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Safety Recommendation Details

Safety Recommendation A-03-054
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: If the panel requested in Safety Recommendation A-03-53 determines that a requirement for the installation of low-airspeed alert systems in airplanes engaged in commercial operations under 14 Code of Federal Regulations Parts 121 and 135 is feasible, establish requirements for low-airspeed alert systems, based on the findings of this panel.(Superseded by A-10-12)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action/Superseded
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: 2/23/2010
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action/Superseded)
Keyword(s): Instruments

Safety Recommendation History
From: NTSB
To: FAA
Date: 2/23/2010
Response: From the safety recommendation letter to the Federal Aviation Administration written in response to the 2/12/2009 accident of a DHC-8-400 (Q400), operated by Colgan Air as Continential Connection flight 3407, in Clarence Center, New York: During the almost 6 years since the NTSB issued Safety Recommendations A 03 53 and 54, (which were reiterated in July 2006 after another event involving decreasing airspeed and loss of control), accidents and incidents involving a lack of flight crew awareness of decreasing airspeed have continued, indicating that existing stall warnings are not a reliable method for preventing inadvertent hazardous low-speed conditions. The NTSB notes that human factors concerns associated with a low-airspeed alert do not require more than 6 years of study for a solution to be implemented. The NTSB notes that several other airplanes certificated under 14 CFR Part 25, including the Boeing 747-400 and 777, provide pilots with an amber band on the airspeed display above the low-speed cue. This amber band typically represents the airspeed between the stall warning speed and the minimum maneuvering speed. Operations are not normally conducted with airspeeds in the amber band, which, in effect, provides pilots with a visual indication of a developing low speed condition before the onset of the stall warning. AC 25-11A, Electronic Flight Displays, discusses the visual design of low-speed awareness cues and states, the preferred colors to be used are amber or yellow to indicate that the airspeed has decreased below a reference speed that provides adequate maneuver margin, changing to red at the stall warning speed. The speeds at which the low speed awareness bands should start should be chosen as appropriate to the airplane configuration and operational flight regime. For example, low speed awareness cues for approach and landing should be shown starting at Vref with a tolerance of +0 and -5 knots. The NTSB concludes that the Q400 airspeed indicator lacked low-speed awareness features, such as an amber band above the low-speed cue or airspeed indications that changed to amber as speed decrease toward the low-speed cue, which would have facilitated the flight crew’s detection of the developing low-speed situation. Therefore, the NTSB recommends that the FAA require that airspeed indicator display systems on all aircraft certified under 14 CFR Part 25 and equipped with electronic flight instrument systems depict a yellow/amber cautionary band above the low-speed cue or airspeed indicator digits that change from white to yellow/amber as the airspeed approaches the low-speed cue, consistent with AC 25-11A, Electronic Flight Displays. At the public hearing for this accident, an FAA certification specialist testified that current certification rules under 14 CFR 25.1329 indicate that there should be speed protection and/or alerting within the normal speed range while under flight guidance system (autopilot) control. The certification specialist stated, there should be low speed alerting occurring prior to stall warning, if you’re under flight guidance system or autopilot control. And that low speed alerting can take many forms, but it needs to be aural and visual. On July 9, 2009, the FAA issued a notice of proposed rulemaking (NPRM) for flight crew alerting, which included a requirement that alerts necessitating immediate crew awareness be presented using two sensory modalities. For example, a visual alert accompanied by an aural alert can help to capture and focus a pilot’s attention in the event that the pilot is not looking at the alerting cue. In this accident, the pilots did not likely see the rising low-speed cue on the IAS display, the downward pointing trend vector, or the airspeed indications change to red. As a result, the NTSB concludes that an aural warning in advance of the stick shaker would have provided a redundant cue of the visual indication of the rising low-speed cue and might have elicited a timely response from the pilots before the onset of the stick shaker. Therefore, the NTSB recommends that, for all airplanes engaged in commercial operations under 14 CFR Parts 121, 135, and 91K, the FAA require the installation of low-airspeed alert systems that provide pilots with redundant aural and visual warnings of an impending hazardous low-speed condition. Because of the FAA’s inactivity with regard to Safety Recommendations A-03-53 and 54, the NTSB classifies the recommendations CLOSED -- UNACCEPTABLE ACTION/ SUPERSEDED and classifies Safety Recommendation A-10-12 "Open -- Unacceptable Response."

From: NTSB
To: FAA
Date: 4/3/2007
Response: Shortly after these recommendations were issued, the FAA asked for more information about the 18 aircraft accidents, referenced in the letter that transmitted these recommendations to the FAA, that are the basis for these recommendations. On January 21, 2004, the Safety Board supplied this information to the FAA. On April 12, 2004, the FAA stated that it shared the Safety Board’s concern regarding flight crew awareness of low airspeed situations, and outlined several alerts or other cues that presently exist on some airplanes. The FAA stated that it would review the list of accidents supplied on January 21, 2004, and consider efforts already in progress in determining what actions to take in response to these recommendations. On January 12, 2005, the Safety Board replied that the FAA had supplied no information regarding planned actions. At that time, the recommendations were already a year old, and the Board asked for an expedited response regarding the FAA’s intended actions. Pending that information, Safety Recommendations A-03-53 and -54 remained classified "Open--Await Response." In the intervening 2 years, no further information has been received from the FAA regarding any actions being taken in response to these recommendations. In its October 3, 2006, letter, the FAA indicated that because these recommendations had been reiterated, the FAA had formed an internal team to assess the feasibility of low airspeed alerting systems. Although the FAA’s letter indicated that a status update would be provided by November 17, 2006, the FAA later advised the Safety Board that this information would not be available until March 2007. The FAA recently indicated that it would not be able to supply this information before July 2007. Although the FAA has not taken action in the 3 years since these recommendations were issued, the Board is encouraged that the FAA has formed a team to begin addressing the recommendation. Accordingly, Safety Recommendations A-03-53 and -54 are classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/3/2006
Response: Letter Mail Controlled 10/11/2006 2:41:26 PM MC# 2060500: - From Marion C. Blakey, Administrator: In consideration of the Board's reiteration of these recommendations, the FAA has formed an internal team of experts to assess the feasibility of new low airspeed alerting systems. If outside expertise is needed, the team will consult with representatives from the National Aeronautics and Space Administration or other organizations, as appropriate. We will provide a status update by November 17, 2006.

From: NTSB
To: FAA
Date: 7/10/2006
Response: Safety recommendation A-03-053 and A-03-054 was reiterated in the letter issuing Safety Recommendations A-06-48 through A-06-51, issued on July 10, 2006.

From: NTSB
To: FAA
Date: 1/12/2005
Response: The FAA reported that it shares the Safety Board's concern regarding flight crew awareness of low airspeed situations. The FAA also outlined several alerts or other cues that presently exist on some airplanes. The FAA requested, and the Board provided, more complete information regarding other accidents that support these recommendations. The FAA reports that it will review these accidents and consider efforts already in progress in determining what action needs to be taken to address this safety issue. The Safety Board appreciates the FAA's agreement that low-speed awareness is an ongoing safety issue. However, there is no information regarding planned actions by the FAA. Since these recommendations were issued a year ago, the Board would appreciate an expedited response regarding the FAA's intended actions regarding these two safety recommendations. Pending this information, Safety Recommendations A-03-53 and -54 remain classified OPEN -- AWAIT 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: The FAA shares the Board's concern regarding flightcrew awareness of low airspeed situations. As noted in the Board's letter dated December 2, 2003, failure to maintain adequate airspeed can result in unsafe circumstances like loss of control, impact with terrain or water, hard landings, and tail strikes. The Board further states that it has investigated numerous accidents and incidents involving commercial flightcrcws that inadvertently failed to maintain airspeed. For example, the Board has investigated at least 11 events since 1982 involving 14 CFR Part 135 flights and at least seven events involving 14 CFR Part 121 flights in which stall or failure to maintain airspeed during approach or landing phases was cited as a causal or contributing factor and in which icing was not cited as a factor. Current rules require stall warning (stick shaker or natural buffet) for both small airplanes and transport airplanes. The Board acknowledges the existing requirements for stall warning, but challenges the premise that stall warnings and flightcrew vigilance provide adequate low airspeed awareness. The Board states that a low airspeed alert, which would be activated at some airspeed higher than stall warning, would provide additional protection against low airspeed conditions that may lead to stall. The Board noted the existing installation of a low airspeed alert in the Embraer 120. The FAA required this alert as an interim solution until Embraer redesigns the stall warning system to account for icing conditions adequately. Many current transport airplanes include additional cues on airspeed indicators. These cues are intended to provide improved low airspeed awareness. While not alerts, these color-coded symbols indicate the low airspeed region (the maneuver margin, typically at about 1.3 Vstall) in which the airplane is approaching the stall warning speed. As noted by the Board, such displays are now becoming available for use in less sophisticated general aviation airplanes. Additionally, the Board has recognized that there are unresolved technical, operational, and human factors issues that will need to be carefully evaluated and addressed in connection with the design and implementation of a low airspeed alert system. On January 21,2004, the Board provided the FAA with more complete information on the 18 accidents cited by the Board to support these safety recommendations. The FAA will include a review of these 18 accidents in determining what action needs to be taken to address the safety issue. The FAA will also consider efforts already accomplished or in progress under the Safer Skies programs and other initiatives dealing with airspeed awareness. I will keep the Board informed of the FAA's progress on these safety recommendations.