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From:
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NTSB
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To:
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FAA
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Date:
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10/27/2009
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Response:
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The opening of the December 22, 2003, letter that transmitted this recommendation to the FAA stated that the NTSB has investigated numerous accidents involving turbine-powered aircraft not required to operate with either a CVR or an FDR. Significantly, these accidents involved aircraft operating under 14 CFR Parts 91 and 135. In its November 20, 2008, letter, the FAA stated that it had decided not to mandate the recommended requirement for existing aircraft operating under Part 91 or 135 in the March 7, 2008, final rule. The FAA stated further that it was not able to quantify or justify the potential burden of the CVR retrofit requirements.
The NTSB’s December 22, 2003, letter explained that this recommendation had been prompted in part by the need for turbine-powered, nonexperimental, nonrestricted-category aircraft with the capability of seating six or more passengers but certificated for single pilot operation to be required to carry, maintain, and use a CVR. This recommendation was also prompted by the widely held but incorrect belief that a CVR is no longer required if an operator converts a passenger-carrying aircraft to one carrying cargo.
The same letter stated that the recommended action was intended for turbine powered aircraft including the Beech King Air, Cessna Citation, Cessna Caravan, and Piper Cheyenne airplanes, as well as Bell 407 and Bell 206L helicopters. These single-pilot-certificated aircraft are heavily used in Part 135 passenger charter and other commercial operations. Under Parts 91 and 135 operations, a CVR is required only if the aircraft are certificated for operation by two pilots. Although CVR data from single-pilot operations may not provide the same level of operational information as would be expected when two or more crewmembers are present, the recorder can capture events that are important to accident investigators. Significantly, despite their single-pilot certification, aircraft in this category are often operated with two pilots to meet insurance requirements or for other reasons, such as safety-of-flight, making the presence of a CVR even more valuable to NTSB investigations. Aircraft covered by this recommendation were involved in more than 100 accidents investigated by the NTSB in the period January 2000 through December 2003. Most of these aircraft were not equipped with CVRs, and in only one case was the CVR operating at the time of the accident. In particular, the Beech King Air was involved in 45 of these investigations. Of those accidents, three of the aircraft were equipped with CVRs, although they were not required by federal regulation to be so equipped, but only one of the CVRs was operational and provided data that aided in the investigation. NTSB statistics also show that the Piper Cheyenne and the Cessna Citation were involved in 18 accidents during the same period, but CVRs had not been installed on any of the Piper Cheyennes. Although one Cessna Citation was equipped with a CVR, the recorder did not contain any useful audio information. The NTSB investigated a significant number of rotorcraft accidents during this period. The Bell 407- and Bell 206L-series helicopters are certificated to operate with one pilot and to carry at least six passengers. From January 2000 to December 2003, these helicopters were involved in more than 50 accidents investigated by the NTSB; none of these helicopters was equipped with a CVR. Finally, from September 1985 through December 2003, Cessna Caravans were involved in over 100 accidents. Without fully operational data recorders, the NTSB is disadvantaged in its ability to thoroughly investigate the large number of accidents involving these aircraft.
On May 8, 2006, the NTSB sent a letter to the FAA referencing this recommendation and its relationship to the October 24, 2004, crash into mountainous terrain in Stuart, Virginia, of a Beech King Air 200, operated by Hendrick Motorsports. The flight was operating under Part 91, and both pilots were qualified and experienced, with the captain’s having accumulated 10,733 hours of total flying time. The airplane was not equipped with a CVR, an FDR, or a video image recorder. The probable cause of this accident, as stated in the NTSB’s report, was “the flight crew’s failure to properly execute the published instrument approach procedure, including the published missed approach procedure, which resulted in controlled flight into terrain. However, the lack of recorders prevented the NTSB from more fully developing the scenario that led to the crew’s failure to properly execute the approach. Issues that were discussed in the accident report, but not fully developed due to lack of recorder data, include crew resource management, possible misuse of the global positioning system rather than use of the instruments available for a nonprecision approach, and possible reasons why an experienced crew had not properly flown the missed approach. In the May 8, 2006, letter the NTSB stated that the absence of any recorders on this airplane reemphasized the need for Safety Recommendation A-03-63. In the same letter, the NTSB stated that between December 22, 2003 (when this recommendation was issued), and February 6, 2006 (the day before the NTSB’s meeting concerning the Hendrick Motorsports accident), we investigated 22 accidents involving Beech King Air aircraft in which no recorder of any type was available. Of these 22 accidents, 9 were fatal; a total of 43 people died. These numbers involved only the model of aircraft involved in the Hendrick Motorsports accident and not all accidents involving the turbine powered, nonexperimental, nonrestricted-category aircraft that this recommendation addresses.
The NTSB’s recommendation letter also documented that aircraft converted from passenger service to cargo operation constitute another category of aircraft that has been a problem. Although these aircraft had 10 or more seats when in passenger service and were required to have a CVR when certificated, the owner mistakenly believed that when the passenger seats were removed for conversion to cargo service, the requirement to carry and/or maintain and use a CVR no longer applied.
On October 14, 2008, the NTSB classified a number of other recommendations based on the FAA’s March 7, 2008, final rule on recorders. Among the recommendations closed in that letter was Safety Recommendation A-99-16, which asked for a 2-hour CVR for new and existing aircraft. At that time, the NTSB indicated that the recommended action would have led to the elimination of recorders that rely on magnetic tape instead of a solid-state recording medium. The NTSB continues to investigate accidents involving aircraft that use this outdated recording mechanism. Tape-based recordings are very unreliable; investigators consistently find it difficult or impossible to extract from them the data needed for accident investigations. The FAA’s decision to exclude from the requirements the retrofits recommended for aircraft operated under Part 135 or Part 91 will leave this problem unaddressed.
In its current letter, the FAA states that the March 7, 2008, final rule requires new CVRs to have a 2-hour recording capacity but does not require a retrofit for Parts 91 or 135 aircraft. The FAA also stated that for Part 91 aircraft required to carry a CVR, the requirement has been effective since October 11, 1991, and the March 7, 2008, final rule mandated this same requirement for Part 135 newly manufactured aircraft that are required to carry a CVR. However, the FAA does not appear to have addressed (as intended in Safety Recommendation A-03-63) the need for CVRs to be required for aircraft certificated for single pilot operation, nor is there any clarification that conversion to cargo operation does not remove the requirement to equip, maintain, and use the CVR. The failures of the final rule to address the NTSB’s concerns and the FAA’s decision not to clarify that cargo operations are also required to carry and use operational CVRs do not satisfy Safety Recommendation A-03-63. Consequently, the recommendation is classified CLOSED—UNACCEPTABLE ACTION.
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