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Safety Recommendation Details

Safety Recommendation A-03-051
Details
Synopsis: On October 25, 2002, about 1022 central daylight time, a Raytheon (Beechcraft) King Air A100, N41BE, operated by Aviation Charter, Inc., crashed while the flight crew was attempting to execute the VOR approach to runway 27 at Eveleth-Virginia Municipal Airport, Eveleth, Minnesota. The crash site was located about 1.8 nautical miles southeast of the approach end of runway 27. The two pilots and six passengers were killed, and the airplane was destroyed by impact forces and a postcrash fire. The airplane was being operated under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as an on-demand passenger charter flight. Instrument meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Conduct en route inspections and observe ground training, flight training, and proficiency checks at all 14 Code of Federal Regulations Part 135 on-demand charter operations as is done at Part 121 operations and Part 135 commuter operations to ensure the adequacy, quality, and standardization of pilot training and flight operations.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: Eveleth, MN, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA03MA008
Accident Reports: Loss of Control and Impact With Terrain Aviation Charter, Inc., Raytheon (Beechcraft) King Air A100, N41BE
Report #: AAR-03-03
Accident Date: 10/25/2002
Issue Date: 12/2/2003
Date Closed: 11/19/2015
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Flightcrew, Oversight, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 11/19/2015
Response: In a November 20, 2008, letter about this recommendation, the FAA stated its belief that, although en route inspections are one of the most effective methods for surveillance of an operator, arbitrarily assigning a minimum number of en route inspections for all on-demand operations would not necessarily increase safety and would not be the best use of your resources. Instead, the FAA believed that it should prioritize surveillance activities by identifying weaknesses or potential safety risks in operator performance and allowing inspectors to apply the appropriate level of surveillance to any particular operator. The FAA developed the Surveillance Priority Index (SPI), a tool that provided a ranked order of assessed safety risks and was to be used as the basis for surveillance activities, identifying the amount of oversight and prioritizing the timing of surveillance required for a particular operator. The FAA proposed use of the SPI as an alternative action to address this recommendation. We point out that we did not, as your current letter states, request a risk-based surveillance tool; rather, the FAA proposed the SPI as an alternative to our recommended en route inspections of all Title 14 Code of Federal Regulations Part 135 on-demand charter operations. On July 31, 2009, we replied that the plans to develop the SPI and require FAA Part 135 on-demand inspectors to use the SPI to prioritize their oversight activities, including en route surveillance, and to conduct at least one en route inspection annually for each on demand operator, would constitute an acceptable alternate response to this recommendation. We also asked that, using your Program Tracking and Surveillance (PTRS) System, you provide a summary of the specific types of oversight activities conducted on Part 135 on-demand operators in the year before and the one following implementation of the SPI. We were particularly interested in learning how many en route inspections were conducted and the number of different operators for which at least one en route inspection was conducted. On August 4, 2010, the FAA published a change to Order 8900.1, “Flight Standards Information Management System,” volume 6, chapter 2, section 1, which required your inspectors for Part 135 on-demand operators to use the SPI and included a detailed summary of what factors the SPI uses. In your current letter, you provided data regarding the number of Part 135 operators for which en route surveillance was conducted during fiscal years (FY) 2012, 2013, and 2014. You also provided data on the number of collective times these operators were inspected. Our purpose in requesting this data was to evaluate what changes to FAA oversight of Part 135 operators resulted from implementation of the SPI. The changes to Order 8900.1 were made in 2010, so data from FY 2010 and 2011 were needed to address this question. Although the data that you provided cannot be used to evaluate improvements resulting from the use of the SPI, we note that approximately 5% of all Part 135 operators receive en route surveillance each year, and that the number of Part 135 operators receiving en route surveillance decreased each year, We also note that you will be implementing a new oversight system for Part 135, to be called the Safety Assurance System (SAS), and that SAS will replace the SPI. You believe that you have effectively addressed this recommendation and consider your actions complete. Although you have not supplied data documenting changes in your oversight program for Part 135 on demand operators as a result of implementing the SPI, the data that you supplied show that the number of Part 135 operators receiving en route inspections is approximately 5% of all operators, and that the number is declining year over year. Consequently, Safety Recommendation A-03-51 is classified CLOSED—UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 8/20/2015
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) has met the Board's request for a risk-based surveillance tool through mandated use of the Surveillance Priority Index (SPI) for principal Aviation Safety Inspectors (ASIs). The FAA published Notice 8900.132, Work Program Development for 14 CFR Part 13 5 Certificate Holders, on August 12, 201 0. This Notice (previously provided) requires ASIs to use the SPI when planning their work programs and also includes a detailed summary of what factors the SPI uses. (FAA Order 8900.1, volume 6, chapter 2, section 1 ). The FAA monitors the surveillance conducted by AS Is through the use of the Program Tracking and Reporting Subsystem. The current part 135 fleet consists of around 2,050 operators. We have used the SPI to identify operators that require additional oversight, as depicted by the below chart. Due to the passage of time since our previous response and to provide a more current assessment, we used FY 2012-2014 data instead of FY 2010-2011. En-Route Surveillance of Part 135 Operators* FY 2012 FY 2013 FY2014 A. Number of part 135 operators inspected. 108 105 84 B. Number of collective times the operators that makeup '•A'" were inspected. 559 457 398 •Excel spreadsheets of this chart are available upon request The use of SPI allows the FAA to identify the highest-risk operators and perform en route surveillance on these selected operators. We believe this method is working by focusing limited resources on those operators identified by the srr. The FAA's Flight Standards Service (AFS) also established the System Approach for Safety Oversight Program Office to develop and implement a comprehensive system safety approach to the oversight of aviation entities. The goal is to improve safety beyond current levels by enhancing our risk-based. data-supported approach. A Safety Management System (SMS) has four components, which are: safety policy, safety risk management, safety promotion, and safety assurance. The AFS Safety Assurance System (SAS) is the combination of people, processes, and technology that encompass AFS's safety assurance SMS capability. Beginning this year, the AFS SAS will be the new oversight system for part 135, replacing the SPI. I believe that the FAA has effectively addressed this recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 9/22/2011
Response: On November 20, 2008, the FAA stated its belief that, although en route inspections are one of the most effective methods for accomplishing surveillance objectives and responsibilities, arbitrarily assigning a minimum number of en route inspections for all on-demand operations would not necessarily increase safety and, therefore, would not be the best use of its resources. Instead, the FAA believed that it should prioritize surveillance activities, using evaluation processes that identified weaknesses or potential safety risks in operator performance and allowing inspectors to apply the appropriate level of surveillance to any particular operator. The FAA developed the 135 Surveillance Priority Index (SPI), a tool that provides a ranked order of assessed safety risks and that is used as the basis for surveillance activities, identifying the amount of oversight and prioritizing the timing of surveillance required for a particular operator. At that time, the FAA stated that it planned to issue a notice to inspectors of Part 135 on-demand operators instructing them to use the 135 SPI to identify increased safety risk in operator performance and to increase surveillance, including en route surveillance, based on the results of the SPI. In addition, the notice would encourage inspectors to conduct at least one en route inspection annually for each on-demand operator. On July 31, 2009, the NTSB stated that the FAA’s plans to (1) develop the 135 SPI, (2) issue a notice to Part 135 on-demand inspectors to use this tool to prioritize safety risks and increase surveillance, including en route surveillance, and (3) conduct at least one en route inspection annually for each on-demand operator would constitute an acceptable alternate response to this recommendation. We also asked the FAA to provide (1) specific details of what information was collected and used to assign priorities for oversight activities of Part 135 on-demand carriers and (2) a summary of the specific types of oversight activities conducted on Part 135 on-demand operators in the year following issuance of the FAA’s notice to inspectors to use the 135 SPI. We are particularly interested in learning how many en route inspections are conducted during this period and the number of different operators for which at least one en route inspection is conducted. On August 12, 2010, the FAA published Notice 8900.132, “Work Program Development for 14 CFR Part 135 Certificate Holders” which instructs the FAA’s aviation safety inspectors (ASI) to use the SPI when planning their work programs. In addition, on August 4, 2010, the FAA published a change to FAA Order 8900.1, “Flight Standards Information Management System,” volume 6, chapter 2, section 1, which requires ASIs to use the SPI and to include a detailed summary of what factors the SPI uses. In its current letter, the FAA indicated that it is using its Program Tracking and Surveillance System to monitor the completion of required surveillance items conducted by ASIs and that it plans to compare the surveillance activities of Fiscal Year (FY) 2010 to the surveillance activities of FY 2011 and provide the NTSB with a summary of these Part 135 oversight activities. The FAA is continuing the activities that the NTSB previously indicated would constitute an acceptable alternate response to this recommendation. We look forward to reviewing the summary of the FY10 surveillance activities to the FY11 activities. We believe that this summary should demonstrate the effect that use of the SPI has had on Part 135 on-demand surveillance activities, and we again emphasize that we are particularly interested in learning how many en route inspections are conducted during the periods and the number of different operators for which at least one en route inspection was conducted. Pending our receipt and review of this information, Safety Recommendation A-03-51 remains classified OPEN—ACCEPTABLE ALTERNATE RESPONSE.

From: FAA
To: NTSB
Date: 4/25/2011
Response: The Federal Aviation Administration continues to support the implementation of this safety recommendation. We published Notice 8900.132, Work Program Development for 14 CFR Part 135 Certificate Holders, on August 12, 2010 (enclosure 1). Notice 8900.132 instructs aviation safety inspectors (ASIs) to use the Surveillance Priority Index (SPI), a module of the Safety Performance Analysis System, when planning their work programs. Additionally, on August 4, 2010, a change to FAA Order 8900.1, Flight Standards Information Management System, volume 6, chapter 2, section 1 (enclosure 2) was published requiring ASIs to use the SPl. This revision also includes a detailed summary of what factors the SPI uses. The FAA is monitoring the completion of required surveillance items conducted by ASIs through the use of the Program Tracking and Surveillance System. The FAA plans to compare the surveillance activities of Fiscal Year (FY) 2010 to the surveillance activities of FY 2011, and provide the Board with a summary of these part 135 oversight activities. I will keep the Board informed of the FAA's progress on this safety recommendation, and I will provide an update by March 31, 2012.

From: NTSB
To: FAA
Date: 7/31/2009
Response: On April 12, 2004, the FAA stated that it conducts surveillance activities of Part 135 on demand operators that are similar to its surveillance of Part 121 and Part 135 scheduled carriers. These activities include observation of ground and flight training, ramp inspections, operating manual reviews, weight and balance analysis, crew dispatch records, trip records, facility inspections, aircraft records inspections, and numerous maintenance inspections. However, en route inspections for on-demand operators are much more difficult to conduct because, unlike Part 121 operators, on-demand operators typically use small aircraft that do not have jumpseats, have limited seating capacity, and do not fly a fixed schedule. The lack of a fixed schedule is a problem for inspectors, whose efficiency is limited by an unpredictable schedule. Further, since on-demand operators’ flights are often made to smaller airports with no scheduled air transportation, inspectors on these flights would need to also wait at these airports for extended periods of time for the operators’ customers. The FAA believed this would not be an effective use of its limited resources. The FAA concluded its April 12, 2004, letter with its belief that the oversight it currently conducts for Part 135 on-demand operators provides sufficient safety oversight. On January 12, 2005, the NTSB replied to the FAA that it was disappointed that the FAA did not agree that en route surveillance needed to be conducted at the same level for Part 135 on-demand operators as for Part 121 and Part 135 scheduled operators. As described in the letter that transmitted this recommendation, FAA records documented 23 assorted surveillance activities that were conducted on Aviation Charter, Inc., in the year preceding the October 22, 2002, accident, including inspections of required manuals, training records, programs, trip records, ramps, and aircraft line operations. However, there was no en route surveillance, observation of pilot training, or proficiency checks. None of the 23 surveillance activities detected that Aviation Charter was not operating in accordance with its weight and balance procedures; did not have adequate stall recovery guidance, consistent deicer boot guidance, or an in-range checklist; did not adequately make pilots aware of its standard operating procedures; and was not conducting crew resource management training in accordance with its FAA-approved training module. The NTSB stated that it believed en route inspections are essential for ensuring adequate oversight of Part 135 on-demand operations and asked the FAA to reconsider the priority of surveillance activities for Part 135 on-demand operators. At that time, Safety Recommendation A-03-51 was classified Open Unacceptable Response. In its current letter, the FAA stated that it continues to believe that while en route inspections are one of the most effective methods for accomplishing surveillance objectives and responsibilities, arbitrarily assigning a minimum number of en route inspections for all on-demand operations will not necessarily increase the level of safety and is not the best use of resources. The FAA believes it is efficiently utilizing limited resources by prioritizing surveillance activities, using evaluation processes that identify weakness or potential safety risk in operator performance, and allowing inspectors to apply the appropriate level of focus on any particular operator. The FAA has developed the 135 Surveillance Priority Index (SPI), a new module of the Safety Performance Analysis System. The 135 SPI is a tool that provides a ranked order of assessed safety risks that is used as the basis for surveillance activities, identifying the amount of oversight and prioritizing the timing of surveillance required for a particular operator. The FAA stated that it will issue a notice to inspectors of Part 135 on demand operators instructing them to use the 135 SPI to identify increased safety risk in operator performance and to increase surveillance, including en route surveillance, based on the results of the 135 SPI. In addition, the notice will encourage inspectors to conduct at least one en route inspection annually for each on-demand operator. The FAA will generate a specific national use code for the Program Tracking and Reporting Subsystem (PTRS) to track the progress of on-demand surveillance activities. As part of its activities to standardize training conducted by Part 135 on demand operators, the FAA incorporated information in Notice N8000.355, “Inspector Guidance for 14 CFR Part 142 Training Centers” into Order 8900.1, Flight Standards Information Management System. The FAA also stated that it continues to research and develop new surveillance practices, using tools that are flexible and allow efficient use of resources, with the intent of increasing the quality of surveillance for operations of all types. The FAA stated that it is efficiently utilizing limited resources by prioritizing surveillance activities, using evaluation processes that identify weakness or potential safety risk in operator performance, and allowing inspectors to apply the appropriate level of focus on any particular operator. However, the NTSB has completed or is currently investigating several accidents involving Part 135 on-demand operators. In several of these accidents, the investigation is examining whether FAA surveillance activities conducted before the accident were adequate. Among these accidents are the following: 1.Runway Overrun and Collision, Platinum Jet Management, LLC, Bombardier Challenger CL-600-1A11, Teterboro, New Jersey, February 2, 2005 (investigation completed) 2.Ground Impact During Attempted Go-around, East Coast Jets, Hawker Beechcraft BAE 125-800A, Owatonna Denger Regional Airport, Owatonna, Minnesota, July 31, 2008 3.Uncontrolled Descent and Water Impact with Lake Michigan near Milwaukee, Wisconsin, Marlin Air Under Contract to the University of Michigan Health System, Cessna 550 (Citation II), June 4, 2007 4. mpact with Terrain Following Loss of Control after Takeoff, Cessna 500, Wiley Post Airport, Oklahoma City, Oklahoma, March 4, 2008 The FAA’s plans to (1) develop the 135 SPI; (2) issue a notice to Part 135 on-demand inspectors to use this tool to prioritize safety risks and increase surveillance, including en route surveillance; and (3) conduct at least one en route inspection annually for each on-demand operator are acceptable alternate responses to this recommendation. In addition, the generation and use of an appropriate PTRS code will allow the FAA to track inspectors’ activities in response to these actions. Finally, the FAA’s research and development of new surveillance practices with the intent of increasing the quality of surveillance should allow the FAA to develop new surveillance techniques that are effective, considering the unique challenges regarding the size of airplanes that on-demand operators use and the unscheduled operations they conduct. As this research and development proceeds, the NTSB would like to learn of new techniques and practices being considered to address these challenges for on-demand surveillance and oversight. In order to better evaluate the 135 SPI, the NTSB asks the FAA to provide specific details of what information is collected and used to assign priorities for oversight activities of Part 135 on-demand carriers. The NTSB also asks that the FAA use the information entered in PTRS to supply a summary of the specific types of oversight activities conducted on Part 135 on-demand operators in the year following issuance of the FAA notice to inspectors to use the 135 SPI. The NTSB is particularly interested in learning how many en route inspections are conducted during this period and the number of different operators for which at least one en route inspection was conducted. Pending details of the 135 SPI and information of inspectors’ activities in response to the FAA notice, Safety Recommendation A-03-51 is classified OPEN -- ACCEPTABLE ALTERNATE RESPONSE.

From: FAA
To: NTSB
Date: 11/20/2008
Response: Letter Mail Controlled 12/9/2008 2:09:29 PM MC# 2080715: - From Robert A. Sturgell, Acting Administrator: The Federal Aviation Administration continues to find that while en route inspections are one of the most effective methods for accomplishing surveillance objectives and responsibilities, arbitrarily assigning a minimum number of en route inspections to be accomplished for all on-demand operations will not necessarily increase the level of safety and is not the best use of resources. On-demand operations pose significant challenges to accomplishing surveillance activities due to types and areas of operations, limited jump seat provisions on smaller aircraft, and lack of a fixed schedule. The FAA is efficiently utilizing limited resources by prioritizing surveillance activities, using evaluation processes that identify weakness or potential safety risk in operator performance, and allowing inspectors to apply the appropriate level of focus on any particular operator. The 135 Surveillance Priority Index, a new module of the Safety Performance Analysis System (SPAS), is a tool that provides a ranked order of assessed safety risks that become the basis for action. The system assists inspectors in identifying the amount of oversight and prioritizing the timing of surveillance required for a particular operator. The FAA will issue a notice to inspectors of part 135 on-demand operators by April 2009, instructing them to use the SPAS surveillance priority index as a tool to identify increased safety risk in operator performance and then to increase surveillance (to include en route surveillance) as necessary, based on priority. The surveillance priority index tool allows the FAA to leverage resources smartly, focusing proper attention and surveillance where it is most needed. Additionally, in the notice the FAA will highly encourage inspectors to conduct at least one en route inspection annually for each on-demand operator, provided the aircraft is equipped with a suitable jump seat or passenger seat that allows the inspector to have visibility of flight deck operations. A specific national use code for the Program Tracking and Reporting Subsystem will be generated to track the progress of on-demand surveillance activities. FAA Order 1800.56H, National Flight Standards Work Program Guidelines, Appendix A, paragraph 5(a)(9)(d)(l), Training Program, requires at least one pilot ground or pilot flight inspection be conducted on each on-demand operator (except for single-pilot or single-pilot-in- command operators). The national use code mentioned above will allow the FAA to track inspector activities in this area. Special-emphasis item 7a of Order 1800.56H provides guidance for surveillance of commercial air tour operators, advising inspectors to consider the Board's recommendations when planning surveillance. Enclosed is a copy of FAA Order 1800.56H. The FAA is making progress in standardization of training conducted by part 135 on-demand operators. On February 12, 2007, the FAA issued Notice N 8000.355, Inspector Guidance for 14 CFR part 142 Training Centers. That notice provided guidance to principal operations inspectors who have authorized their respective operators to enter into training agreements with part 142 training centers. The notice also prompted an increased level of standardization and is intended to ensure the adequacy and quality of each operator's pilot training and flight operations. Notice N 8000.355 was then incorporated into FAA Order 8900.1, Flight Standards Information Management System, on December 31, 2007. Enclosed is a copy of Volume 6, Surveillance, from Order 8900.1. The FAA continues to review and update inspector manuals, notices, aeronautical information manuals, and provide information through safety alerts for operators and information for operators to the inspectors and the public. The FAA also continues to research and develop new surveillance practices, using tools that are flexible and allow efficient use of resources, with the intent of increasing the quality of surveillance for operations of all types. I believe that the FAA has effectively addressed this safety recommendation.

From: NTSB
To: FAA
Date: 1/12/2005
Response: The Safety Board notes that the FAA identified the Flight Standards Work Program guidelines for surveillance activities of 14 CFR Part 135 on-demand operators. The FAA discussed the similarities of these activities as compared with Part 121 and Part 135 commuter operations. The FAA stated that because of the typically small aircraft and lack of a fixed schedule, en route inspections for Part 135 on-demand operators are not considered an effective use of inspectors' time. Therefore, en route inspections are not required or routinely conducted for Part 135 on-demand operators. However, the FAA reported that in the last 4 years, it had conducted 1,343 en route surveillance activities on some of the 2,800 on-demand operators. The FAA stated that it believes the oversight it currently conducts for Part 135 on-demand operators provides sufficient safety oversight. The Safety Board is disappointed that the FAA does not agree that en route surveillance needs to be conducted at the same level for Part 135 on-demand operators as for Part 121 and Part 135 commuter operators. As outlined in the safety recommendation letter and the accident report, according to FAA records, 23 assorted surveillance activities were conducted on Aviation Charter, Inc., in the year preceding the accident. These included a manual inspection, training records and program inspections, a trip record inspection, a ramp inspection, and aircraft line operation inspections. They did not include en route surveillance, observation of pilot training, or proficiency checks. None of the 23 surveillance activities detected that Aviation Charter was not operating in accordance with its weight and balance procedures; did not have adequate stall recovery guidance, consistent deicer boot guidance, or an in-range checklist; did not adequately make pilots aware of its standard operating procedures; and was not conducting crew resource management (CRM) training in accordance with its FAA-approved training module. FAA Order 8400.10, "Air Transportation Operations Inspector's Handbook," indicates that en route inspections are the most effective method for accomplishing surveillance objectives and responsibilities. The Safety Board concurs. The Board believes that these surveillance activities are essential, not optional, for ensuring adequate oversight of Part 135 on-demand operations. The Board encourages the FAA to reconsider the priority of surveillance activities on Part 135 on-demand operators. If there are a finite number of inspector-hours available per operator, concentration should be on the most effective means of surveillance, that is, en route and training surveillance. Pending implementation of required en route surveillance and observation of ground and flight training activities, Safety Recommendation A-03-51 is classified OPEN -- UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 4/12/2004
Response: Letter Mail Controlled 4/12/2004 12:32:08 PM MC# 2040165 -From Marion C. Blakey, Administrator: Under the Flight Standards National Work Program guidelines, the Federal Aviation Administration (FAA) conducts surveillance activities of 14 CFR Part 135 on-demand operators. This surveillance is similar to that of 14 CFR Part 121 and 14 CFR Part 135 commuter, i.e., observation of ground and flight training (training programs), ramp inspections, operating manual reviews, weight and balance analysis, crew dispatch records, trip records, facility inspections, aircraft records inspections, and numerous maintenance inspections.