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Safety Recommendation Details

Safety Recommendation A-05-014
Details
Synopsis: On December 18, 2003, about 1226 central standard time, Federal Express Corporation (FedEx) flight 647, a Boeing MD-10-10F (MD-10),1 N364FE, crashed while landing at Memphis International Airport (MEM), Memphis, Tennessee. The right main landing gear collapsed after touchdown on runway 36R, and the airplane veered off the right side of the runway. After the gear collapsed, a fire developed on the right side of the airplane. Of the two flight crewmembers and five nonrevenue FedEx pilots2 on board the airplane, the first officer and one nonrevenue pilot received minor injuries during the evacuation. The postcrash fire destroyed the airplane’s right wing and portions of the right side of the fuselage. Flight 647 departed from Metropolitan Oakland International Airport, Oakland, California, about 0832 (0632 Pacific standard time) and was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 on an instrument flight rules flight plan.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require all 14 Code of Federal Regulations Part 121 air carrier operators to establish programs for flight crewmembers who have demonstrated performance deficiencies or experienced failures in the training environment that would require a review of their whole performance history at the company and administer additional oversight and training to ensure that performance deficiencies are addressed and corrected.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Memphis, TN, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA04MA011
Accident Reports: Hard Landing, Gear Collapse Federal Express Flight 647, Boeing MD-10-10F, N364FE
Report #: AAR-05-01
Accident Date: 12/18/2003
Issue Date: 5/31/2005
Date Closed: 3/18/2014
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Flightcrew,

Safety Recommendation History
From: NTSB
To: FAA
Date: 3/18/2014
Response: The November 12, 2013, final rule contains requirements in Sections 121.415(h) and (i) that fully satisfy Safety Recommendation A-05-14. Accordingly, the recommendation is classified CLOSED—ACCEPTABLE ACTION.

From: NTSB
To: FAA
Date: 7/15/2011
Response: Notation 8106A: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration's (FAA) supplemental notice of proposed rulemaking (SNPRM) titled "Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers," published at 76 Federal Register 29336-29526 on May 20, 2011. The notice proposes to amend the regulations for flight and cabin crewmember and aircraft dispatcher training programs in domestic, flag, and supplemental operations. The proposed regulations are intended to contribute significantly to reducing aviation accidents by requiring the use of flight simulation training devices (FSTD) for flight crewmembers and including additional training and evaluation requirements for all crewmembers and aircraft dispatchers in areas that are critical to safety. The proposal also reorganizes and revises the qualification, training, and evaluation requirements. The SNPRM is based on the FAA's review of comments submitted in response to the January 12, 2009, notice of proposed rulemaking (NPRM) on these issues and its determination that the NPRM did not adequately address or clarify some topics; it is also based on provisions of the Airline Safety and Federal Aviation Administration Extension Act of 2010. The SNPRM contains provisions to require a carrier's CAP to identify flight crewmembers with demonstrated performance deficiencies or who have experienced training failures and to provide enhanced monitoring and remedial training. If these provisions are enacted in the final rule, they likely will represent an acceptable response, and Safety Recommendation A-05-14 will be closed.

From: NTSB
To: FAA
Date: 2/23/2010
Response: Safety recommendation A-05-014 was reiterated in the accident report: Loss of Control on Approach Colgan Air, Inc. Operating as Continental Connection Flight 3407, Bombardier DHC-8-400, N200WQ, Clarence Center, New York, February 12, 2009, issued on February 23, 2010. On May 17, 2007, the FAA stated that it would consider identifying, in its work program, a list of required inspections that would reemphasize, to regional office and flight standards district office (FSDO) managers, the need to validate the training that was already required and verify its effectiveness. On September 10, 2008, the NTSB stated that such a list would be responsive to the intent of the recommendation as long as the list provided a strong emphasis on the monitoring and workload management components of a crew resource management (CRM) program. The NTSB classified the recommendation OPEN - - ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 1/21/2010
Response: Letter Mail Controlled 1/25/2010 10:00:08 AM MC# 2100025 - From Tony Fazio, Office of Accident Investigation and Prevention, AVP 420: The FAA issued Notice 8900.78, Focused Program Review of Air Carrier Flight Crewmember Training, Qualification and Management, as part of its Airline Safety and Pilot Training Action Plan. This Notice required principal operations inspectors of part 121 air carriers that do not conduct training under an Advanced Qualification Program (AQP) to meet with the carrier’s director of operations, directory of safety, and company officials responsible for flight crewmember training and qualification programs to determine the carrier’s ability to identify, track, and manage low-time flight crewmembers and those who have failed evaluation events or demonstrated a repetitive need for additional training. The FAA did not include airlines with approved AQP as we believe the data analysis required for AQP already meets the intent of SAFQ 06015. The FAA captured the results of this meeting in a national Constructed Dynamic Observation (ConDOR) titled “Special Tracking of Certain Flight Crewmembers.” These inspections were completed by July 15, 2009. The results of the ConDOR were provided to Mr. Roger Cox in response to NTSB information request 09-070.

From: NTSB
To: FAA
Date: 12/12/2007
Response: On September 8, 2005, the FAA informed the Board that it intended to issue a notice recommending that all Part 121 carriers develop and implement a program consistent with the intent of this safety recommendation. On January 19, 2006, the Board replied that issuing a notice would be an acceptable alternative to requiring carriers to have such programs if the FAA surveyed all Part 121 carriers and determined how many had taken the recommended action. Pending issuance of the notice and confirmation that all Part 121 carriers had established the recommended program, Safety Recommendation A-05-14 was classified Open Acceptable Alternate Response. The Safety Board notes that on October 27, 2006, the FAA issued Safety Alert for Operators (SAFO) 06015, Remedial Training for Part 121 Pilots. The SAFO recommends implementation and incorporation of a voluntary remedial pilot training program for Part 121 carriers. With the issuance of the SAFO, the FAA has completed the first part of the alternative action. However, the FAA needs to survey all Part 121 operators to determine that all have taken the recommended action and achieved the intent of this recommendation. Pending the FAA’s conducting the survey and demonstrating that all Part 121 carriers have programs that address performance deficiencies of flight crewmembers who have demonstrated performance deficiencies or experienced failures in the training environment, Safety Recommendation A-05-14 remains classified OPEN - - ACCEPTABLE ALTERNATE RESPONSE.

From: FAA
To: NTSB
Date: 4/13/2007
Response: Letter Mail Controlled 4/27/2007 8:49:34 AM MC# 2070178: - From Marion C. Blakey, Administrator: The Federal Aviation Administration has issued Safety Alert for Operators (SAFO) 06015 (copy enclosed), recommending implementation and incorporation of a voluntary remedial Part 121 pilot training module to supplement an air carriers’ approved training program. Directors of Safety of Part 121 certificate holders that do not have a voluntary remedial training module for pilots should recommend this type of program to top managers of air carriers. This remedial training program should initiate the review of pilot’s performance history, provide additional remedial training and engage the representatives of pilots to accomplish the objectives of SAFO 06015. I believe that the FAA has satisfactorily responded to this safety recommendation, and I look forward to your response.

From: NTSB
To: FAA
Date: 1/19/2006
Response: The FAA stated that many 14 CFR Part 121 air carriers already have voluntary programs of review, oversight, and remedial training. The FAA further stated that it will issue a notice recommending that all 14 CFR Part 121 certificate holders develop and implement a program consistent with the intent of this safety recommendation. The Safety Board believes that the FAA's proposed action of issuing a notice instead of requiring the establishment of these programs may be an acceptable alternative, so long as the FAA can readily report to the Board how many carriers have established a program. Pending issuance of the notice and confirmation that all Part 121 carriers have established the recommended program, Safety Recommendation A-05-14 is classified OPEN - - ACCEPTABLE ALTERNATE RESPONSE.

From: FAA
To: NTSB
Date: 9/8/2005
Response: Letter Mail Controlled 9/14/2005 3:07:09 PM MC# 2050430 - From Marion C. Blakey, Administrator: The Federal Aviation Administration agrees with the intent of this safety recommendation. Many 14 CFR Part 121 certificate holders already have, in place, voluntary programs of review, oversight, and remedial training developed in cooperation with their respective pilots' collective bargaining unit representatives. These voluntary programs have been shown to be effective. The FAA will issue a notice by December 2005 recommending that all 14 CFR Part 121 certificate holders develop and implement a program consistent with the intent of this safety recommendation. I will provide the Board with a copy of the notice as soon as it is issued.

From: NTSB
To: FAA
Date:
Response: At the February 18, 2010 Board meeting addressing the NTSB’s Most Wanted List of Transportation Safety Improvements (MWL), the Board voted to place Safety Recommendations A-05-01 and A-05-14 on the Federal MWL under the issue category “Improve Oversight of Pilot Proficiency.”