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General Aviation Safety
On November 28, 2004, a Canadair, Ltd., CL-600-2A12, operated by Air Castle Corporation doing business as Global Aviation Glo-Air flight 73, crashed into the ground during attempted takeoff in snowing col~ditions at Montrose Regional Airport (MTJ), Montrose, Colorado. Before the accident flight, the airplane had arrived at MTJ from Van Nuys, California. The airplane remained parked at MTJ for about 45 minutes while wet snow fell in subfreezing temperatures, and the airplane was not deiced before takeoff. The captain, the flight attendant, and one passenger were killed; the first officer and two passengers received serious injuries; and the airplane was destroyed by impact forces and a postcrash fire. The on-demand charter flight was operated under the provisions of 14 Code ofFederal Regulations (CFR) Part 135.
TO THE FEDERAL AVIATION ADMINISTRATION: Develop visual and tactile training aids to accurately depict small amounts of upper wing surface contamination and require all commercial airplane operators to incorporate these training aids into their initial and recurrent training.
Original recommendation transmittal letter:
Closed - Unacceptable Action
Montrose, CO, United States
Crash During Takeoff in Icing Conditions, Canadair, Ltd., CL-600-2A12, N873G
Addressee(s) and Addressee Status:
FAA (Closed - Unacceptable Action)
Icing, Training and Education, Weather
Safety Recommendation History
The FAA previously responded that it had issued various guidance documents that it believed met the intent of this recommendation. In our reply, the NTSB emphasized that none of the FAA's documents addressed the intent of this recommendation, which was to develop visual and tactile training aids to accurately depict small amounts of upper wing surface contamination. Accordingly, on March 3, 2007, the recommendation was classified "Open-Unacceptable Response." In its current letter, the FAA asked the NTSB to reconsider this classification and to consider additional actions the FAA has taken recently, including the issuance of Information for Operators (InFO) document 09016 and a final rule that removed the allowance for polished frost. The NTSB has reconsidered the FAA's response, but we continue to believe that it is difficult or impossible with words alone to convey to pilots the small amounts of upper wing ice contamination that can have a significant aerodynamic performance impact. However, through the development of accurate pictures and tactile training aids, pilots can be educated on what they need to look for when flying. The NTSB also believes that the FAA's concerns about negative training are misplaced. We believe that negative training may occur when pilots fly through ice and come to believe that they can safely fly through icing conditions that appear to be less extreme but are, in fact, more dangerous. If these pilots were exposed to a visual and/or tactile training aid giving them some exposure to how dangerous some benign-appearing ice accumulations are, they would be better prepared to make decisions. However, because the FAA has indicated that it does not plan to take any further action to address this recommendation, Safety Recommendation A-06-42 is classified CLOSED – UNACCEPTABLE ACTION.
Letter Mail Controlled 6/3/2010 10:56:21 AM MC# 2100191 - From J. Randolph Babbitt, Administrator: In the Board's letter dated March 8, 2007, it stated that Federal Aviation Administration actions in response to Safety Recommendation A-06-42 were classified "Open-Unacceptable Response." We are asking you to reconsider your response. In our previous response, we provided references to several publicly available guidance documents issued or revised by the FAA to emphasize the identification and removal of even small amounts of contamination from the aircraft critical surfaces. These documents were issued with the intent of providing more specific guidance to the industry on this significant issue and addressing the concern raised by this safety recommendation. The revised documents were Advisory Circular 120-60B, Ground Deicing and Anti-icing Program and the Aeronautical Information Manual. Documents issued to address the concern raised by the Board in Safety Recommendation A-06-42 included, Notice 8000.308, Reevaluation of Deicing/ Anti-Icing Programs and Safety Alert for Operators 06002, Ground deicing practices for turbine aircraft in nonscheduled 14 CFR Part 135 operations and in Part 91. Specific to the Board's recommendation on October 1, 2009 we issued Information for Operators (InFO) 0901 6 "Identifying Small Amounts of Frost, Snow, Ice or Slush on Aircraft and the Effects on Aircraft Control and Performance" (copy enclosed). On December 1, 2009 the FAA published the final rule which removed the allowance for polished frost from $5 91.527, 135.227 and 125.221\ (copy enclosed). This rule change should help remedy the false belief that operations with small amounts of frost are acceptable. The FAA recognizes that these guidance documents and rule changes do not specifically address the Board's request for the development and use of visual and tactile training aids, but we believe these documents provide the same safety benefit. The FAA has not discounted your recommendation for the development of visual and tactile training aids. We have discussed this across the relevant lines of business and determined that it is not feasible to develop training aids to cover all possible contamination conditions. If training aids do not address all possible combinations of aircraft surface textures and contaminate conditions, then the unintended consequence of negative training may occur. The best training aid for any particular aircraft is the aircraft itself. The FAA discusses the use of an aircraft for training in the InFO, which addresses the recognition and removal of even very small amounts of contamination from the critical surfaces of an aircraft. Additionally, the FAA is concerned that it does not have a process or specific authorization to control the production, quality, and accuracy of such training aids. Without the ability to provide the necessary quality control of these training aids, the FAA is again concerned that the risk for negative training outweighs the benefit. In summary, the FAA has previously provided guidance to operators and pilots to have procedures to detect small amounts of contamination on the critical surfaces of the aircraft and has emphasized the necessity for the removal of all levels of contamination prior to flight. The recent rule changes that removed the allowance for polished frost, further address the false impression by some that small amounts of frost are acceptable for operations. Additionally, the InFO provides more detailed guidance on recommended contamination recognition techniques and reemphasizes the need to remove all contamination from aircraft critical surfaces, regardless of how spotty or thin the contamination may be. This InFO calls for the use of an actual aircraft as a training tool instead of a training aid. The FAA does not believe a training aid that accurately represents the various aircraft surface textures and forms, thicknesses, and spottiness of contamination can be developed. Aside from the InFO and final rule the FAA plans no furtheraction to address Safety Recommendation A-06-42.
In its November 1, 2006, letter, the FAA stated that in response to this recommendation, it had recently made several changes to various documents, including Advisory Circular 120-60B, Notice N8000.308, Safety Alert for Operators 06002, and revisions to the Aeronautical Information Manual. While the Safety Board acknowledges the value of these revisions in focusing attention on (1) the dangers of aircraft icing and (2) pilot and operator responsibilities to take appropriate actions in response, and that these documents specify the need for a tactile (hands on) check when feasible, none of the documents address the intent of this recommendation. Safety Recommendation A-06-42 asks the FAA to develop visual and tactile training aids (emphasis added) to accurately depict small amounts of upper wing surface contamination, and to require that these training aids be incorporated into pilot initial and recurrent training. The Safety Board believes that it is difficult or impossible with words alone to convey to pilots the small amounts of upper wing ice contamination that can have a significant aerodynamic performance impact. However, through the development of high-resolution photographs, videos, interactive animations, and tactile training aids that simulate the size, texture, and other characteristics of minute levels of contamination, pilots can be better educated on what they need to look for (regarding ice) when flying. Pending the development of visual and tactile training aids that accurately depict small amounts of upper wing surface contamination, and institution of a requirement for incorporation of these training aids into initial and recurrent pilot training, Safety Recommendation A-06-42 is classified OPEN -- UNACCEPTABLE RESPONSE.
Letter Mail Controlled 11/9/2006 2:20:01 PM MC# 2060547: - From Marion C. Blakey, Administrator: The FAA has made several changes to various documents that we believe address this recommendation. These include Advisory Circular (AC) 120-60B, Notice N8000.308, Safety Alert for Operators (SAFO) 06002 and revisions to the Aeronautical Information Manual (AIM). Selected portions of these documents are discussed below, and copies are enclosed. AC 120-60B This AC provides an industry wide standard means for obtaining approval of a Ground Deicing /Anti-Icing Program in accordance with 14 CFR Part 121, section 12 1.629. Paragraph 6d. Of this AC states: 6d. Frozen Contaminants on the Aircraft. Per section 121.629(b), the aircraft must be free of all frozen contaminants adhering to the wings, control surfaces, propellers, engine inlets, or other critical surfaces before takeoff. Paragraph 6(d)(3) of the AC further states: (3) Recognition Techniques. Certificate holder’s Initial, Transition, Recurrent, Upgrade, or Advanced Qualification Program (AQP) and Continuing Qualification training curricula should include aircraft type-specific techniques for use by the flight crew and other personnel for recognizing contamination on aircraft surfaces. The flight crew and other personnel should use these type-specific techniques while conducting preflight aircraft icing checks, pre-takeoff checks, and pre-takeoff contamination checks. Frozen contaminants can take the form of ice, frost, snow, or slush. NOTE: The formation of clear ice may be difficult to detect visually. Therefore, specific techniques for identification of clear ice should be included in all training programs. Notice N8000.308 To supplement this AC, FAA issued Notice N8000.308, Reevaluation of Deicing/Anti- Icing Programs,’’ on October 5, 2005, to provide guidance and information for inspectors, pilots, and operators regarding the evaluation of deicing/anti-icing programs. This notice provided the following guidance regarding training: 6d. Training Requirements. (1) Verify that each of the following training subjects is included in the curriculum for all personnel directly involved in the program. This training must be tailored to specific aircraft types. (f) Cold weather preflight inspection procedures. (g) Techniques for recognizing contamination on the aircraft. NOTE 1: All personnel must receive training in all subjects listed. The details of that training must be tailored to their respective job functions. NOTE 2: If the duties of pilots include supervising offline deice/anti-ice operations, detailed training must be provided to address these job functions. (2) Encourage the operator to enhance the training by ensuring that it conforms to AC 120-60, current edition. Industrywide conformance to the standards set by AC 120-60 makes it possible for operators to use (give credit for) the training provided by other operators, in effect making the training interchangeable for similar type aircraft. SAFO 06002 In addition to these publications, the FAA issued a Safety Alert for Operators SAFO 06002, Ground deicing practices for turbine aircraft in nonscheduled 14 CFR part 135 operations and in part 91, on March 29, 2006. This document includes this cautionary note: NOTE: There is no acceptable amount of airframe icing at takeoff. In addition, even when otherwise permitted, operators should avoid smooth or polished frost on lift-generating surfaces as an acceptable preflight condition. AIM revision dated February 16, 2006 A recent change to paragraph 7-5-14 b.1. of the Aeronautical Information Manual cautions all pilots to: Ensure that your aircraft’s lift-generating surfaces are COMPLETELY free of contamination before flight through a tactile (hands on) check of the critical surfaces when feasible. Even when otherwise permitted, operators should avoid smooth or polished frost on lift-generating surfaces as an acceptable preflight condition.
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