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Safety Recommendation Details

Safety Recommendation A-04-011
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: Develop detailed on-the-job (OJT) training requirements for 14 Code of Federal Regulations (CFR) Part 121 air carriers that rely on OJT as a maintenance training method. These requirements should include, but not be limited to, best practices, procedures, and methods for accomplishment and administration of this training. Ensure that these OJT requirements are incorporated into 14 CFR Part 121 air carrier maintenance training programs.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Aviation
Location: Charlotte, NC, United States
Is Reiterated: Yes
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:
Addressee(s) and Addressee Status: FAA (Open - Unacceptable Response)
Keyword(s): Maintenance

Safety Recommendation History
From: NTSB
To: FAA
Date: 2/10/2017
Response: We note that, as discussed below regarding Safety Recommendations A-04-15 and A-10-96 and -97, in August 2015, you cancelled your Air Carrier Maintenance Training (ACMT) Programs rulemaking project due to a lack of supporting accident data. You have previously said that, when completed, this rulemaking project would satisfy all of the recommendations discussed in this letter. To satisfy Safety Recommendation A-04-11, you now plan to produce an advisory circular (AC) with best practices for ACMT that will provide clear training standards for OJT training, and you will encourage all Part 121 air carriers to implement the best practices outlined in the AC. You plan to issue the draft AC for public comments soon. The AC, as currently planned, will satisfy this recommendation, but we remain concerned about the very long time this recommendation has remained open. We generally expect that action to satisfy our recommendations will take 3 to 5 years to complete, and Safety Recommendation A-04-11 is now 13 years old. Pending your issuing the AC for best practices for ACMT programs and its inclusion of clear standards related to OJT, Safety Recommendation A-04-11 remains classified OPEN-UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/18/2016
Response: -From Michael P. Huerta, Administrator: Overall FAA Comment. In our May 9, 2014, response, the Federal Aviation Administration (FAA) indicated that we had initiated the Air Carrier Maintenance Training Programs rulemaking project and would be issuing a notice of proposed rulemaking to set clear training standards, including on-the-job training and comprehensive human factors training. This rulemaking effort was cancelled in August 2015 due to a lack of accident data to support rulemaking activities. The FAA plans to produce a best practices Advisory Circular (AC) for air carrier maintenance training that will provide clear training standards for OJT training. The FAA will encourage all 14 CFR Part I21 air carriers to implement the best practices outlined in this AC. We anticipate this document will be ready for public comments by December 30, 2016. I will keep the Board informed of the FAA's progress on this safety recommendation and provide an update by April 2017.

From: NTSB
To: FAA
Date: 7/11/2014
Response: You have been developing Air Carrier Maintenance Training Programs (ACMTP) rulemaking since the project received internal FAA approval, in May 2010. As recently as November 2012, you indicated that the notice of proposed rulemaking (NPRM) for the ACMTP was in senior management coordination and was expected to be published in 2013. On the basis of descriptions in your letters of the revisions planned for inclusion in the NPRM, we have stated that it would address these recommendations, but we have expressed concern for the slow pace of progress in developing and issuing the regulation. We note that the NPRM was not published in 2013 and has subsequently been placed on hold because of limited rulemaking resources within the FAA and changes in priorities to address other unrelated rulemakings mandated by the Congress in the Airline Safety and Federal Aviation Administration Extension Act of 2010 and the FAA Modernization and Reform Act of 2012. Although we acknowledge that these Congressional mandates have resulted in the latest delays to the ACMTP rulemaking, we point out that the recommendations issued as a result of our investigation of the January 8, 2003, accident in Charlotte, North Carolina, are over 10 years old, and there has been little to no progress thus far in responding to them. We remain hopeful that the NPRM will propose the recommended actions, but the continuing delays are not acceptable. Accordingly, pending timely issuance of the ACMTP NPRM and of a final rule that fully satisfies these recommendations, Safety Recommendations A-04-11 and -15 remain classified OPEN—UNACCEPTABLE RESPONSE and Safety Recommendations A-10-96 and -97 are classified “Open—Unacceptable Response.”

From: FAA
To: NTSB
Date: 5/9/2014
Response: -From Michael P. Huerta, Administrator: As mentioned in our previous letter, the Federal Aviation Administration (FAA) initiated the Air Carrier Maintenance Training Programs (ACMTP) rulemaking project, which was approved in May 20 10 by the FAA Rulemaking Council (FRC). The ACMTP Notice of Proposed Rulemaking (NPRM) sets clear training standards to ensure uniform compliance with ACMTPs, including on-the-job training and comprehensive human factors training. A requirement for the FAA to approve (rather than accept) maintenance training programs was added to the NPRM. This NPRM was placed on hold due to limited rulemaking resources and changes in priorities to address the remaining rulemakings mandated by provisions called out in the Airline Safety and Federal Aviation Administration Extension Act of 2010 and the FAA Modernization and Reform Act of2012. The ACMTP NPRM will likely be removed from this hold in 2014. The FAA issued the Air Carrier Contract Maintenance Requirements (ACCMR) NPRM on November 13, 2012 (77 FR 67584). The ACCMR NPRM proposes to require operators to develop policies, procedures, methods, and instructions for performing contract maintenance that are acceptable to the FAA and to include them in their maintenance manuals. The NPRM also proposes to require operators to provide the FAA a list of all persons with whom they contract their maintenance. The ACCMR Final Rule will likely be published in 2015. I will keep the Board informed of the FAA's progress on these recommendations and provide an update by April 30, 2015.

From: NTSB
To: FAA
Date: 2/11/2013
Response: The NTSB notes that the notice of proposed rulemaking (NPRM) has been delayed and is now expected to be published sometime in 2013. We continue to believe that, although the NPRM and advisory circular (AC) may satisfy Safety Recommendations A-04-11 and 15, the delay anticipated for their publication is unacceptable, given that these recommendations were issued nearly 9 years ago. Accordingly, pending our timely receipt and review of both documents, Safety Recommendations A-04-11 and -15 remain classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 11/6/2012
Response: -From Michael P. Huerta, Acting Administrator: As previously stated, the federal Aviation Administration (FAA) initiated the Air Carrier Maintenance Training Program (ACMTP) rulemaking project in May 2010. We also noted that the notice of proposed rulemaking (NPRM) will propose setting clear training standards to ensure uniform compliance with ACMTPs, including OJT and comprehensive human factors training. This rulemaking project continues to be a priority, and we are working expeditiously to publish this NPRM in 2013. In conjunction with the NPRM, we continue to develop advisory material to outline the content and structure of these ACMTPs. I will keep the Board informed of the FAA's progress on these recommendations and provide an update by December 31, 2013.

From: NTSB
To: FAA
Date: 3/6/2012
Response: The NTSB looks forward to reviewing the published NPRM and advisory circular; however, we remain concerned with the continued delays. Accordingly, pending our timely receipt and review of both documents, Safety Recommendations A-04-11 and -15 remain classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 11/16/2011
Response: -From J. Randolph Babbitt, Administrator: The FAA initiated the Air Carrier Maintenance Training Programs (ACMTPs) rulemaking project that was approved in May 20 I0 by the rulemaking council. The NPRM will propose clear training standards to ensure uniform compliance with ACMTPs, including OJT and comprehensive human factors training, as well as requiring FAA approval of ACMTPs. This NPRM was approved by the rulemaking council and is expected to be published by June 30, 2012, for public comment. In addition to the NPRM, the FAA will issue an advisory circular to guide proper implementation. I will keep the Board informed of the FAA's progress on these recommendations, and I will provide an update by October 31, 2012.

From: NTSB
To: FAA
Date: 7/7/2011
Response: The FAA indicated that it is drafting a notice of proposed rulemaking (NPRM) that would propose requiring FAA approval of Air Carrier Maintenance Training Programs (ACMTPs) and would set clear training standards to ensure uniform compliance with ACMTPs and on-the-job training. The FAA also indicated plans to develop additional advisory material that will outline the content and structure of the ACMTPs. The NTSB looks forward to reviewing the published NPRM; however, we remain concerned with the continued delays. Accordingly, pending our timely receipt and review of the NPRM, Safety Recommendations A-04-11 and -15 remain classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 2/15/2011
Response: CC# 201100069: - From J. Randolph Babbitt, Administrator: The Federal Aviation Administration initiated the Air Carrier Maintenance Training Program (ACMTP) ru1emaking project in May 2010. A notice of proposed rulemaking (NPRM) is being developed, which will propose requiring FAA approval of ACMTPs. This NPRM will also set clear training standards to ensure uniform compliance with ACMTPs, including OJT and comprehensive human factors training. This NPRM is expected to be published by the end of summer 2011. In conjunction with this NPRM, the FAA is developing advisory material to outline the content and structure of these ACMTPs, which will include best practices, procedures, and methods for accomplishing and administering OJT. The advisory material will also include further guidance for gaining FAA approval and making revisions to these programs. In previous responses, we have detailed many actions taken by the FAA and industry in the area of human factors programs to reduce the likelihood of human error-induced problems in aviation maintenance. As Safety Recommendation A-04-16 is a very broad based recommendation, the FAA believes that the intent of this recommendation is best met by requiring air carriers to include both initial and recurrent training on human factors in their FAA approved ACMTPs, as described above. I will keep the Board informed of the FAA's progress on these safety recommendations, and I will provide an update by September 30, 2011.

From: NTSB
To: FAA
Date: 5/28/2010
Response: From the greensheet issuing A-10-096 and A-10-097: On June 18, 2004, the FAA indicated that it would develop guidance material in response to these recommendations by October 2007. On October 12, 2005, the NTSB indicated that, pending the revision of 14 CFR 121.375, Safety Recommendations A-04-11 and -15 were classified Open Acceptable Response. On October 26, 2009, the FAA stated that it intended to address these safety recommendations via rulemaking for Part 121 air carrier maintenance organizations and Part 145 repair stations. The FAA indicated that this rulemaking will implement an OJT training program that will include best practices, procedures, methods for accomplishment, and administration of training. Although the NTSB welcomes this planned rulemaking, there has been little progress on these recommendations in the 6 years since they were issued. The NTSB notes that the AWAC incident reinforces the need for clear OJT requirements for those Part 121 carriers that rely on OJT as a maintenance training method and for the FAA to review and approve air carrier maintenance training programs. In the AWAC incident, the maintenance training program was accepted by the FAA. However, the FAA did not have the authority to approve the program. If the FAA had had the authority to approve AWAC’s maintenance training program, some of the unacceptable training practices may have been detected. Therefore, the NTSB reiterates Safety Recommendations A-04-11 and -15 and classifies both OPEN -- UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/26/2009
Response: Letter Mail Controlled 11/11/2009 2:32:07 PM MC# 2090683: - From J. Randolph Babbitt, Administrator: FAA Comment. The Federal Aviation Administration intends to address these safety recommendations via rulemaking for 14 CFR part 121 air carrier maintenance organizations and 14 CFR part 145 repair stations. This rulemaking will implement a coinprehensive integrated human factors program and an on-the-job (OJT) training program that will include best practices, procedures, methods for accomplishment, and administration of training. The rulemaking team is currently working on a Phase I1 rulemalcing project record that they plan to bring to the agency's Rulemaking Council for approval in March 2010. To address these recommendations the FAA has completed the following items to help reduce the lilcelihood of human error in aviation maintenance: New guidance manual, Operator's Manual for Human factors in Aviation Maintenance, October 6,2005 (copy enclosed); I-Iired a Chief Scientist and Technical Advisor for Human Factors in Aircraft Maintenance Systems and an Aviation Safety Inspector as a maintenance human factors subject matter expert. Collectively, they provide human factors lectures at industry workshops, renewals, symposiums, and conferences to educate the aviation community further on many maintenance human factors issues; Co-sponsored four Aviation Maintenance Human factors International Symposiums with the Air Transport Association of America; and Recently developed the Maintenance Human Factors Presentation System that is DVD based and features 170 Powerpoint slides, 11 video snippets, and 40 animation files. The program is a foundation for any organization to provide human factors training in aviation maintenance and is free to anyone who wishes a copy.

From: NTSB
To: FAA
Date: 10/12/2005
Response: The FAA reports that rulemaking activities will be initiated for 14 CFR 121.375 to require that air carrier maintenance training programs be approved by the FAA. The FAA also reports that guidance material for OJT training requirements will be developed in conjunction with this rulemaking process. The Safety Board appreciates the FAA's agreement that maintenance training programs need the same oversight as pilot, dispatcher, and other safety-critical Part 121 training programs. Requiring formal approval will increase the oversight of these crucial training programs throughout the industry and should also ensure that instructional personnel who provide the training are qualified. Because of the wide-ranging direct and indirect benefits of effectively overseeing maintenance training programs, the Board encourages the FAA to place this project high on its rulemaking priority list. Pending the revision of 14 CFR 121.375 to require FAA approval of air carrier maintenance training programs and promulgation of OJT guidance, Safety Recommendations A-04-11 and -15 are 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: - From Marion C. Blakey, Administrator: The FAA will develop guidance material for on-the-job training requirements in conjunction with rulemaking activities for Safety Recommendation A-04-15. It is anticipated that the guidance material will be developed by October 2007.