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Safety Recommendation Details

Safety Recommendation A-04-015
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: Require that all 14 Code of Federal Regulations Part 121 air carrier maintenance training programs be approved.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
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: 2/10/2017
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s): Maintenance

Safety Recommendation History
From: NTSB
To: FAA
Date: 2/10/2017
Response: We issued these recommendations because ACMT programs are accepted by the FAA rather than approved by the FAA. Before a program is approved, an FAA inspector has considerable authority to influence the carrier to make needed changes to their ACMT program. In contrast, when a program is accepted, the FAA inspector has considerably less authority to require changes to the carrier’s ACMT program. A major change planned for the ACMT rulemaking was to require that ACMT training programs be approved rather than just accepted. Implementing that change would have satisfied these recommendations. However, as a result of a 2014 reevaluation, you cancelled the ACMT programs rulemaking project in 2015. When you performed your original regulatory analysis in 2011, you believed the planned rule would have mitigated 35 past accidents. In 2014, you reevaluated the accidents used in the original regulatory evaluation and found that only two would have been mitigated. In addition, these two accidents did not occur within the segment of the industry that would have been the subject of the rule (that is, Part 121 carriers). In your letter, you said that you believe that your recently implemented Safety Assurance System (SAS) is an alternative approach that satisfies our recommendations. ACMT training programs are part of an air carrier’s continuous airworthiness maintenance program, which is required for a carrier to be acceptable to the FAA. The acceptability of the ACMT program is evaluated using information collected with SAS data collection tools ED 4.1.3 and EP 4.1.3, and by using the procedures in FAA Order 8900.1, “Flight Standards Information Management System,” volume 3, chapter 24, section 1, “Safety Assurance System: Training Program Evaluation.” The procedures in Order 8900.1 require FAA aviation safety inspectors (ASIs) to evaluate the design and performance of Part 121 ACMT programs. In issuing these recommendations, we were emphasizing that a carrier’s ACMT program needs a more thorough review than that likely to occur with a program that an ASI could not require to be revised. With the implementation of SAS, procedures are now in place to collect and evaluate specific information about the ACMT programs that are accepted. That is the level of review that we anticipated would result from requiring that the training program be approved; although, because the programs continue to be accepted rather than approved, ASIs will still not be able to compel carriers to revise their ACMT programs. We believe that if your SAS review of a carrier’s ACMT program reveals problems, the ASI is likely to discuss the issues identified with the carrier, and the carrier is likely to revise the program to address the issues of concern. Therefore, we agree with you that implementing the SAS procedures described in your letter is an alternative approach that satisfies these recommendations. As a result, Safety Recommendations A-04-15 and A-10-96 and -97 are classified CLOSED—ACCEPTABLE ALTERNATE ACTION.

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 Air Carrier Maintenance Training Programs rulemaking project was cancelled in August 2015 due to a lack of accident data to support rulemaking activities. The FAA expected the proposed required training would have mitigated 3 5 past accidents in the 2011 regulatory evaluation of the rulemaking. During a 2014 reevaluation of the accidents used in the original regulatory evaluation, the FAA found only two accidents that would have been mitigated by the proposed rule; however, these accidents did not occur within the proposed regulated community. In order to satisfy the intent of this safety recommendation, the FAA has developed alternative actions. The FAA's Safety Assurance System (SAS) provides standardized criteria to evaluate air carrier's maintenance training programs, which includes system safety attributes. The FAA applies SAS as a risk-based, data-supported system to conduct oversight that validates the certificate holder's ability to manage risk and achieve safety objectives. The implementation of system safety principles into a part 12 I air carrier's program started in 1998 with the Air Transportation Oversight System (A TOS) for large and complex carriers. However, smaller part 121 air carriers were not transitioned into the ATOS until much later. All part 121 carriers were completely transitioned into the A TOS by December 31, 2007. The ATOS has evolved and been enhanced into the SAS. As of December 3 1, 2015, all part 12 I carriers have been transitioned into the SAS. Currently, there is no regulatory requirement for the approval of part I2I air carrier maintenance training programs. However, the maintenance training program is part of the air carrier's Continuous Airworthiness Maintenance Program, which is required to be acceptable to the FAA Administrator. The acceptability of this program is monitored through the Safety Assurance System Data Collection Tools ED 4.1.3 and EP 4.1.3, in accordance with FAA Order 8900.1, Flight Standards Information Management System, Volume 3, Chapter 24, Section I , Safety Assurance System: Training Program Evaluation. This Order requires FAA Aviation Safety Inspectors to evaluate the design and performance of the part 121 air carrier maintenance training program. The FAA has determined that the current regulations and guidance are sufficient alternatives to rulemaking and satisfy the intent of this recommendation. Therefore, we consider our actions complete and request closure.

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 initiate rulemaking activities on 14 CFR 121.375 to require air carrier maintenance program to be approved by the FAA. It is anticipated that this effort will be completed by October 2007.