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Safety Recommendation Details

Safety Recommendation A-08-016
Details
Synopsis: On February 18, 2007, about 1506 eastern standard time, Delta Connection flight 6448, an Embraer ERJ-170, N862RW, operated by Shuttle America, Inc., was landing on runway 28 at Cleveland Hopkins International Airport (CLE), Cleveland, Ohio, during snow conditions when it overran the end of the runway, contacted an instrument landing system (ILS) antenna, and struck an airport perimeter fence. The airplane’s nose gear collapsed during the overrun. Of the 2 flight crewmembers, 2 flight attendants, and 71 passengers on board, 3 passengers received minor injuries. The airplane received substantial damage from the impact forces. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 from Hartsfield-Jackson Atlanta International Airport, Atlanta, Georgia. Instrument meteorological conditions prevailed at the time of the accident.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121, 135, and Part 91 subpart K operators to include, in their initial, upgrade, transition, and recurrent simulator training for turbojet airplanes, (1) decision-making for rejected landings below 50 feet along with a rapid reduction in visual cues and (2) practice in executing this maneuver.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: Cleveland, OH, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA07MA072
Accident Reports: Runway Overrun During Landing Shuttle America, Inc. Doing Business as Delta Connection Flight 6448 Embraer ERJ-170, N862RW
Report #: AAR-08-01
Accident Date: 2/18/2007
Issue Date: 4/15/2008
Date Closed: 6/13/2014
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Flightcrew, Go Around, Simulator, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/13/2014
Response: Your September 26, 2008, letter regarding this recommendation said that a planned notice of proposed rulemaking (NPRM) to revise 14 CFR Part 121, Subparts N and O would address the issues that are the focus of this recommendation. You also described your plan to issue a safety alert for operators (SAFO) that would discuss the issues involved in the Shuttle America flight 6448 accident, and that initial, upgrade, transition and recurrent simulator training programs should include loss of visual cues at minimums, as part of the rejected landing procedures at 50 feet. When we replied on June 22, 2009, we said that it had been our experience that SAFOs were limited to a single page, providing little detailed information, and we were concerned that the proposed SAFO would not include sufficient detail to allow operators to revise their training programs. In addition, since SAFOs are guidance material with no associated mandate for compliance, we questioned whether a SAFO could satisfy our recommendation for a requirement. Nevertheless, we stated that, if you were to survey all operators and determine that they had incorporated the guidance into their training programs, such action might constitute an acceptable alternate response. On October 20, 2009, you issued SAFO 09016, “Rejected Landing Due to Loss of Visibility.” Our concern regarding this action was well founded, as the SAFO was only one page long and contained little detailed information. On January 12, 2009, you published an NPRM titled “Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers” and on May 20, 2011, you published a supplemental notice of proposed rulemaking (SNPRM), both of which proposed to revise crewmember and aircraft dispatcher qualification, training, and evaluation requirements in Part 121, subparts N and O. We commented on both of these proposals and pointed out that each contained proposed requirements that addressed Safety Recommendation A-08-16, but only for Part 121. The final rule was published on November 12, 2013, but many needed revisions that had been proposed in the NPRM and SNPRM were eliminated in the final rule. Among the proposed revisions that were missing were the requirements that would have addressed Safety Recommendation A-08-16. Because (1) the final rule does not address this recommendation, (2) issuance of the SAFO alone does not constitute an acceptable response, and (3) even if the SAFO had adequately addressed the issue, the FAA did not document that operators had acted as recommended, Safety Recommendation A-08-16 is classified CLOSED—UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 4/9/2014
Response: -From Michael P. Huerta, Administrator: fn a notice of proposed rulemaking (NPRM) titled Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers published on January 12, 2009 (74 FR I 280), and a supplemental notice of proposed rulemaking (SNPRM) published on May 20, 2011 (76 FR 29335), the Federal Aviation Administration (FAA) proposed to revise crewmember and aircraft dispatcher qualification, training, and evaluation requirements in the existing subparts N and 0 of part 12 1. After reviewing the changes proposed in the NPRM and the SNPRM, the FAA determined it was necessary to move forward with a final rule to address certain safety-critical provisions proposed in the SNPRM that enhance pilot training for rare, but high risk scenarios that provide the greatest safety benefit. The final rule was published on November 12, 2013 (78 FR 67799). The remaining proposals in the SNPRM require further deliberation. This includes proposed requirements that would have addressed the recommendations listed above, which were included in the SNPRM and were discussed in our previous letters to the Board. On January 21, 2014, the FAA chartered an Air Carrier Training Aviation Rulemaking Committee (ARC), which will consider these recommendations in its deliberations. The first meeting of the ARC is scheduled for April 14-16, 2014. The FAA has taken additional steps to address A-08-16 by publishing a Safety Alert for Operators (SAFO) on October 20, 2009. SAFO 09016, titled Rejected Landing Due to Loss of Visibility, is applicable to operators under parts 121 , 135, and 91 subpart K. The FAA does not intend to survey operators for compliance as suggested in the Board's letter dated June 22, 2009, since we are not requiring these actions. In previous responses to A-09-25, the FAA stated that it planned to revise Order 8900.1, Flight Standards Information Management System, to comply with the proposed requirements in the Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers SNPRM as they pertained to th is recommendation. Given that the provisions in the SNPRM pertinent to A-09-25 were not in the final rule, the FAA does not plan on updating Order 8900.1. I believe that the FAA has effectively addressed these recommendations and consider our actions complete.

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. In its comments on the NPRM, the NTSB stated that the proposed requirement to use a simulator for training on rejected landing maneuvers, including the initiation of a rejected landing between 30 and 50 feet above the runway, specifically addressed the second part of this recommendation and that decision-making would likely be covered during training in the maneuver. The SNPRM retains these requirements, which partially respond to the recommendation because they address only Part 121 carriers. Action for Part 135 and Part 91 subpart K operators will be needed before this recommendation can be closed acceptably.

From: NTSB
To: FAA
Date: 6/22/2009
Response: The FAA replied that Part 121, Part 135, and Part 91 subpart K include a requirement to instruct pilots on visual cues before and during descent below the decision altitude/decision height or minimum descent altitude. On January 12, 2009, the FAA published a notice of proposed rulemaking (NPRM) to revise regulations concerning the qualifications, service, and use of aircraft crewmembers. The FAA indicated that the issues addressed by this recommendation are among the topics addressed in the NPRM for Part 121 carriers. The NTSB reviewed this extensive NPRM and provided detailed comments to the associated docket. Although flight training for pilots includes rejected landings that include a normal missed approach after the landing is rejected, the training requirements do not specify that the landing be rejected because of a loss of visibility. To address this concern, the FAA plans to issue a safety alert for operators (SAFO) that will discuss the issues in this accident. The SAFO will recommend that initial, upgrade, transition, and recurrent simulator training programs include loss of visual cues as part of the rejected landing procedures at 50 feet. The SAFO will state that this training should account for the possibility that pilots may need to reject a landing because of rapidly deteriorating weather conditions. The SAFO will also state that this training should include the decision-making required by a pilot in this situation. It has been the NTSB’s experience that SAFOs are frequently limited to a single page providing little detailed information. The NTSB is concerned that the proposed SAFO may not include sufficient detail to allow operators to revise their training programs accordingly. In addition, SAFOs are guidance material with no associated mandate for compliance; however, this recommendation asks that the training be required. If the FAA surveys all Part 121, Part 135, and Part 91 subpart K operators and determines that they have incorporated the guidance in the proposed SAFO into their training programs, this may be an acceptable alternative response to this recommendation. Pending the NTSB’s review of the proposed SAFO and determination that it provides sufficient detail and the FAA’s conducting a survey of all Part 121, Part 135, and Part 91 subpart K operators to confirm that the training has been incorporated into the operators’ training programs, Safety Recommendation A-08-16 is classified OPEN -- ACCEPTABLE ALTERNATE RESPONSE.

From: NTSB
To: FAA
Date: 5/7/2009
Response: Notation 8106: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration's (FAA) notice of proposed rulemaking (NPRM) titled, "Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers," which was published in 74 Federal Register 1280 on January 12, 2009. The NPRM proposes a requirement to use a simulator for training on rejected landing maneuvers, including the initiation of a rejected landing between 30 and 50 feet above the runway. Thus, the NPRM addresses the second part of this recommendation "practice in executing this maneuver." In addition, although the NPRM did not specifically address decisionmaking, this topic may be covered during training in the maneuver. Safety Recommendation A-08-16 is currently classified "Open-Response Received." The NPRM partially responds to the recommendation because it addresses only Part 121-and not Part 135 or Part 91 subpart K--carriers. Action for Part 135 and Part 91 subpart K operators will still be needed before this recommendation can be closed.

From: FAA
To: NTSB
Date: 9/26/2008
Response: Letter Mail Controlled 10/8/2008 4:09:46 PM MC# 2080610: - From Robert A. Sturgell, Acting Administrator: The Federal Aviation Administration notes that the requirement to instruct pilots under operations conducted under parts 121, 135, and 91 subpart K on visual cues before and during descent below decision altitude/decision height (DA/DH) or minimum decent altitude (MDA) is currently included in the pilot’s Initial, Transition, and Upgrade Ground Training as specified in §§ 121.419(a)(l)(vii), 135.345(a)(7), and 91.1 l0l(a)(7). The FAA also notes that pilots of part 121 and 135 operators are instructed not to begin the final approach segment of an approach unless the latest weather report issued by that airport’s reporting facility indicates that weather conditions are at or above the authorized instrument flight rules (IFR) landing minimums for that procedure, as specified in §§ 121.65l(b) and 135.225(a), respectively. Both operating rules specify that if the weather deteriorates while on the final approach segment, the approach may continue to minimums. However, descent below the DA/DH/MDA may not be made unless conditions are at or above the minimums prescribed for the procedure being used. Section 91.175(1) specifies the same flight visibility and visual references for the intended runway are also clarified for pilots of operators who use Enhanced Flight Vision Systems (EFV). Additionally, the results of the Aviation Rulemaking Committee (ARC) for 14 CFR part 121 subparts N & O are currently at the Federal Register for publication as a notice of proposed rulemaking. We believe that the proposed approach requirements for part 121 operators by the ARC address the issues the Board has raised. These requirements include: ·Insure a timely decision at DA or DH to either initiate a missed approach or proceed to a landing with suitable visual reference; ·Initiate the missed approach procedure when at DH or DA, and the required visual references for the runway, or the intended landing area, are not distinctly visible or identifiable; and ·Transition to a normal landing approach only when the required visual references for the runway, or the intended landing area, are distinctly visible and identifiable, and the aircraft is in a position from which a descent to a landing on the runway, or the intended landing area, can be made at a normal rate of descent using normal maneuvering. The FAA agrees that this is an area that should also be emphasized in current pilot training by all part 121, 135, and 91 subpart K operators. As the Board pointed out, the flight training for pilots under Appendix E of part 121 (both the pilot-in-command and second-in-command) includes rejected landings that include a normal missed approach after the landing is rejected, but does not specify that this rejected landing be done due to a loss of visibility. Within 90 days, we will issue a safety alert for operators (SAFO), emphasizing the issues involved in this accident. The SAFO will request that the approved Initial, Upgrade, Transition and Recurrent simulator training program of part 121, 135, and 91 subpart K operators include loss of visual cues at minimums, as part of the rejected landing procedures at 50 feet. This training should then account for the possibility that pilots may need to reject a landing because of rapidly deteriorating weather conditions and assist pilots with the decision-making required.