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General Aviation Safety
On July 13, 2003, about 1530 eastern daylight time, Air Sunshine, Inc. (doing business as Tropical Aviation Services, Inc.), flight 527, a Cessna 402C, N314AB, was ditched in the Atlantic Ocean about 7.35 nautical miles west-northwest of Treasure Cay Airport, Treasure Cay, Great Abaco Island, Bahamas, after the in-flight failure of the right engine. Two of the nine passengers sustained no injuries, five passengers and the pilot sustained minor injuries, and one adult and one child passenger died after they evacuated the airplane. The airplane sustained substantial damage. The airplane was being operated under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as a scheduled international passenger commuter flight.
TO THE FEDERAL AVIATION ADMINISTRATION: Develop specific criteria regarding the number of accidents and/or incidents that would cause an increase in oversight of an operator.
Original recommendation transmittal letter:
Closed - Acceptable Action
Treasure Cay, Bahamas
In-Flight Engine Failure and Subsequent Ditching Air Sunshine, Inc., Flight 527, Cessna 402C, N314AB, About 7.35 Nautical Miles West-Northwest of Treasure Cay Airport
Addressee(s) and Addressee Status:
FAA (Closed - Acceptable Action)
Safety Recommendation History
On September 26, 2008, the FAA revised Order 1800.56J, “National Flight Standards Work Program Guidelines,” to require that principal inspectors of Part 135 carriers use the Surveillance Priority Index (SPI) to develop a planned surveillance program. The SPI considers the number of incidents and fatal and non-fatal accidents a carrier has experienced within the last 3 years, among other factors, to determine a carrier’s SPI score. Accidents and incidents increase a carrier’s score, leading to increased surveillance. This system links accident and incident data with the level of oversight a carrier receives, as recommended. Accordingly, Safety Recommendation A-05-9 is classified CLOSED -- ACCEPTABLE ACTION.
Letter Mail Controlled 8/9/2010 10:46:01 AM MC# 2100267 - From J. Randolph Babbitt, Administrator: In the Board's last letter dated January 18, 2006, it was noted that the Federal Aviation Administration has not developed sufficient criteria to determine if increased oversight of an operator is required. The FAA has fulfilled this safety recommendation by publishing FAA Order 1800.56J, National Flight Standards Work Program Guidelines, on September 26, 2008 (enclosure 1). This order requires that principal inspectors (PI) who provide surveillance of part 135 operators use the Safety Performance Analysis System (SPAS) for safety assessment, surveillance planning, decision making, certification, and investigation, as appropriate. SPAS functions as the prime aviation safety database incorporating a range of government-provided aviation safety data. SPAS is a major tool for managing a risk-based work program and is the foundation for a data-driven approach to safety. The Surveillance Priority Index (SPI) is a tool within SPAS that provides the PI with 19 SPAS derived criteria and 9 PI derived criteria to determine the level of additional oversight of an operator. We have enclosed an example SPI report showing the factors and criteria on which an operator is rated (enclosure 2), and a further description of PI assessment factors (enclosure 3). We successfully use the SPI to determine the level of additional oversight required by each operator. I believe the FAA has effectively addressed this safety recommendation, and I consider our actions complete.
The FAA states that the purpose of its oversight program is to verify that air carriers comply with regulatory standards and that FAA surveillance programs are not quality control programs, which is the air carrier's responsibility. The FAA also states that analysis of systemic causes of accidents and incidents is important and it factors these systemic causes into adjusting its surveillance programs. The FAA plans to amend FAA Order 1800.56, "National Program Guidelines," to require principal inspectors to consider accident/incident trends, patterns, and factors when developing their planned surveillance programs. The Safety Board does not understand why the FAA indicates that its oversight program is not intended as a quality control program. The Board believes that even if there are no violations of FAA regulatory programs, increased numbers of accidents and incidents are indicative of a safety problem, and that the FAA's oversight program needs to ensure that the safety problem is resolved. The Board notes that the FAA will revise its oversight program guidelines to consider accident/incident trends. The Board reiterates that this recommendation asks for the development of specific criteria regarding the number of accidents and/or incidents that indicate a need for increased oversight. Pending the development of specific criteria regarding the number of accidents and/or incidents that indicate a need for increased oversight, Safety Recommendation A-05-9 is classified OPEN -- ACCEPTABLE RESPONSE.
Letter Mail Controlled 8/22/2005 10:56:53 AM MC# 2050386: - From Marion C. Blakey, Administrator: The focus of FAA's oversight program is to verify that air carrier systems comply with regulatory standards and to validate that those programs perform as intended. FAA surveillance programs are not quality control programs--quality control is an air carrier function. Analysis for the identification of systemic causes of accidents and incidents is important. The FAA factors these systemic causes into adjusting its surveillance programs. The FAA will amend FAA Order 1800.56, National Program Guidelines, for fiscal year 2007 to require principal inspectors to consider accident/incident trends, patterns, and factors when developing their planned surveillance programs. I will keep the Board informed of the FAA's progress on this safety recommendation.
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