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Safety Recommendation Details

Safety Recommendation A-04-004
Details
Synopsis: On January 8, 2003, about 0847:28 eastern standard time, Air Midwest (doing business as US Airways Express) flight 5481, a Raytheon (Beechcraft) 1900D, N233YV, crashed shortly after takeoff from runway 18R at Charlotte-Douglas International Airport, Charlotte, North Carolina. The 2 flight crewmembers and 19 passengers aboard the airplane were killed, 1 person on the ground received minor injuries, and the airplane was destroyed by impact forces and a postcrash fire. Flight 5481 was a regularly scheduled passenger flight to Greenville-Spartanburg International Airport, Greer, South Carolina, and was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Adopt a program for performing targeted surveillance and increased oversight of maintenance practices at 14 Code of Federal Regulations Part 121 air carriers to ensure that maintenance instructions are being followed as written and that maintenance personnel (including, but not limited to, management, quality assurance, tooling, and training personnel, as well as mechanics) are following all steps in the instructions unless authorization has been granted in accordance with the air carrier's maintenance program.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Charlotte, NC, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA03MA022
Accident Reports: Loss of Pitch Control During Takeoff Air Midwest Flight 5481, Raytheon (Beechcraft) 1900D, N233YV
Report #: AAR-04-01
Accident Date: 1/8/2003
Issue Date: 3/5/2004
Date Closed: 7/1/2008
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Maintenance, Oversight

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/1/2008
Response: The FAA previously described special emphasis surveillance programs that it had implemented in 2004 and 2005 and had subsequently completed to evaluate Part 121 airline outsourced maintenance management and oversight. In response, the Safety Board stated that this recommendation applied to all maintenance, not only to outsourced maintenance. Pending implementation of a similar program for maintenance performed by an airline’s own staff at its own facilities, Safety Recommendation A-04-4 remained classified Open Acceptable Response. In its current letter, the FAA indicated that the intent of this recommendation is one of the foundations of the air transportation oversight system (ATOS). Performance assessment is the ATOS function that ensures operational safety. FAA inspectors conduct performance assessments to confirm that maintenance instructions are being followed as written and that maintenance personnel are following all steps given in the instructions. The FAA believes that ATOS elements 1.3.1 (Maintenance Program) and 1.3.2 (Inspection Program) address the substance of this recommendation. The safety attribute inspections for these elements address whether systems are in place to implement solid maintenance and inspection programs. The element performance inspections are then used by FAA aviation safety inspectors to observe maintenance and inspection programs and determine whether maintenance is being performed in accordance with approved programs. This recommendation was issued because the Air Midwest accident, as well as other maintenance-related aviation accidents investigated by the Safety Board, has shown the need for FAA maintenance inspectors to observe actual maintenance work being performed and to confirm that the correct procedures are being used. Because the Board remains concerned that FAA staffing levels for inspectors may result in inadequate time being available to observe the actual maintenance work being performed, we will be examining this issue carefully in our accide accident investigations. ATOS elements 1.3.1 and 1.3.2 emphasize the need to observe actual work being performed. Through its use of ATOS and the completion of a special emphasis program for outsourced maintenance, the FAA has met the intent of this recommendation. Consequently, Safety Recommendation A-04-4 is classified Closed Acceptable Action.

From: FAA
To: NTSB
Date: 12/7/2007
Response: Letter Mail Controlled 12/18/2007 9:50:02 AM MC# 2070753: Robert Sturgell, Acting Administrator, FAA, 12/7/07 The Federal Aviation Administration initially responded to the recommendation by citing a campaign to review all part 121 air carrier outsourced maintenance programs, an effort initiated in July 2004 and now completed. In the Board’s April 26, 2006 letter, it classified our response as Open-Acceptable Response. In addition to our previous action, the Board recommended that we conduct a similar campaign to review maintenance that is not outsourced. The FAA shares the Board’s concern for ensuring that maintenance is performed in accordance with an air carrier’s approved maintenance and inspection programs, regardless if the maintenance is outsourced or performed directly by the air carrier. In fact, this is a key component of the maintenance surveillance conducted under the Air Transportation Oversight System (ATOS). ATOS is a risk-based system that allows an FAA inspector to review the air carrier’s system based on risk. Currently ATOS is in the process of changing to version 1.2, where the inspections are broken into two types of assessments, performance and design. Performance assessment is the ATOS function that ensures operational safety. FAA inspectors conduct performance assessments to confirm that an air carrier’s operating system produces the intended result, including mitigation or control of hazards and associated risks. ATOS uses time-based performance assessments to detect latent, systemic failures that may occur due to subtle environmental changes. Performance assessment schedules are also adjustable based on known risks or safety priorities. Inspectors use surveillance to provide the FAA with accurate, real-time, comprehensive information for performance assessments and risk management. ATOS elements 1.3.1 (Maintenance Program) and 1.3.2 (Inspection Program) further address the substance of the Board’s recommendation. The safety attribute inspections (SAIs) for these elements address whether air carriers have systems in place to implement solid maintenance and inspection programs. The element performance inspections (EPIs) are then used to examine these systems to ensure that they are working properly. Utilizing the EPIs, FAA aviation safety inspectors observe maintenance and inspection programs and determine whether maintenance is performed in accordance with approved programs. Performance assessments of these two elements using EPIs are required semi-annually and may be accelerated through retargeting resources based on risk assessment. When conducting this surveillance, if an inspector identifies an element that may be a risk, he/she may schedule the carrier for a more in-depth evaluation and on-sight surveillance based upon the amount and severity of the identified risk. The EPIs for elements 1.3.1 Maintenance Program and 1.3.2 Inspection Program can be found at the following Web sites: http://www.faa.gov/safety/programs_initiatives/oversight/atos/library/data_collection/media/e1_3_1_1x_aw.pdf http://www.faa.gov/safety/programs_initiatives/oversight/atos/library/data_collection/media/e1_3_2_1x_aw.pdf As of November 4, 2007, ATOS is in use for 111 air carriers operating under part 121. The remaining eight part 121 air carriers will be transitioned to ATOS by December 31, 2007. In the interim, the surveillance and evaluation program requires principal inspectors of non-ATOS air carriers to use the SAIs and EPIs cited above when maintenance or inspection programs are associated with increased risks. I believe that the FAA has satisfactorily responded to this safety recommendation by adopting the ATOS program, and I look forward to your response.

From: NTSB
To: FAA
Date: 4/26/2006
Response: The Safety Board notes that on July 23, 2004, the FAA issued Notice 8300.115, "Evaluation of Part 121 Air Carrier Outsourced Maintenance Arrangements and Organizational Processes by Non-Air Transportation Oversight System (ATOS) Certificate-Holding District Offices." The Board further notes that a similar memorandum was distributed on June 14, 2004, for ATOS air carriers. These documents implemented special emphasis surveillance programs to evaluate Part 121 airline outsourced maintenance management and oversight. The purpose of these special emphasis programs was (1) to verify that airlines have adequate provisions to manage and oversee organizations with whom they contract to perform maintenance and (2) to validate the effectiveness of the airlines' management and oversight of outsourced maintenance through evaluation of maintenance records and onsite surveillance. In the Board's previous letter concerning this recommendation, dated October 12, 2005, we requested examples of items developed for these special emphasis programs, including an enhanced job aid, a copy of the 2004 National Program Guidelines, and a sample of a completed Element Performance Inspection performed on a Part 121 air carrier under these guidelines. The FAA supplied these items with its current letter. The Board reviewed these items and found them to be acceptable and responsive to part of the recommendation. In the Board's previous letter, we also noted that the FAA had indicated that it would instruct inspectors to conduct their own surveillance of maintenance personnel to ensure air carriers are following all company instructions in the approved maintenance program. The Air Midwest accident, as well as other maintenance-related aviation accidents investigated by the Board, showed a need for FAA maintenance inspectors to observe actual maintenance work being performed and to confirm that the correct procedures have been used. While we commend the FAA for actions taken, the special emphasis programs appear to be limited to outsourced maintenance, while this recommendation covers all Part 121 air maintenance activities, including those performed in an airline's own facilities, by its own staff. To fully meet the intent of this recommendation, a similar special emphasis program is needed for maintenance that is not outsourced; however, we did not see any documents that pertained directly to in-house maintenance. Any such program will similarly need to include a requirement that FAA maintenance inspectors observe actual maintenance work being performed and confirm that the correct procedures have been used. Pending implementation of a similar program for maintenance that is not outsourced, Safety Recommendation A-04-4 remains classified "Open-Acceptable Response."

From: FAA
To: NTSB
Date: 11/17/2005
Response: Letter Mail Controlled 11/30/2005 11:37:53 AM MC# 2050552 Marion C. Blakey, Administrator, FAA, 11/17/05 On July 23, 2004, the Federal Aviation Administration issued Notice 8300.115, Evaluation of Part 121 Air Carrier Outsourced Maintenance Arrangements and Organizational Processes by Non-Air Transportation Oversight System (ATOS) Certificate-Holding District Offices. I have enclosed a copy of the notice for the Board's information. The notice places special emphasis on a surveillance program to evaluate 14 CFR Part 121 air carrier outsourced maintenance management and oversight. Principal maintenance inspectors (PMI) will verify that their assigned certificate holders have adequate provisions to manage and oversee organizations that they have made arrangements to perform maintenance in accordance with 14 CFR 121.363. PMIs will also validate the overall effectiveness of their assigned certificate holders' management and oversight of outsourced maintenance through evaluation of certificate holders' records and on-site surveillance by using system safety tools. A similar memorandum was signed and distributed on June 14, 2004, for ATOS air carriers. I have enclosed a copy of the memorandum for the Board's information. Both the notice and memorandum announce a special emphasis surveillance program for air carrier outsourced maintenance management and oversight. The evaluation had two objectives: "To verify that certificate holders have adequate provisions to manage and oversee organizations with which they have made arrangements to perform maintenance in accordance with 14 CFR 121.363 (hereafter referred to as "outsourced maintenance"); and "To validate the overall effectiveness of their assigned certificate holders' management and oversight of outsourced maintenance through evaluation of certificate holders' records and onsite surveillance by using system safety tools. Inspectors are instructed to use two standardized job aids to assist them in these inspections. I am enclosing a completed Outsource Maintenance Element Performance Inspection record for the Board's information. I have also enclosed a copy of Order 1800.56D, National Flight Standards Work Program Guidelines, for the Board's information. The order restates the policy for developing and executing annual surveillance work programs.

From: NTSB
To: FAA
Date: 10/12/2005
Response: The FAA reported that job aids for its inspectors were enhanced in the 2004 National Program Guidelines, which require inspectors to place special emphasis on compliance with all provisions of the air carrier's maintenance instructions, training, and required inspection item activities. The Safety Board notes that the FAA indicated that the job aids were to be completed by October 31, 2004, but the Board has been unable to obtain copies of these enhanced job aids. The FAA also indicates that it will instruct inspectors to conduct their own surveillance of maintenance personnel to ensure they are following all company instructions in the air carrier's maintenance program. The Air Midwest accident, as well as other maintenance-related aviation accidents investigated by the Board, showed a need for FAA maintenance inspectors to observe actual maintenance work being performed and to confirm that the correct procedures are used. The Board believes the proposed enhancements will address this need. The enhancement of the inspector job aids and the planned areas of emphasis in the 2004 National Program Guidelines are responsive to the intent of the recommendation. The Safety Board requests an example of an enhanced job aid, a copy of the 2004 National Program Guidelines, and a sample of a completed Element Performance Inspection performed on a Part 121 air carrier under these guidelines when they become available. Pending the Safety Board's receipt and review of the requested materials, Safety Recommendation A-04-04 is classified "Open--Acceptable Response."

From: FAA
To: NTSB
Date: 6/18/2004
Response: Letter Mail Controlled 6/28/2004 3:14:12 PM MC# 2040357 In January 2004 the Federal Aviation Administration (FAA) enhanced the job aids Air Transportation Oversight System (ATOS) inspectors utilize to conduct these inspections by issuing revisions to the Safety Attribute Inspection and Element Performance Inspection elements for Maintenance Programs, RII activities, Outsource Organization, and Continuing Analysis and Surveillance Systems (CASS). FAA expanded the job aids to non-ATOS air carriers by requiring the use of the CASS job aid in the 2004 National Program Guidelines. Additionally, the FAA will require inspectors to place special emphasis on compliance with all provisions of the air carrier's required maintenance instructions, maintenance training, and RII activities in the 2004 National Program Guidelines. The Safety Attribute Inspections for these elements provide guidance for FAA inspectors to use when evaluating the design of an air carrier's maintenance program. The Performance Observables Section of the Element Performance Inspections instruct the FAA inspectors to ensure the carrier is conducting oversight of their maintenance personnel or outsourced maintenance personnel, and to confirm that all maintenance policies and procedures are achieving the desired result. The Element Performance Inspections also instruct inspectors to conduct their own surveillance of maintenance personnel to ensure they are following all company instructions in the air carrier's maintenance program. The inspector guidance for these enhanced job aids will be issued in a notice by July 30, 2004, to all air carrier certificate holding district offices requiring the completion of the ATOS and non-ATOS job aids by October 31, 2004.