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Safety Recommendation Details

Safety Recommendation A-08-017
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, practice for pilots in accomplishing maximum performance landings on contaminated runways.
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,

Safety Recommendation History
From: NTSB
To: FAA
Date: 3/4/2015
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) draft Advisory Circulars (AC) 25-X, “Takeoff Performance Data for Operations on Contaminated Runways,” and AC 25-X, “Landing Performance Data for Time-of-Arrival Landing Performance Assessments,” which were posted for comment on the FAA’s website on January 21, 2015. Both of these draft ACs provide guidance and standardized methods that data providers, such as type certificate (TC) holders, supplemental type certificate (STC) holders, applicants, and airplane operators can use when developing performance data for transport category airplanes for operations on contaminated runways. The AC also promotes the use of consistent terminology for runway surface conditions used among data providers and FAA personnel. The NTSB has investigated several accidents within the last 10 years that involve issues addressed by these ACs. As a result of these investigations, the NTSB issued Safety Recommendations A 07 57 through 64, A 08 17, A 08 41 through 43, and A 11 28 and 29.

From: NTSB
To: FAA
Date: 6/13/2014
Response: On October 20, 2009, you issued SAFO 09015, “Training for Maximum Performance Landings on Contaminated Runways,” which emphasizes the importance of including maximum performance landings on contaminated runways in initial, upgrade, transition, and recurrent simulator training. The SAFO also recommends the minimum elements that should be included in training programs for landing on these runways. The January 12, 2009, NPRM and May 20, 2011, SNPRM proposed requirements for Part 121 carriers to include the recommended training in their programs. As with Safety Recommendation A-08-16, we were concerned that a SAFO does not constitute a mandate and that you did not plan to act to ensure that the information was incorporated into operators’ programs. On November 21, 2012, you informed us that you had been unable to develop a cost-benefit justification that would support a requirement for Part 135 and Part 91 subpart K operators, but that the SNPRM proposed the requirement for Part 121 operators. You also indicated that you did not plan to survey Part 135 or Part 91 subpart K operators to determine their compliance with the SAFO. On February 4, 2013, we said that the requirements the SNPRM proposed would satisfy this recommendation, but only for Part 121 operators. We acknowledged that all rulemaking projects must pass the strict reviews performed by the Office of Management and Budget for a positive cost benefit, and that you did not possess the data needed to pass this review for the recommended revisions to Part 135 or Part 91 subpart K. We therefore concluded that the regulatory reforms proposed in the SNPRM would constitute an acceptable alternate means of satisfying the recommendation. As discussed above, the final rule based on the SNPRM was published on November 12, 2013, but many needed revisions proposed in the NPRM and SNPRM had been eliminated. Among the proposed revisions missing from the final rule were the requirements that would have addressed Safety Recommendation A-08-17; consequently, this recommendation 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: 2/4/2013
Response: On January 12, 2009, the FAA issued a notice of proposed rulemaking (NPRM), titled “Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers,” which proposed requirements for Part 121 operations to train their flightcrews as recommended. On May 20, 2011, the FAA issued a supplemental notice of proposed rulemaking (SNPRM) with the same title. We submitted comments on both of these documents, stating our general support for the actions proposed; however, we also stated that we had been unable to identify the specific language proposing the requirement related to this recommendation in either document. We thank the FAA for providing in its current letter the specific reference in the SNPRM. The FAA anticipates publishing a final rule in late 2013. On October 20, 2009, the FAA published Safety Alert for Operators (SAFO) 09015, “Training for Maximum Performance Landings on Contaminated Runways,” which the FAA states emphasizes the importance of including maximum performance landings on contaminated runways in initial, upgrade, transition, and recurrent simulator training. The SAFO also recommends the minimum elements that should be included in training programs for landing on these runways. We are aware that a SAFO is an advisory document, not a mandate. Although the SNPRM contains requirements for Part 121 operators, the FAA feels the SAFO is an appropriate action to implement this recommendation for Part 135 and Part 91 subpart K operators, and it does not plan on taking rulemaking action to revise Parts 135 and 91 subpart K, nor does the FAA plan to survey operators to evaluate compliance with the SAFO. However, the FAA will consider requiring this training for additional rule parts if their cost becomes justified. The FAA previously informed us of its plans to issue the SAFO. In our June 22, 2009, letter, we stated that it had been our experience that SAFOs were limited to a single page in length and provided little detailed information. Accordingly, we were concerned that the proposed SAFO would not include sufficient detail to assist operators in revising their training programs as recommended. Another of our concerns was that SAFOs are guidance material and do not mandate compliance, whereas Safety Recommendation A-08-17 specifies that the training be required. We stated that issuance of a SAFO might be an acceptable alternative solution, provided that the SAFO was sufficiently detailed and if, after the SAFO’s issuance, the FAA were to survey all operators and to determine that they had incorporated the SAFO’s guidance into their training programs. We recently reviewed a copy of the SAFO, and found that our concerns expressed on June 22, 2009, were well-founded, as the SAFO is brief (only one page) and provides little useful information. The FAA has also indicated that it does not plan to survey operators to determine how effective the SAFO has been. Therefore, we do not believe that the FAA’s issuance of the SAFO satisfies this recommendation. The SNPRM, however, does satisfy this recommendation, but only for Part 121 operators. We considered the FAA’s statement that it does not plan to propose similar rulemaking for Part 135 and Part 91 subpart K unless these rulemakings can be cost-justified. We acknowledge that all FAA rulemaking projects must pass the strict reviews performed by the Office of Management and Budget for a positive cost benefit, and that the FAA does not possess the data needed to pass this review for the recommended revisions to Part 135 or Part 91 subpart K. The FAA has agreed to consider such rulemaking if data documenting the extent of the problem become available. We therefore conclude that the regulatory reforms proposed in the SNPRM constitute an acceptable alternative means of satisfying this recommendation. Accordingly, pending issuance of a final rule based on the SNPRM containing a requirement for simulator training for flightcrew on landings on contaminated runways, Safety Recommendation A-08-17 remains classified OPEN—ACCEPTABLE ALTERNATE RESPONSE.

From: FAA
To: NTSB
Date: 11/21/2012
Response: -From Michael P. Huerta, Acting Administrator: The Federal Aviation Administration (FAA) has existing policy and guidance that supports this recommendation. As we reported in our September 26, 2008, response, FAA Order 8900.1, Flight Standards Information Management System (FSIMS), lists pertinent guidance and requests that principal operations inspectors (POIs) bring winter operations issues to the attention of operators. The order also directs POIs to ensure that operators' manuals contain specific instructions and information for flight crews operating in adverse weather conditions and to review the content of their assigned operator's training program to ensure adequate coverage of adverse weather operations. We indicated in our September 26, 2008, letter that we planned on publishing a Safety Alert for Operators (SAFO) to address the issues surrounding this recommendation. On October 20, 2009, we published SAFO 09015, Training for Maximum Performance Landings on Contaminated Runways. This SAPO emphasizes the importance of including maximum performance landings on contaminated runways in initial, upgrade, transition, and recurrent simulator training, and recommends the minimum elements that should be included in training programs for landing on these runways. The SAFO applies to Title 14 Code of Federal Regulations (14 CFR) parts 121, 135, and 91K operators. SAFO 09015 can be found at the following link http://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safetylsafo/all_safos/media/2009/SAF009015.pdf We also reported in our September 26, 2008, response that the forthcoming Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers Notice of Proposed Rulemaking would contain elements addressing this recommendation. We published this NPRM on January 12, 2009, and issued a supplemental notice of proposed rulemaking (SNPRM) on May 20, 2011. We acknowledge the Board's comment to this SNPRM that SNPRM language describing how to accomplish maximum performance landings on contaminated runways could not be found. Landing on contaminated runways is specifically included in the SNPRM at Table 3A, Job Performance Tasks: Training and Evaluation. This table indicates landing on contaminated runways as a piloting task, which is required for all curriculum categories (initial, transition, conversion, upgrade, requalification. and recurrent training). This information can be found within the SNPRM (76 FR 29447). We anticipate publishing a final rule in late 2013. The Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers rule contains requirements for certificate holders required to train under 14 CFR part 121. The FAA feels the SAFO is an appropriate action to this recommendation for 14 CFR parts 135 and 9lK operators. SAFOs alert industry regarding issues of concern to operators. The responsibility to implement any action recommended in a SAFO rests with the operator. The FAA currently does not plan on taking rulemaking action to revise parts 135 and 91K, as we believe the SAFO is the appropriate response for these industry segments. On occasion, the FAA assesses industry's follow-up to a SAFO, but this is not a normal practice. The FAA has no plans to survey compliance with this SAFO. We will consider requiring this training for additional rule parts if they become cost justified. I will keep the Board informed of the FAA's progress on this safety recommendation and provide an update by August 30, 2013.

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. As with the earlier NPRM, the NTSB did not find any language in the SNPRM describing how to accomplish maximum performance landings on contaminated runways. In addition, any requirements associated with this proposed rulemaking would only apply to Part 121 carriers and not Part 135 or Part 91 subpart K operators. This recommendation is currently classified ""Open-Acceptable Alternate Response." Action for Part 121, 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 Order 8900.1, Flight Standards Information Management System, lists pertinent advisory circulars (ACs) and booklets and requests that principal operations inspectors (POIs) bring winter operations issues to the attention of operators. Order 8900.1 also directs POIs to ensure that operator’s manuals contain specific instructions and information for flight crews operating in adverse weather conditions, and to review the content of their assigned operator’s training program to ensure adequate coverage of adverse weather operations. The FAA does not believe it necessary to modify the guidance for its inspectors; however, the FAA plans to publish a SAFO that will request that initial, upgrade, transition, and recurrent simulator training programs include training for pilots in applying maximum braking and maximum reverse thrust on contaminated runways until a safe stop is ensured. This recommendation was issued after the NTSB investigated two runway overrun accidents, within a short period of time, in which the flight crew did not fully utilize the braking performance available on a contaminated runway. In addition to the February 18, 2007, Shuttle America accident, the NTSB also investigated the runway overrun in snowy conditions involving Southwest Airlines flight 1248 at Chicago-Midway Airport on December 8, 2005. On this basis, the activities of the POIs and the ACs referenced by the FAA have not been effective in addressing the problem that prompted this recommendation. The NTSB has many of the same concerns with the FAA’s response to this recommendation as it had with the response to Safety Recommendation A-08-16. As with Safety Recommendation A-08-16, the issuance of a SAFO may constitute an acceptable alternative solution, provided that the SAFO is sufficiently detailed, and if, after the SAFO’s issuance, 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. Pending the NTSB’s review of the proposed SAFO to determine that it provides sufficient details and the FAA 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-08-17 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 NTSB did not find any language describing how to accomplish maximum performance landings on contaminated runways. In addition, any proposed requirements associated with this NPRM would only apply to Part 121 carriers and not Part 135 or Part 91 subpart K operators. This recommendation is currently classified "Open-Response Received."

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 FAA continues to highlight awareness of winter operations and associated operational issues. FAA Order 8900.1 lists pertinent Advisory Circulars (AC) and booklets and requests that principal operations inspectors (POIs) bring the following issues to the attention of operators: ·AC 91-6, Water, Slush and Snow on the Runway, for guidelines concerning the operation of turbojet aircraft with water, slush, and wet or dry snow on runways; ·AC 91-13, Cold Weather Operation of Aircraft, for discussion of aircraft cold weather preparation and operations; ·AC 91-51, Airplane Deice and Anti-Ice Systems, for information on ice protection system approval and the results of in-flight icing; ·AC 135-9, FAR Part 135 Icing Limits, for guidance concerning compliance with FAR 135.227; and ·Winter Operations Guidance for Air Carriers, booklet prepared by Flight Standards Service. FAA Order 8900.1, volume 4, chapter 3, section 5, paragraph 4-597, directs POIs to ensure that the operator’s manuals contain specific instructions and information to flight crews for operating in adverse weather conditions or prohibit such operations. POIs are also to review the content of each operator’s training program to ensure adequate coverage of adverse weather operations. For example, the following items should be included in the operator’s training program under winter operations: ·A description of the performance and control problems that would differ from normal conditions during takeoff and landing with water, slush, or wet snow on the runway; ·The hazards associated with wet snow or slush in wheel wells when entering freezing temperatures; ·Techniques and procedures for braking, steering, and reversing with water, slush, or snow on taxiways and runways; ·Criteria for takeoff, en route, and destination weather conditions; The causes and effects to the aircraft from hydroplaning or aquaplaning; ·A description of landing surface conditions and appropriate braking action; and The speed, weight, and runway length adjustments that would be made when operating on contaminated runways. The FAA finds that it does not need to modify the guidance for its inspectors at this time. However, we will publish a SAFO within 90 days bringing out the issues in this accident. The SAFO will request that approved Initial, Upgrade, Transition, and Recurrent simulator training programs of part 121, 135, and 91 subpart K operators include training for pilots in applying maximum braking and maximum reverse thrust on contaminated runways until a safe stop is ensured. We find that the proposed Approach Requirements for part 121 operators in the revised N & O subparts address the issues the Board has raised. These requirements include: ·Establish the approach and landing configuration appropriate for the runway and meteorological conditions, and adjust the engine controls as required; ·Maintain a stabilized approach; ·Touchdown must be 500 to 3,000 feet (150 to 900 meters) past the runway threshold, not to exceed one-third of the runway length, with the runway centerline between the main gear, and with the airplane tracking parallel to the runway centerline; ·Use spoilers, propeller reverse or thrust reverse, and wheel brakes in a manner that ensures bringing the aircraft to a safe speed considering the point of touchdown and the runway remaining; and ·Maintain positive directional control and crosswind correction during the after-landing roll.