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Safety Recommendation Details

Safety Recommendation A-07-045
Details
Synopsis: On August 27, 2006, about 0606:35 eastern daylight time, Comair flight 5191, a Bombardier CL-600-2B19, N431CA, crashed during takeoff from Blue Grass Airport (LEX), Lexington, Kentucky. The flight crew was instructed to take off from runway 22 but instead lined up the airplane on runway 26 and began the takeoff roll. The airplane ran off the end of the runway and impacted the airport perimeter fence, trees, and terrain. The captain, flight attendant, and 47 passengers were killed, and the first officer received serious injuries. The airplane was destroyed by impact forces and postcrash fire. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 and was en route to Hartsfield-Jackson Atlanta International Airport, Atlanta, Georgia. Night 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 91K, 121, and 135 operators install on their aircraft cockpit moving map displays or an automatic system that alerts pilots when a takeoff is attempted on a taxiway or a runway other than the one intended.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: Lexington, KY, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA06MA064
Accident Reports: Attempted Takeoff From Wrong Runway Comair Flight 5191 Bombardier CL-600-2B19, N431CA
Report #: AAR-07-05
Accident Date: 8/27/2006
Issue Date: 8/28/2007
Date Closed: 7/23/2014
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Instruments,

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/23/2014
Response: We note that you have finished evaluating in-cockpit runway safety systems and have drafted policy changes based on your evaluation. We do not agree with you, however, that leaving it up to operators to voluntarily install moving map displays satisfies this recommendation. Because you do not plan to develop and issue a requirement for in-cockpit runway safety systems, Safety Recommendation A-07-45 is classified CLOSED—UNACCEPTABLE ACTION.
From: FAA
To: NTSB
Date: 4/9/2014
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) completed its work with U.S. air carriers to fund in-cockpit runway safety systems for data collection and evaluation. A total of six airlines volunteered and ultimately three airlines participated in the program. The FAA has drafted pol icy changes based on lessons learned through this program and a desire to improve implementation of airport moving maps displaying own-ship position. We expect this policy to be published by March 2014. These changes include: • Advisory Circular 120-76B, Guidelines for the Certification, Airworthiness, and Operational Use of Electronic Flight Bags; • Update to FAA Order 8900.1, Volume 4, Chapter 15, Section 1; and • Creating a detailed job aid for FAA inspectors. The FAA promotes the development and adoption of cockpit moving map displays that show ownership position on the airport surface. As certificated operators adopt and utilize the FAA's new policy, the need to mandate such functions through rulemaking decreases. There are no plans to require all Title 14, Code of Federal Regulations Part 91 K, 121, and 135 operators to install aircraft cockpit moving map displays or an automatic system alerting pilots when a takeoff is attempted on a taxiway or a runway other than the runway intended. The FAA finds that voluntary installation of moving map displays meets the intent of this recommendation and the policy changes discussed above will enable increased use of this technology without requiring rulemaking. I will keep the Board informed of the FAA's progress on this safety recommendation and provide an update by September 2014.
From: NTSB
To: FAA
Date: 2/11/2013
Response: Since this recommendation was issued, the FAA has agreed with the intent of the recommendation, but believed that it was premature to mandate the equipment because the related technologies were in development and had not yet reached maturity. We have acknowledged that alerting system technology may not yet be sufficiently developed to justify a mandate but that moving map technology is, and therefore, the FAA should mandate its use. An industry standard for moving map displays, RTCA DO-257A has long been available, and in 2003, the FAA incorporated this standard into Technical Standards Order C165, “Electronic Map Display Equipment for Graphical Depiction of Aircraft Position.” In April 2007, the FAA published Advisory Circular (AC) 20-159, “Obtaining Design and Production Approval of Airport Moving Map Display Applications Intended for Electronic Flight Bag Systems,” which provides guidance on how operators can implement moving map displays using a portable electronic flight bag at substantially lower cost than previously available cockpit displays. Finally, moving map capability has been implemented for several years in some new production aircraft. On the basis of these standards, we believed the FAA could mandate this equipment, as recommended. The FAA has sponsored a number of activities, including the development of standards for systems that use automatic dependent surveillance-broadcast technologies, and a program in which the FAA works with selected US air carriers to fund in-cockpit runway safety systems for data collection and evaluation. Six carriers have participated, or are currently participating, in the program, with three of these having equipped up to 20 of their aircraft with airport moving map displays. These carriers are providing the FAA with operational data to evaluate the effectiveness of the installed equipment. On January 11, 2011, we pointed out that the FAA’s planned operational and safety study of moving map technology was not scheduled for completion until September 2011, over 4 years after Safety Recommendation A-07-45 had been issued. We considered that timeframe to be unacceptable and reiterated our belief that the development of alerting systems need not be completed before mandating the use of moving map displays. In its current letter, the FAA indicated that data collection in this study had been extended until the end of 2012. After completion of the data collection phase, the FAA plans to evaluate the data for the operational use and safety impact of this technology before considering any future actions. We continue to believe that the technology is ready and that the FAA should not delay taking action to require that airplanes be equipped with moving map technology. The end of 2012, when the FAA’s data collection was to conclude, has now passed. Accordingly, we urge the FAA to complete its analysis and mandate the installation and use of cockpit moving map displays. Pending completion of that action, Safety Recommendation A-07-45 remains classified OPEN—UNACCEPTABLE RESPONSE.
From: FAA
To: NTSB
Date: 10/29/2012
Response: -From Michael P. Huerta, Acting Administrator: The Federal Aviation Administration (FAA) continues to evaluate the operational feasibility of cockpit moving map displays that indicate "own-ship" position on the airport surface. Meanwhile, as noted in a previous response to the Board, we requested RTCA develop standards for two capabilities related to alerting systems. • Special Committee 214 continues to work on developing standards for the use of data link to send taxi clearances; and • Special Committee 186 has developed RTCA DO• 317. Minimum Operational Performance Standards for Aircraft Surveillance Applications System, which includes standards for Airport Surface Situational Awareness equipment that uses the receive capability of Automatic Dependent Surveillance - Broadcast. We incorporated those standards into Technical Standards Order (TSO)-C 195, Avionics Supporting Automatic Dependent Surveillance - Broadcast Aircraft Surveillance Applications, on September 27. 2010. This TSO was revised in February 2012 and was published as TSO-C 195a. The revised TSO became effective on February 29, 2012. Additionally the FAA continues to work with U.S. air carriers to fund in-cockpit runway safety systems for data collection and evaluation. Six carriers have participated in or are currently participating in the program. Three of these carriers have equipped up to 20 aircraft per carrier with airport moving maps that display own-ship position. In exchange for this new equipment these carriers are providing the FAA with operational data to evaluate the effectiveness of the installed equipment. Originally, the FAA planned to have the data collection completed by 2011, but that data collection will continue until the end of20 12. After completion of the data collection phase, we will evaluate the data for the operational use and safety impact of this technology before considering any future actions. The FAA will continue to evaluate airport map, surface traffic, and surface alerting systems as they are implemented and mature to determine its actions for full adopt ion of this recommendation. I will keep the Board informed of the FAA's progress on this safety recommendation and provide an update by October 2013.
From: NTSB
To: FAA
Date: 1/11/2011
Response: The NTSB disagrees with the FAA that cockpit moving map displays have not yet reached sufficient maturity for the FAA to mandate their installation and use. The FAA's planned operational and safety study of moving map technology is not scheduled for completion until September 2011, over 4 years after Safety Recommendation A-07-45 was issued. We consider this time frame unacceptable and reiterate our belief that the development of alerting systems need not be completed before mandating the use of moving maps. Accordingly, pending the FAA's taking the recommended action in a timely mal1l1er, Safety Recommendation A-07-45 is classified OPEN – UNACCEPTABLE RESPONSE.
From: FAA
To: NTSB
Date: 7/13/2010
Response: Letter Mail Controlled 7/30/2010 11:46:02 AM MC# 2100259 - From J. Randolph Babbitt, Administrator: In the Board's August 22, 2008 letter, it indicated the Federal Aviation Administration provided evidence, with the availability of Technical Standards Order (TSO) C165 and Advisory Circular (AC) 20-159, that moving map technology is sufficiently developed and should be mandated. In response, the FAA maintains the position that the technology has not yet reached maturity but continues to support its development through a systematic program. A TSO provides a minimum performance standard for articles to be used on aircraft. An article with TSO design approval makes it eligible for installation on an aircraft. AC 20-159 is a guide for obtaining design and production approval under TSO C165 for the software and database used to provide an airport moving map display intended for use on a Class 2 electronic flight bag (EFB) for ground operations. A Class 2 EFB is one that is portable and connected to an aircraft mounting device during normal operations. With these and other publications, the FAA has completed the necessary steps to make it possible to equip aircraft with airport moving map display technology. The FAA now needs to evaluate the operational use and safety impact of this technology before considering any future actions. Most recently, the FAA contracted with six U.S. air carriers to fund in-cockpit runway safety systems in a program called Capstone 3. This agreement provides at least two EFBs for each aircraft and an option to also fund the installation of the Honeywell Runway Awareness and Advisory System (RAAS). RAAS is a product intended to improve situational awareness by providing pilots with aural advisories on their position during taxi and ground operations. It is available as a software option hosted in Honeywell enhanced ground proximity warning system units. Up to 20 aircraft per carrier may be outfitted with airport moving maps that display own-ship position and a possible RAAS installation. In exchange for this new equipment, these carriers must provide the FAA with operational data to allow evaluation of its effectiveness. Installation of this equipment began in September 2009 and testing will continue through September 2011. The data collected will be analyzed to determine usability of the equipment and provide recommendations for inclusion in the cockpit. In addition, the FAA is working with industry to develop standards for Airport Surface Situational Awareness equipment that uses the receive capability of Automatic Dependant Surveillance -Broadcast. This equipment will use state of the art displays, position sensors, and databases to depict own aircraft and traffic on a detailed map of the airport surface. This work is being carried out through Working Group 4 of RTCA Special Committee 186. An initial version of the standard is available in RTCA Document DO-317. The FAA will publish a TSO that references this document by September 30, 2010. I will keep you informed of the progress on this safety recommendation.
From: NTSB
To: FAA
Date: 10/28/2008
Response: At the 2008 Board Meeting to address the issues requiring Federal action on the NTSB's Most Wanted List of Safety Improvements, Safety Recommendation A-07-045 was added to the list under the issue area, "Runway Incursions."
From: NTSB
To: FAA
Date: 8/22/2008
Response: The FAA stated that it agrees with this recommendation’s intent but believes that rulemaking is premature at this time because the related technologies are in development and have not yet reached maturity. The FAA reviewed its activities related to the development of moving map technology and alerting systems. For moving map displays, the FAA noted that an industry standard, Radio Technical Commission for Aeronautics (RTCA) DO-257A has been developed and published and that, in 2003, the FAA incorporated this standard into Technical Standards Order (TSO) C165. The FAA further stated that, in April 2007, it published additional guidance in Advisory Circular (AC) 20-159, Obtaining Design and Production Approval of Airport Moving Map Display Applications Intended for Electronic Flight Bag Systems. This AC provides guidance on how operators can implement moving map displays using a portable electronic flight bag at substantially lower cost than previously available cockpit moving map displays. The FAA also indicated that moving map capability has been implemented in some new production aircraft. For alerting systems, the FAA stated that it has requested RTCA to develop standards for the use of data link technology to send taxi clearances and to develop standards for a cockpit alerting system based on Automatic Dependent Surveillance-Broadcast (ADS-B). The FAA further stated that implementation of these technologies is dependent on the development of supporting infrastructure, such as ground automation, data link, and ADS-B, and that this infrastructure will be developed over the next 5 to 10 years. Finally, the FAA indicated that, in the future, it would consider rulemaking to mandate moving map displays or alerting systems in aircraft after the technology for these functions has been better developed. The Safety Board acknowledges that technology for alerting systems may not yet be sufficiently developed to justify a mandate, but the Board believes that the FAA has provided evidence that moving map technology is sufficiently developed for the FAA to mandate its use. The FAA reported that standards for this equipment have existed for almost 5 years, and the FAA has issued a TSO for this equipment as well as an AC on lower-cost alternatives. As further proof that this technology is ready for a mandate, the FAA reported that some newly manufactured aircraft are already equipped with cockpit moving map displays. Consequently, the Board believes the FAA should now mandate moving map displays. Pending the FAA’s implementing such a requirement, Safety Recommendation A-07-45 is classified OPEN -- ACCEPTABLE RESPONSE.
From: FAA
To: NTSB
Date: 11/30/2007
Response: Letter Mail Controlled 12/11/2007 7:49:41 AM MC# 2070726: - From Robert A. Sturgell, Acting Administrator: The FAA agrees with the Board’s safety intent but finds that rulemaking to require moving map displays or alerting systems is premature at this time. The related technologies are in development and have not yet reached maturity. The FAA, however, has taken important steps to support development and implementation of those technologies. Moving map displays: The FAA has committed to promoting the development and adoption of cockpit moving map displays, which will show "own ship" position on the airport surface. Industry standards for this function, called aerodrome moving map display, have been developed and published in RTCA/DO-257A. The FAA incorporated those standards into TSO-C165 in 2003. Moving map capability has already been implemented in certain new production aircraft. In April 2007, the FAA published additional guidance in AC 20-159, Obtaining Design and Production Approval of Airport Moving Map Display Applications Intended for Electronic Flight Bag Systems (enclosed). AC 20-159 explains how operators can implement this important safety enhancement using a portable electronic flight bag, permitting operators to install moving map displays at substantially lower cost than previously in the retrofit market. Alerting systems: The FAA has requested RTCA to develop standards for two related capabilities. Special Committee 214 is developing standards for the use of data link to send taxi clearances which would enable better awareness of and alerting to pilots relative to the issued clearance. Special Committee 186 is developing standards for a cockpit alerting system based on Automatic Dependent Surveillance - Broadcast (ADS-B) that could alert of potential aircraft conflicts, including runway incursions. Implementation of these technologies is dependent on the supporting infrastructure: ground automation, data link, and ADS-B Out for all aircraft in the terminal area. That infrastructure will be developed over the next 5 to 10 years. The FAA, in the future, will consider rulemaking that would mandate moving map displays or alerting systems in aircraft once the technology for these functions better develops. I believe that the FAA has satisfactorily responded to this safety recommendation, and 1 look forward to your response.