.154. These providers can be certificate holders providing training and operating under Parts 141, 142, 121, or 135, and each provider must receive approval of their ATP certification training program by the FAA Air Transportation Division (AFS-200). The NTSB notes that, theoretically, centralization should help to ensure standardization of these programs, but suggests that additional guidance documentation with more specific and robust detail about the content of the proposed training is necessary to provide a solid foundation on which the FAA can evaluate the program content (and to assist training providers to develop courses likely to receive FAA approval). For example, additional detail, such as cross-referencing material from draft AC 120-STALL, would be appropriate in the discussion of stall training in AC 61-ATP. In addition, the FAA will need to provide the appropriate oversight resources to these programs—not only in their initial approval but also to conduct ongoing oversight to demonstrate that the content delivered is consistent with the approved program. The rigor with which these programs are implemented and overseen will determine their ultimate influence on improving safety in air carrier operations. Pilot-in-Command Requirements for Air Carrier Operations The NPRM proposes primarily experience-based requirements for new PICs in air carrier operations. However, the NTSB has previously issued safety recommendations addressing the need for a specific leadership training course for upgrading captains. Although the NPRM cites Safety Recommendation A-10-15 and describes it as applicable to leadership and professionalism training, it addresses only the latter topic. The NPRM does not mention Safety Recommendations A-10-13 and -14, which were issued with -15, but the NTSB believes that a leadership training course for upgrading captains is within the scope of the proposed rulemaking and that section 121.436 should be amended to include a specific requirement for such a course. In addition to the requirements already outlined in section 121.434, the NTSB has recommended that Part 135 pilots who need a type rating for the aircraft they fly be required to have a minimum level of initial operating experience. Given the applicability of the NPRM to Part 135 pilots who are engaged in air carrier operations, the NTSB believes it would be appropriate to incorporate similar experience requirements for these pilots as exist for Part 121 pilots. The NTSB supports the use of simulators in training environments and notes that the training program outlined in the NPRM specifies that training on topics such as low energy states/stalls and upset recovery techniques will be conducted in a Level C or higher full-flight simulator. Simulators, regardless of their fidelity, are dependent on their physical limits of motion, as well as the efficacy of the available computer programs (which are often limited in issues of upset training because of the lack of flight test data at the extreme areas of the flight envelope). Simulators are not always adequate in portraying upsets and stalls and may inadvertently introduce negative training. Consistent with Safety Recommendation A-04-62, the FAA should allow flexibility in determining what level of simulation or automation is appropriate for specific training. Summary Observations This NPRM addresses many training issues applicable to becoming an air carrier pilot, including some critical issues demonstrated in recent accident history to be responsible for accidents. The NTSB is encouraged that its recommendations were considered in the development of this proposed rule, especially as the issue areas relate to the core content to be provided to new entrant pilots through the ATP certification training program. However, the intent of our recommendations in this area is for all pilots to receive training in these topics. Therefore, it is important that air carriers provide equally robust training in these topic areas for their current air carrier pilots on a recurrent basis. The NTSB appreciates the opportunity to comment on this NPRM.

From: NTSB
Date: 7/22/2002
Response: The Safety Board thanks the FAA for the actions it has taken in response to these recommendations. The Board notes that the FAA's review of training programs was limited to the programs of operators of Airbus airplanes. The Board believes that the training programs of operators of other manufacturers' airplanes should also be reviewed. The FAA's plan to use nonregulatory means to meet the intent of Safety Recommendation A-02-01 may represent an acceptable alternative; however, the FAA also indicates that it may ultimately make a regulatory change. The Board will assume, until the FAA indicates otherwise, that the FAA will develop some regulatory changes in pilot training programs in response to Safety Recommendation A-02-01. Pending completion of changes to pilot training programs in response to the recommendations, the determination of whether these revisions will be implemented through the procedures in HBAT 99-07 or through regulatory changes, and the FAA's consideration of reviewing the training programs of operators of other manufacturers' airplanes, Safety Recommendations A-02-01 and A-02-02 are classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
Date: 4/15/2002
Response: Letter Mail Controlled 05/07/2002 10:58:22 AM MC# 2020458 - From Jane F. Garvey, Administrator: The Federal Aviation Administration (FAA) agrees with the intent of these safety recommendations and has taken the following action based on the results of the accident investigation to date. The FAA immediately sent several aviation safety inspectors to review the three main Airbus operators' training programs. This review showed that none of the operators conduct training on the rudder in a way that could result in dangerous combinations of sideslip angles and rudder position or other flight parameters. Based upon the review and the FAA's familiarity with other air carrier training programs, the FAA is confident that the operators are not training their pilots to use dangerous combinations of sideslip angles and rudder position or other flight parameters. On February 15, 2002, the FAA issued Notice N8400.28, Transport Category Airplanes--Rudder and Vertical Stabilizer Awareness, to notify principal operations inspectors (POI) of air carriers that operate transport-category airplanes of the operational use of rudder pedals and the potential subsequent effects on the vertical stabilizer. The notice discusses the current facts related to the ongoing accident investigation and discusses the Board's concerns outlined in these safety recommendations. The notice directs POIs to bring the following points to the attention of their air carriers that operate transport-category airplanes: · Sequential full opposite rudder inputs (sometimes referred to as "rudder reversals"), even at speeds below the design. Maneuvering speed, may result in structural loads that exceed those addressed by the 14 CFR Part 25 requirements. In fact, pilots may have the impression that the rudder limiter systems installed on most transport-category prevent sequential full opposite rudder deflections from damaging the structure. However, the 14 CFR Part 25 structural certification requirements for transport-category airplanes do not take such maneuvers into account; therefore, such sequential opposite rudder inputs, even when a rudder limiter is in effect, can produce loads higher than those required for certification and may exceed the structural capabilities of the aircraft. · Pilots may not be aware that, on some airplane types, full available rudder deflections can be achieved with small pedal movements and comparatively light pedal forces. In these airplanes, at low speeds the rudder pedal forces required to obtain full available rudder may be three times greater than those required to obtain full available rudder at higher airspeeds. · Notwithstanding the concerns noted above regarding the potential danger or large and/or sequential rudder inputs in flight, it should be emphasized that pilots should not become reluctant to command full rudder when required and when appropriate, like during an engine failure shortly after takeoff or during strong or gusty crosswind takeoffs or landings. The instruction of proper rudder use in such conditions should remain intact, but should also emphasize the differences between aircraft motion resulting from a single, large rudder input and that resulting from a series of full or nearly full opposite rudder inputs. The notice directs POI's to provide a copy of the notice to representatives of each transport airplane operator for information and voluntary implementation as deemed appropriate by the operator. I have enclosed a copy of the notice for the Board's information. In addition, on February 15, 2002, the FAA contacted selected manufacturers and industry organizations to inform them that it shares the Board's concern regarding pilot training on the use of the rudder in transport-category airplanes. A letter was subsequently sent to raise awareness of the Board's safety recommendations. The FAA will work together with a cross-section of airplane manufacturers, operators, pilot groups, and industry associations in a collaborative process to initiate actions in regard to this safety issue. The FAA's objective is to develop a common approach across all transport-category airplane types to address the intent of the Board's safety recommendations. Based on the aforementioned letter from the FAA and request from transport operators, the selected manufacturers have committed to addressing the issues identified in these safety recommendations. These manufacturers have prepared flight technical operations bulletins that address the Board and FAA shared concerns and will be distributed to all of their operators. FAA Notice N8400.28 is an interim step to ensure that the shared concerns of the Board and the FAA are known to the operators of transport-category airplanes and that they are conveyed to those operators' pilots as quickly as possible. Similarly, the distribution of the technical operations bulletins proposed by the manufacturers will convey the best information available from each manufacturer in respect to those concerns. Changing training program requirements by rulemaking is usually a time-consuming process with no guarantee of final passage into rule. However, by the procedures contained in HBAT 99-07, Flight Standards Policy - Company Operating Manuals and Company Training Program Revisions for Compliance with Current Airplane [or Rotorcraft] Flight Manual Revisions (AFM), certain changes in the approved sections of the Airplane Flight Manual are more readily captured into pilot training programs. As pertinent safety information is developed by the manufacturers, changes in the respective Airplane Flight Manuals may be appropriate. Training programs may also be changed by mutual agreement of the operator and the FAA based on technical operations bulletins. The FAA will continue to review the information developed by manufacturers and the information resulting from the Board's ongoing accident investigation. The FAA may consider. Initiating rulemaking to change training program requirements as appropriate as more information is available.