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Safety Recommendation Details

Safety Recommendation A-03-052
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: Require that 14 Code of Federal Regulations (CFR) Part 135 on-demand charter operators that conduct dual-pilot operations establish and implement a Federal Aviation Administration-approved crew resource management training program for their flight crews in accordance with 14 CFR Part 121, subparts N and O. (Supersedes Safety Recommendation A-02-012)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Eveleth, MN, United States
Is Reiterated: Yes
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: 5/2/2011
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Crew Resource Management,Part 135,Training and Education

Safety Recommendation History
From: NTSB
To: FAA
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
To: FAA
Date: 5/2/2011
Response: On May 1, 2009, the FAA issued a notice of proposed rulemaking (NPRM), and the NTSB submitted comments to the docket indicating our overall support for the NPRM, as well as our opposition to allowing Part 135 operators to waive the requirement to provide initial CRM training to crewmembers who had previously received initial CRM training elsewhere. We were pleased to subsequently learn that the final rule removed the provision that would have waived these initial training requirements. On March 15, 2011, the NTSB met to adopt the final investigation report on the July 31, 2008, crash during attempted go-around after landing at Owatonna, Minnesota, of East Coast Jets flight 81, a Hawker Beechcraft BAE 125-800A. This flight had been operated under the provisions of Part 135, and problems with the flight crew’s CRM practices were a contributing cause of the accident. During the meeting, the Board reviewed the recently implemented final rule and the likely affect on the accident flight crew, had the rule been in place before the accident. As a result, the Board classified Safety Recommendation A-03-52 CLOSED – ACCEPTABLE ACTION.

From: NTSB
To: FAA
Date: 12/29/2009
Response: On May 1, 2009, the FAA issued a notice of proposed rulemaking (NPRM) titled, Crew Resource Management Training for Crewmembers in Part 135 Operations, which proposes a requirement for all 14 CFR Part 135 certificate holders, both single-pilot and dual-pilot operations, to implement FAA-approved CRM training for crewmembers. On July 15, 2009, the NTSB submitted comments to the docket for this NPRM, indicating support for the proposed rule and stating that, if the NPRM were enacted as a final rule, it would largely meet the intent of Safety Recommendation A-03-52. The proposed rule would require initial and recurrent CRM training for crewmembers working for Part 135 on-demand operators. The proposed rule exceeds the scope of the recommendation in that the rule would apply to all Part 135 on-demand operators, including those who conduct single-pilot operations. It also specifies the minimum course content required for an approved CRM training program. The NTSB expressed concern that the proposed rule exempts Part 135 operators from providing initial CRM training to crewmembers who have previously received initial CRM training from another Part 135 operator. The proposed rule specifies uniform curriculum requirements for Part 135 operators, which is used to justify granting training credit to subsequent operators. Although we supported the establishment of uniform curriculum requirements, the NTSB did not support allowing Part 135 operators to waive the requirement to provide initial CRM training to crewmembers who have previously received initial CRM training elsewhere. Such an allowance would not be consistent with CRM training requirements for Part 121 operations, and, in the interest of safety, it should not be allowed for Part 135 operations. Further, Part 135 on-demand operations are characterized by a wide range of operational environments, applications, aircraft and automation capabilities, and crew complements. Therefore, the NTSB urged the FAA to withdraw the proposal to allow certificate holders to give credit for initial CRM training received from another Part 135 carrier. Pending issuance of the final rule without an allowance for certificate holders to give credit for initial CRM training received from another Part 135 carrier, Safety Recommendation A-03-52 is classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/13/2009
Response: Letter Mail Controlled 8/31/2009 2:13:29 PM MC# 2090552: - From J. Randolph Babbitt, Administrator: FAA Comment. On May 1,2009, the Federal Aviation Administration issued Notice of Proposed Rulemaking (NPRM), Crew Resource Management Training for Crewmembers in Par1 135 Operations (74 FR 20263) (enclosed). 'The NI'RM proposes a requirement for all part 135 certificate holders, both single pilot and dual pilot operations, to implement FAAapproved crew resource management training for crewmembers.

From: NTSB
To: FAA
Date: 7/15/2009
Response: Notation 8131: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) notice of proposed rulemaking (NPRM) titled “Crew Resource Management Training for Crewmembers in Part 135 Operations,” published at 74 Federal Register 20263-20270 on May 1, 2009. The notice proposes to amend the regulations for all certificate holders conducting operations under 14 Code of Federal Regulations (CFR) Part 135 to include in their training programs crew resource management (CRM) for all crewmembers, including pilots and flight attendants. This proposal is needed to ensure that crewmembers in Part 135 operations receive training and practice in the use of CRM principles, as appropriate for their operation. The proposed rule responds to two NTSB recommendations, addresses a recommendation from the Part 125/135 Aviation Rulemaking Committee, codifies current FAA guidance, and aims to reduce the frequency and severity of crew errors and the accidents and incidents such errors cause in Part 135 operations. The NTSB is supportive of the proposed rule and believes that it would largely meet the intent of the NTSB’s Safety Recommendation A-03-52. The recommendation asked the FAA to “require that 14 [CFR] Part 135 on-demand charter operators that conduct dual-pilot operations establish and maintain a Federal Aviation Administration-approved crew resource management training program for their flight crews in accordance with 14 CFR Part 121, subparts N and O.” This recommendation is currently on the NTSB’s Most Wanted List of Transportation Safety Improvements and is classified “Open—Unacceptable Response.” Consistent with Safety Recommendation A-03-52, the proposed rule requires initial and recurrent CRM training for crewmembers working for Part 135 on-demand operators. The proposed rule exceeds the scope of the NTSB’s recommendation in that the rule would apply to all Part 135 on-demand operators, including those who conduct single-pilot operations. The NTSB notes that the proposed rule also specifies the minimum course content required for an approved CRM training program. The NTSB concurs with these three aspects of the proposed rule. However, the NTSB is concerned that the proposed rule exempts Part 135 operators from providing initial CRM training to crewmembers who have previously received initial CRM training from another Part 135 operator. Specifically, proposed 14 CFR 135.329(b) states, “…no certificate holder may use a person as a flightcrew member or flight attendant unless that person has completed approved crew resource management initial training with that certificate holder or with another certificate holder.” The uniform curriculum requirements for Part 135 operators specified in the proposed rule are used to justify granting training credit to subsequent operators. Although the NTSB supports the FAA’s establishment of uniform curriculum requirements, we do not support allowing Part 135 operators to waive the requirement to provide initial CRM training to crewmembers who have previously received initial CRM training elsewhere. Such an allowance would not be consistent with CRM training requirements for Part 121 operations, and, in the interest of safety, it should not be allowed for Part 135 operations. Further, we believe that Part 135 on-demand operations are characterized by a wide range of operational environments, applications, aircraft and automation capabilities, and crew complements. This variety especially necessitates initial CRM training consistent with the particular circumstances of a certificate holder’s operation. Differences in operations could require that different areas of the uniform curriculum elements be emphasized. Operational differences would also affect the content of the proposed CRM curriculum’s final element: “aeronautical decision-making and judgment training tailored to the operator’s flight operations and aviation environment.” Therefore, the NTSB urges the FAA to withdraw the proposal to allow certificate holders to give credit for initial CRM training received from another Part 135 carrier. Lastly, the FAA specifically requested comment on whether there is justification for applying the proposed rule differently in intrastate operations in Alaska under Section 1205 of the FAA Reauthorization Act of 1996. Given the accident history outlined in the NPRM, the NTSB believes that there is no justification for applying the rule differently in Alaska. In addition, NTSB Safety Recommendation A-95-124 specifically addressed components of the proposed CRM training for Alaska operations. This recommendation asked the FAA to require that Part 135 operators in Alaska, “provide flight crews, during initial and recurrent training programs, aeronautical decision-making and judgment training that is tailored to the company’s flight operations and Alaska’s aviation environment…” The proposed rule, if applied to Alaska—and without the previously mentioned exception for crewmembers trained with another operator—would appear to be consistent with the action sought in Safety Recommendation A 95-124, which is currently classified “Open—Unacceptable Response.” We believe that the CRM training described in the proposed rule would improve safety for all 14 CFR Part 135 on demand operations, including certificate holders in Alaska. In summary, the NTSB strongly supports the proposed rule, without the previously described exception for crewmembers trained with another operator and without an exemption for Alaska pilots. Thank you for the opportunity to comment on this NPRM.

From: NTSB
To: FAA
Date: 11/7/2008
Response: The Safety Board notes the continued delays in the FAA’s rulemaking process. More than 4 years have passed since this recommendation was issued. Throughout this period, the FAA has indicated to the Board that a notice of proposed rulemaking (NPRM) was in development with an anticipated publication date first, of mid-2007 and then, at the end of 2008. The Board points out that, in addition to this delay, following publication of the NPRM, additional time will be required for the submission and analysis of public comments before a final rule is issued, further increasing the delay in implementing this needed requirement. The Safety Board is concerned that this rulemaking may be made a part of the FAA’s more comprehensive Part 135 revision/update, which could take significantly longer to publish, considering the wider range of issues being addressed. It remains unclear why the publishing date has once again been extended when existing rule language pertaining to Part 121 operators could also suffice for Part 135 operators. At an October 28, 2008, meeting to update its List of Most Wanted Transportation Safety Improvements, the Board again expressed its concern over the continuing delays in issuing this regulation, which it believes are unacceptable. Accordingly, pending issuance of the NPRM and final rule, Safety Recommendation A-03-52 remains classified OPEN -- UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 4/3/2008
Response: Letter Mail Controlled 4/9/2008 12:42:11 PM MC# 2080185: - From Robert A. Sturgell, Acting Administrator: The Federal Aviation Administration initiated a rulemaking project to require all part 135 certificate holders, both single pilot and dual pilot operations, to implement FAA-approved crew resource management training for crewmembers and flight followers. The FAA intends to have a notice of proposed rulemaking published by the end of 2008.

From: FAA
To: NTSB
Date: 6/13/2006
Response: FAA briefed the Board on the status of CRM rulemaking in response to A-03-52. The NPRM is now due in mid 2007. FAA anticipates a single NPRM with multiple rules.

From: NTSB
To: FAA
Date: 5/2/2006
Response: Safety Recommendation A-03-052 was reiterated in the accident report of the Crash During Takeoff in Icing Conditions, Canadair, Ltd., CL-600-2A12, N873G, Montrose, Colorado, November 28, 2004. (adopted May 2, 2006, AAB-06-003) In the same report the Safety Board classified Safety Recommendation A-03-52 (previously classified "Open-Acceptable Response") OPEN -- UNACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 1/12/2005
Response: The Safety Board acknowledges that the pending revision to 14 CFR Part 135 will incorporate many needed changes to Part 135 operations, including the requirement for CRM training. The Board notes that the NPRM is approximately 1 year away and is only the first step in the rulemaking process. The Board encourages the FAA to expedite the process wherever possible to improve the safety of Part 135 operations. Pending completion of the 14 CFR Part 135 revision, including the requirement for CRM training, Safety Recommendation A-03-52 is classified OPEN -- ACCEPTABLE 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: Crew resource management training is currently required in 14 CFR Part 121 and new 14 CFR Part 91, subpart K. At this time, an Aviation Rulemaking Committee is in session to revise and improve 14 CFR Part 135 in many respects, including requiring crew resource management training for 14 CFR Part 135 operators of airplanes with two pilots. The Aviation Rulemaking Committee has a 2-year charter with a notice of proposed rulemaking (NPRM) targeted in fiscal year 2005.

From: NTSB
To: FAA
Date:
Response: At the November 14, 2006 Board meeting addressing the NTSB’s Federal Most Wanted List of Transportation Safety Improvements (MWL), the Board voted to place Safety Recommendations A-03-52 on the Federal MWL under the issue category “Crew Resource Management: Part 135.”