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Safety Recommendation Details

Safety Recommendation A-04-016
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 14 Code of Federal Regulations Part 121 air carriers implement comprehensive human factors programs to reduce the likelihood of human error in aviation maintenance.
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: There are two actions needed to satisfy this recommendation. First, carriers must implement training programs for their maintenance personnel about human factors issues that may cause errors during aviation maintenance activities. The second action concerns other aviation maintenance human factors issues, such as tooling and workspace layouts, required signoffs and inspections, and work shift change procedures. With regard to training maintenance personnel, we note that you accept, rather than approve, ACMT programs; however, your SAS program evaluates and monitors human factors training in ACMT programs. The procedures for this monitoring are described in FAA Order 8900.1, volume 3, chapter 24, section 2, “Safety Assurance System: Evaluate and Accept a Maintenance Human Factors Training Program,” and the procedures use information collected through SAS data collection tools ED 4.1.3 and EP 4.1.3. When accepting an ACMT program, ASIs are required to determine whether the program includes needed human factors content. We believe that if an ASI identifies issues with an ACMT program’s human factors training, the ASI will discuss these issues with the carrier, and the carrier will be likely to revise the ACMT program to address the issues. This is an acceptable alternative that satisfies the first component of this recommendation. With regard to other human factors components in an air carrier’s maintenance program, we note that you are updating the guidance material in FAA Order 8900.1 and AC 120 72, “Maintenance Resource Management Training,” to include the latest human factors information and research. You are also developing an AC that will address fatigue risk management in aircraft maintenance activities. Finally, we note that you provide additional information and resources on maintenance human factors through a public website that includes videos, presentations, and training aids. Although you have addressed human factors training in aviation maintenance (and continue to do so), the time it has taken you to complete these actions is unacceptable. As with Safety Recommendation A-04-11, this recommendation is 13 years old, and we generally expect that actions to satisfy our recommendations will be completed in 3 to 5 years. Pending completion of the revisions to FAA Order 8900.1 and AC 120-72, and your issuing the new AC on aviation maintenance fatigue risk management, Safety Recommendation A-04-16 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. All part 121 air carriers are encouraged to adopt and implement a comprehensive maintenance human factors training program. Currently, these programs are accepted by the FAA through an extensive evaluation process outlined in FAA Order 8900.1, Volume 3, Chapter 24, Section 2, Safety Assurance System: Evaluate and Accept a Maintenance Human Factors Training Program. This program is continuously monitored by the FAA through SAS Data Collection Tools ED 4.1.3 and EP 4.1.3. The SAS Data Collection Tools require that Aviation Safety Inspectors determine if the air carrier includes human factors in the accepted maintenance training program, and a negative response may result in elevated risk for the maintenance training element. As of December 31, 2015, all part 121 carriers have been transitioned into the SAS. The FAA is in the process of updating the guidance material in FAA Order 8900.1 and AC 120-72, Maintenance Resource Management Training, to include the latest human factors information and research. The update is being coordinated closely with the FAA's Chief Scientific and Technical Advisor for Human Factors in Aircraft Maintenance Systems and will include the addition of an AC for Aircraft Maintenance Fatigue Risk Management. The FAA provides additional information and resources on maintenance human factors through a public Web site (http://www.faa.gov/about/initiatives/maintenance_hf/). These resources include videos, presentations, and training aids. 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: Since this recommendation was issued, you have responded that you planned to require air carriers to include both initial and recurrent training on human factors in their FAA-approved ACMTPs, and you have provided periodic updates on your progress in developing and issuing the NPRM. We have consistently replied that, although training can constitute an effective component of a human factors program, human factors considerations are not confined to training. A program that addresses training alone would not satisfy the recommendation; accordingly, the recommendation has been classified “Open—Unacceptable Response.” In addition to training mechanics on human factors considerations in their work, an acceptable response to Safety Recommendation A-04-16 will involve explicit consideration by the operator of human factors issues in maintenance operations. In our investigation of the AWAC incident that was the basis for reiterating this recommendation on May 28, 2010, we found that, at the time of the incident, AWAC offered a human factors training program for new hires that consisted of an 8 hour presentation covering a range of topics, including communication, fatigue, and shift turnovers. However, other human factors issues that contributed to the incident were not adequately addressed in the training. Among these issues were the challenges mechanics faced when working in a confined space with limited lighting, and the importance of using a flashlight and mirror to ensure that tasks were completed successfully. We invite you to show us how FAA inspectors are trained to consider these issues, the guidance available to your inspectors on human factors in maintenance operations, and how you provide appropriate oversight (for example, through the air transportation oversight system) to ensure that approved maintenance programs have adequately incorporated consideration of human factors issues. Pending our receipt of information showing that human factors are among the evaluation components you use in approving a carrier’s maintenance program, Safety Recommendation A 04-16 remains 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: As we have indicated in previous correspondence, although training can be an effective component of a human factors program, human factors considerations encompass more than this element. Therefore, the FAA’s plan to require that air carriers include both initial and recurrent training on human factors in their FAA-approved air carrier maintenance training programs will not, by itself, satisfy the intent of this recommendation. Accordingly, pending the FAA’s instituting a requirement for air carriers to implement comprehensive human factors programs, Safety Recommendation A-04-16 remains classified OPEN—UNACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 1/29/2013
Response: -From the aircraft accident report Loss of Control, Sundance Helicopters, Inc. Eurocopter AS350-B2, N37SH, Near Las Vegas, Nevada, December 7, 2011, report adopted on January 29, 2013: 3.2.3 Lack of Human Factors Training for Maintenance Personnel Currently, federal regulations do not require maintenance personnel to receive human factors training. However, some foreign authorities do require human factors training for their maintenance personnel and have developed human factors guidance and curriculums that address various issues, including fatigue. The NTSB has not previously made a specific recommendation that maintenance personnel should be provided human factors or fatigue training. However, on March 5, 2004, as a result of the January 8, 2003, accident in which a Raytheon (Beechcraft) 1900D, operated by Air Midwest (doing business as US Airways Express) as flight 5481, crashed shortly after takeoff from runway 18R at Charlotte-Douglas International Airport, Charlotte, North Carolina, the NTSB issued Safety Recommendation A-04-16, which asked the FAA to do the following: Require that 14 Code of Federal Regulations Part 121 air carriers implement comprehensive human factors programs to reduce the likelihood of human error in aviation maintenance. On June 18, 2004, the FAA agreed that a human factors component should be part of a maintenance training program and stated that it would address this recommendation via future guidance and rulemaking on air carrier maintenance training programs. On October 12, 2005, the NTSB stated that its recommendation for a human factors program was broader than simply providing human factors training to maintenance personnel and, therefore, classified Safety Recommendation A-04-16 “Open?Unacceptable Response.” Subsequent FAA correspondence on Safety Recommendation A-04-16 described the development and availability of guidance material on maintenance human factors and outreach activities in this area. On February 15, 2011, the FAA reasserted its position that the best strategy to address this recommendation was through a requirement for initial and recurrent training in maintenance human factors. The FAA further stated that it had initiated the Air Carrier Maintenance Training Program rulemaking project to develop a notice of proposed rulemaking (NPRM) proposing to require the approval of air carrier maintenance training programs and set clear training standards that include comprehensive human factors training. On July 7, 2011, the NTSB acknowledged that training could be an effective component of a human factors program but stated that pending a requirement for air carriers to implement comprehensive human factors programs, Safety Recommendation A-04-16 would remain classified “Open?Unacceptable Response.” On November 16, 2011, the FAA stated that the NPRM addressing air carrier maintenance training programs that includes comprehensive human factors training and FAA approval of maintenance training programs was expected to be published by June 30, 2012. On March 6, 2012, the NTSB reiterated its position and classification of Safety Recommendation A-04-16. Therefore, although the FAA has developed substantial guidance for the industry about maintenance human factors in the almost 9 years that have elapsed since Safety Recommendation A-04-16 was issued and has repeatedly stressed the importance of human factors training as a way to address the intent of this recommendation, there remains no requirement for human factors training for maintenance personnel involved in air carrier operations. On November 6, 2012, the FAA provided an update stating that it expected to issue the NPRM sometime in 2013. The NTSB notes that the FAA issued an NPRM on May 21, 2012, proposing that repair stations operating under 14 CFR Part 145 provide human factors training relevant to aviation maintenance for employees performing maintenance, preventive maintenance, alterations, or inspection functions. However, if adopted, the rule would not require maintenance personnel working for Part 121 and 135 operators or Part 91 Subpart K programs to receive human factors training. The FAA has also developed guidance, which contains sample educational materials, that addresses human factors affecting maintenance personnel, including ways to prevent fatigue during maintenance activities, in its online resources addressing human factors in maintenance and inspection. As discussed in section 3.2.1.2, one strategy to prevent human error in maintenance resulting from fatigue is through the implementation of duty-time limitations. Another important strategy to help reduce the risk of fatigue-related errors in maintenance is to train and educate maintenance personnel through human factors training, including training on the causes of fatigue, its effects on performance, and actions individuals can take to prevent the development of fatigue. The NTSB concludes that all maintenance personnel would benefit from receiving human factors training, including training on the causes of fatigue, its effects on performance, and actions individuals can take to prevent the development of fatigue, which would help to reduce the likelihood of human errors in aviation maintenance. Because comprehensive human factors programs could reduce the likelihood of human error in aviation maintenance, the NTSB reiterates Safety Recommendation A-04-16. Further, the NTSB recommends that the FAA require that personnel performing maintenance or inspections under 14 CFR Parts 121, 135, 145, and 91 Subpart K receive initial and recurrent training on human factors affecting maintenance that includes a review of the causes of human error, including fatigue, its effects on performance, and actions individuals can take to prevent the development of fatigue.

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: As we have indicated in previous correspondence, although training can be an effective component of a human factors program, human factors considerations encompass more than this element. Therefore, the FAA’s plan to require that air carriers include both initial and recurrent training on human factors in their FAA-approved air carrier maintenance training programs will not, by itself, satisfy the intent of this recommendation. Accordingly, pending the FAA’s instituting a requirement for air carriers to implement comprehensive human factors programs, Safety Recommendation A-04-16 remains 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 NTSB notes the FAA’s plan to require that air carriers include both initial and recurrent training on human factors in their FAA-approved ACMTPs. We point out that training can be an effective component of a human factors program; however, human factors considerations are not confined only to training. Therefore, a program limited only to training will not satisfy the intent of this recommendation. In addition, we believe that guidance highlighting the specific topics to be addressed in the training program is needed. In a recent investigation of an incident involving Air Wisconsin Airlines Corporation (AWAC), we found that AWAC offered a human factors training program for new hires that consisted of an 8-hour presentation covering a wide range of topics, including communication, fatigue, and shift turnovers. However, some of the topics did not specifically address human factors issues related to aircraft maintenance, and the exercises did not necessarily correlate to real-world experiences that mechanics might face. Although the presentation provided knowledge of human factors issues, it did not encourage skill development in how to prevent human factors events. The NTSB believes that the training would have been more useful if it had discussed, for example, the challenges mechanics face when working in a confined space with limited lighting and the importance of using a flashlight and mirror to ensure that tasks are completed successfully. Pending the FAA’s instituting a requirement for air carriers to implement comprehensive human factors programs, Safety Recommendation A-04-16 remains 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 stated that it would issue guidance on human factors training. However, in its October 12, 2005, response, the NTSB indicated that it was concerned that the FAA did not understand the intent of the recommendation, which was to add a comprehensive human factors program to aviation maintenance programs. The NTSB noted that human factors considerations are not just confined to training and that a program limited to training will not satisfy the intent of this recommendation. Safety Recommendation A-04-16 was classified “Open—Unacceptable Response.” On October 26, 2009, the FAA indicated that the planned rulemaking for Part 121 air carrier maintenance organizations and Part 145 repair stations would also address human factors issues in these programs. The FAA stated that, to address this recommendation until the rulemaking was completed, it issued guidance material in October 2005 on human factors in aviation maintenance, co-sponsored four aviation maintenance human factors symposia, and developed and distributed to the aviation industry guidance material on human factors considerations and training for aviation maintenance operations. The investigation of the AWAC incident revealed that AWAC offered a human factors training program for new hires that consisted of an 8-hour PowerPoint presentation covering a wide range of topics, including communication, fatigue, and shift turnovers. The NTSB’s investigation revealed that some of the topics did not relate specifically to maintenance human factors issues, and the exercises did not necessarily correlate to real-world experiences that mechanics might face. The presentation provided knowledge of human factors issues but did not encourage skill development of how to prevent human factors events. For example, the training would have been more useful if it had discussed the challenges faced when working in a confined space with limited lighting and the importance of using a flashlight and mirror to ensure tasks are completed successfully. As part of implementing Safety Recommendation A-04-16, the FAA should provide guidance on what topics, specifically, to include in human factors training. The NTSB concludes that the guidance material produced and distributed by the FAA did not provide sufficiently detailed information to use in creating an acceptable maintenance human factors program or to be used by an FAA inspector to review such a program if it were required. Safety Recommendation A-04-16 was issued almost 6 years ago, and the FAA has not yet adequately addressed this recommendation. Therefore, the NTSB reiterates Safety Recommendation A-04-16. (Safety Recommendation A-04-16 remains classified 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: In response to this recommendation, the FAA stated that it agrees that a human factors component should be part of a maintenance training program (emphasis added). The FAA further states that it will accomplish this recommendation in conjunction with Safety Recommendation A-04-15 and issue guidance in conjunction with the rulemaking. The Safety Board is concerned that the FAA does not understand the intent of this recommendation, which asks that the FAA require the addition of a comprehensive human factors component in aviation maintenance programs. Although there are human factors considerations in aviation maintenance training, many human factors issues in aviation maintenance are not related to training. For example, FAA-sponsored meetings about human factors in aviation maintenance have identified numerous human factors issues such as availability of proper technical reference documents and guidance, availability of proper and appropriate tools and fixtures, and procedures related to continuation of work from one shift to the next. A program limited to only training is not responsive to this recommendation. Pending the recommended action being taken, Safety Recommendation A-04-16 is classified OPEN -- UNACCEPTABLE 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 agrees that a human factors component should be part of a maintenance training program. The FAA will accomplish this recommendation in conjunction with Safety Recommendation A-04-15 and issue guidance that is in conjunction with the rulemaking. It is anticipated that the guidance will be available by October 2007.