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Safety Recommendation Details

Safety Recommendation A-08-018
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 have a written policy emphasizing that either pilot can make a go-around callout and that the response to the callout is an immediate missed approach.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable 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: 11/18/2016
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Go Around,Procedures

Safety Recommendation History
From: NTSB
To: FAA
Date: 11/18/2016
Response: We note that, on October 20, 2014, you published a revision to FAA Order 8900.1, “Flight Standards Information Management System.” This revision directs inspectors of Parts 91K, 121, 125, and 135 operators, who are responsible for approving or accepting manuals/procedures, to require that operators publish or reinforce written policies and procedures emphasizing that either the pilot flying or the pilot monitoring may make a go-around callout. The flying pilot’s immediate response to a go-around callout by the non-flying pilot, then, would be to execute a missed approach, as applicable. We are also encouraged to learn that you are in the process of updating Safety Alert for Operators 10005, “Go-Around Callout and Immediate Response,” and revising Advisory Circular 120-71, “Standard Operating Procedures for Flight Deck Crewmembers.” We look forward to reviewing these updated guidance documents once they have been published, and we believe that the revisions to Order 8900.1 will satisfy the intent of Safety Recommendation A-08-18. Accordingly, the recommendation is classified CLOSED—ACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 9/1/2016
Response: -From Michael P. Huerta, Administrator: On October 20,2014, the Federal Aviation Administration (FAA) published an update to FAA Order 8900.1. flight Standards Information Management System (enclosed). The revision to Order 8900.1. volume 3. chapter I 0, section I, paragraph 3-277 applies to inspectors of parts 91 K, 121, 125, 135 operators responsible for approving or accepting manuals/procedures and requires operators to publish or reinforce written policies and procedures. This order emphasizes that either the pilot flying or the pilot monitoring may make a go-around callout. and the flying pilot's immediate response to a go-around callout by the non-flying pilot is execution of a missed approach, as applicable. On March 29,2012, the FAA completed its survey of all principal operation inspectors (POIs) for part 121 operators; 90 percent of POIs responded their operators have either incorporated or already were in compliance with Safety Alert for Operators (SAFO) 10005, Go-Around Callout and Immediate Response. We anticipate publication of an update to SAFO I 0005 in late 20 17. Although not required to address this recommendation, we are also in the process of revising Advisory Circular (AC) 120-71. Standard Operating Procedures for Flight Deck Crewmembers, which is expected to be complete in late 2017. I will keep the Board informed of the FAA ·s progress on this safety recommendation and update the Board by November 2017.

From: NTSB
To: FAA
Date: 11/6/2012
Response: The FAA published Safety Alert for Operators (SAFO) 10005, “Go-Around Callout and Immediate Response,” on March 1, 2010, recommending that operators (Parts 121, 125, 135, and 91 subpart K) publish or reinforce existing written policy emphasizing that either the pilot flying or the pilot monitoring may make a go-around callout, and emphasizing that the flying pilot’s immediate response to a go-around callout by the non-flying pilot is execution of a missed approach. However, the FAA reported that a survey conducted had found that not all operators had adopted the action recommended in SAFO 10005. We note that the FAA plans to ensure both compliance and oversight in the SAFO by changing FAA Order 8900.1, “Flight Standards Information Management System.” We also note that the FAA is in the process of updating Advisory Circular 120-71, “Standard Operating Procedures for Flight Deck Crewmembers,” to include changes addressing go-around callouts and initiation of immediate action by the pilot flying, if a go-around is called by either pilot. Pending the FAA’s revising Order 8900.1 and completing the survey to ensure that all operators have developed and implemented the recommended written policy, Safety Recommendation A-08-18 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/2/2012
Response: -From Michael P. Huerta, Acting Administrator: The Federal Aviation Administration (FAA) published Safety Alert for Operators (SAFO) 10005, Go-Around Callout and Immediate Response, on March 1,2010, recommending parts 121, 125, 135, and 91 subpart K (91K) operators should publish or reinforce existing written policy emphasizing that: • Either the pilot flying or the pilot monitoring may make a go-around callout; and • The flying pilot's immediate response to a go-around callout by the non-flying pilot is execution of a missed approach. The FAA also published Notice 8900.151 , Verification of Go-Around Callout Written Policy (Parts 121, 135, and 91K) on March 25,2011 , directing principal operations inspectors (POIs) responsible for parts 121, 125, and 135 certificate holders and part 91K program managers to survey and report on each of their operator's status on the recommended action in SAFO 10005. As of March 29,2012, ninety percent ofPOIs for part 121 operators have responded indicating their operators have either incorporated or already were in compliance with SAFO 10005. Since the notice also included part 135 single-pilot and helicopter operators, tracking voluntary compliance with applicable (i.e. two pilot crew aircraft) part 135 operators was problematic. After excluding helicopter and single-pilot operations, the amount of part 135 operators incorporating the recommendation in the SAFO was less than optimal. The same held true for parts 125 and 91K operators. To address this, the FAA will ensure compliance and oversight with the suggested recommendations in the SAFO by changing FAA Order 8900.1, Flight Standards Information Management System (FSMIS), volume 3, chapter 19, section 3, paragraph 3-1145. Section H of this paragraph, Concepts of Instrument Procedures, will be modified to include "Missed Approach/Go-Around callouts and immediate compliance by either Pilot Flying (PF) and/or Pilot Monitoring (PM)." The FAA is also considering changes to FAA Order 8900.1 in volume 3, chapter 19, section 6. Additionally, the FAA is in the process of updating Advisory Circular 120-71, Standard Operating Procedures for Flight Deck Crewmembers. These changes are in internal FAA review and include changes addressing go-around callouts and initiation of immediate action by the pilot flying if called by either pilot. I will keep the Board informed of the FAA's progress on this safety recommendation and provide an update by August 2013.

From: NTSB
To: FAA
Date: 4/30/2012
Response: Notation 8406: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) notice of proposed rulemaking (NPRM) titled “Pilot Certification and Qualification Requirements for Air Carrier Operations,” which was published at 77 Federal Register (FR) 12374 on February 29, 2012. The notice proposes to create new certification requirements for pilots in air carrier operations, including requiring that first officers in 14 Code of Federal Regulations (CFR) Part 121 operations hold an airline transport pilot (ATP) certificate and type rating for the aircraft to be flown; allowing pilots with an aviation degree or military pilot experience but fewer than 1,500 hours total time as a pilot to obtain an ATP certificate with restricted privileges; and requiring at least 1,000 flight hours in air carrier operations to serve as pilot in–command (PIC) in Part 121 air carrier operations. The notice also proposes to modify the requirements for obtaining an ATP certificate with an airplane category multiengine class rating or type rating to require 50 hours of multiengine flight experience and completion of a new FAA-approved ATP certificate training program that would include academic training and training in a flight simulation training device. According to the NPRM, these changes would help to ensure that pilots entering an air carrier environment have the training and aeronautical experience necessary to adapt to a complex, multicrew environment in a variety of operating conditions. The NPRM cites the 2009 Colgan Air accident near Buffalo, New York, as an event that focused public, congressional, and industry attention on flight crew experience requirements and training for conducting Part 121 air carrier operations. In February 2010, the FAA published an advance notice of proposed rulemaking (ANPRM), titled “New Pilot Certification Requirements for Air Carrier Operations” (75 FR 6164, February 8, 2010) that sought input on current Part 121 eligibility, training, and qualification requirements for seconds-in-command (SICs). The current NPRM is based on comments in response to the ANPRM, input received from an aviation rulemaking committee established in July 2010, and statutory requirements for modifying ATP certification outlined in the Airline Safety and Federal Aviation Administration Extension Act of 2010 (Public Law 111-216). Adding to that foundation, the NPRM states that the FAA conducted a study of 61 NTSB investigation reports from fiscal year (FY) 2001 through FY 2010 (31 Part 121 accidents and 30 Part 135 air carrier accidents, with 107 fatalities, 28 serious injuries, and 44 minor injuries). The study showed that the accidents examined involved pilot deficiencies in aircraft handling, including stall and upset recognition and recovery, high altitude training, active pilot monitoring skills, effective crew resource management (CRM), stabilized approaches, operations in icing conditions, and hypoxia training. The NPRM asserts that the changes to air carrier pilot qualification would address, in part, 21 NTSB safety recommendations in the following areas: Safety Issue Recommendations Training flight crews to respond to sudden, unusual, or unexpected aircraft upsets: A-96-120, A-04-62, A-07-3, and A-09-113 Developing and conducting stall recovery training and providing stickpusher familiarization training for pilots of stickpusher-equipped aircraft: A-10-22 and -23 Training in high altitude operations: A-07-1 and -2 Training and guidance for rudder use in transport-category aircraft: A-02-2 Airport situational awareness: A-07-44 Stabilized approach concept: A 01 69 and A-08-18 Landing performance calculations: A-07-59 and A-08-41 CRM training: A-03-52 Pilot monitoring duties: A-10-10 Requirements for flight crewmember academic training regarding leadership and professionalism: A-10-15 Training in icing conditions: A-07-14 Hypoxia awareness training: A 00 110 Training in landing and taking off in crosswinds with gusts: A 10-110 and -111 The NTSB is generally supportive of the proposed rule as it relates to many of the issues previously identified in our safety recommendations. Specific comments on several areas of the NPRM follow. Academic Credit To Reduce Flight Experience Requirements Although the NTSB has not made recommendations for flight hour minimums for air carrier pilots (instead focusing its recommendations on specific procedures and training, needed regulations, and needed guidance to crews and operators), we stated in our comments on the ANPRM that: Ensuring a high level of knowledge, skills, and professionalism for flight crewmembers is essential, but total flight hours or an airline transport pilot certificate does not necessarily equate to the level of knowledge, skills, and professionalism required for consistently safe flight operations. The comments went on to state that, “the NTSB recognizes the value of academic training for air carrier pilots, but the NTSB also believes that academic training is not a substitute for practical experience.” An important tenet in the recent NPRM is the concept that, “in certain circumstances, the combination of focused academic training and structured flight training can substitute for actual flight experience” (p. 12379). The NTSB concurs with the FAA’s acknowledgement that there may be multiple pathways to becoming a qualified air carrier pilot. However, there remain unresolved issues for how academic credit should be applied, including student performance within an accredited academic program and the type of degree conferred. These issues are not addressed in the NPRM and require more evaluation before this proposal is implemented. It is essential that the content and rigor involved in academic training be clearly defined and, most importantly, appropriate resources allocated to conduct evaluation and oversight of these alternative methods of qualification. ATP Certification Training Program The NPRM discusses the establishment of an FAA-approved ATP certificate training program for a multiengine class ATP or type rating. The proposed training program outlined under section 61.154 would include 24 hours of classroom training and 16 hours of simulator training (8 in a full flight simulator of at least Level C standards) and is intended to provide pilots with the core knowledge and understanding in areas critical to operating high performance aircraft in a complex and high altitude environment. The training would be provided by an authorized training provider and would be required to be completed before a pilot would be eligible to take the ATP knowledge test. Issued as part of the NPRM, draft Advisory Circular (AC) 61-ATP, “Airline Transport Pilot Certification Training Program for Airplane Category Multiengine Class Rating or Type Rating,” contains an outline of the curriculum topics and objectives for both the classroom and simulator training making up this training program. The AC is intended for use by training providers when developing the program and by the FAA when reviewing and approving the programs. Many of the topics contained in the draft AC address issues from NTSB safety recommendations; in fact, the FAA notes that most of the 21 recommendations cited in the NPRM are addressed, in part, by the proposed amendments and advisory material. Although the NTSB concurs with the FAA’s assessment that, in most cases, the topics addressed will serve to partially satisfy the action requested in existing recommendations, the amount of specificity provided in the proposed rule and AC does not allow a comprehensive review of the degree to which the FAA’s proposed actions would satisfy the intent of the NTSB’s recommendations. In some instances, neither document provides evidence that a recommendation topic is addressed. The NTSB notes that recent safety recommendations in this area have focused on attempts to improve crew response to in-flight emergencies, including task prioritization and training. While AC 61-ATP does include a classroom training objective named “differences between emergency and non-normal checklist procedures and checklists,” the guidance on emergency procedures should be made more explicit to incorporate the issues identified in these NTSB recommendations. CRM is another topic relevant to previous NTSB recommendations and outlined in AC 61-ATP. However, the list of proposed topics in the AC does not explicitly refer to the importance of first officer assertiveness, which is an issue addressed in Safety Recommendation A-11-39. This recommendation is not cited in the NPRM, but the NTSB believes that it is within the scope of the draft advisory material and suggests amending the AC to include information consistent with Safety Recommendation A-11-39 to help support this important aspect of CRM. The NTSB is encouraged that the NPRM proposes to centralize the process for approving ATP certification training programs. Specifically, the NPRM states that only authorized training providers can administer the training required under section 61.154. These providers can be certificate holders providing training and operating under Parts 141, 142, 121, or 135, and each provider must receive approval of their ATP certification training program by the FAA Air Transportation Division (AFS-200). The NTSB notes that, theoretically, centralization should help to ensure standardization of these programs, but suggests that additional guidance documentation with more specific and robust detail about the content of the proposed training is necessary to provide a solid foundation on which the FAA can evaluate the program content (and to assist training providers to develop courses likely to receive FAA approval). For example, additional detail, such as cross-referencing material from draft AC 120-STALL, would be appropriate in the discussion of stall training in AC 61-ATP. In addition, the FAA will need to provide the appropriate oversight resources to these programs—not only in their initial approval but also to conduct ongoing oversight to demonstrate that the content delivered is consistent with the approved program. The rigor with which these programs are implemented and overseen will determine their ultimate influence on improving safety in air carrier operations. Pilot-in-Command Requirements for Air Carrier Operations The NPRM proposes primarily experience-based requirements for new PICs in air carrier operations. However, the NTSB has previously issued safety recommendations addressing the need for a specific leadership training course for upgrading captains. Although the NPRM cites Safety Recommendation A-10-15 and describes it as applicable to leadership and professionalism training, it addresses only the latter topic. The NPRM does not mention Safety Recommendations A-10-13 and -14, which were issued with -15, but the NTSB believes that a leadership training course for upgrading captains is within the scope of the proposed rulemaking and that section 121.436 should be amended to include a specific requirement for such a course. In addition to the requirements already outlined in section 121.434, the NTSB has recommended that Part 135 pilots who need a type rating for the aircraft they fly be required to have a minimum level of initial operating experience. Given the applicability of the NPRM to Part 135 pilots who are engaged in air carrier operations, the NTSB believes it would be appropriate to incorporate similar experience requirements for these pilots as exist for Part 121 pilots. The NTSB supports the use of simulators in training environments and notes that the training program outlined in the NPRM specifies that training on topics such as low energy states/stalls and upset recovery techniques will be conducted in a Level C or higher full-flight simulator. Simulators, regardless of their fidelity, are dependent on their physical limits of motion, as well as the efficacy of the available computer programs (which are often limited in issues of upset training because of the lack of flight test data at the extreme areas of the flight envelope). Simulators are not always adequate in portraying upsets and stalls and may inadvertently introduce negative training. Consistent with Safety Recommendation A-04-62, the FAA should allow flexibility in determining what level of simulation or automation is appropriate for specific training. Summary Observations This NPRM addresses many training issues applicable to becoming an air carrier pilot, including some critical issues demonstrated in recent accident history to be responsible for accidents. The NTSB is encouraged that its recommendations were considered in the development of this proposed rule, especially as the issue areas relate to the core content to be provided to new entrant pilots through the ATP certification training program. However, the intent of our recommendations in this area is for all pilots to receive training in these topics. Therefore, it is important that air carriers provide equally robust training in these topic areas for their current air carrier pilots on a recurrent basis. The NTSB appreciates the opportunity to comment on this NPRM.

From: NTSB
To: FAA
Date: 6/22/2009
Response: The FAA plans to publish a SAFO that will discuss the hazards of cockpit crewmembers not immediately and instinctively reacting to a go-around callout at any phase of flight while on an approach for landing. The FAA also plans to revise Order 8900.1 to incorporate guidance instructing POIs to have all Part 121, Part 135, and Part 91 subpart K operators develop a written policy emphasizing that either pilot can make a go-around callout and that the response to the callout is an immediate missed approach. The planned revision to Order 8900.1 is responsive to this recommendation; however, to fully meet the intent of this recommendation, the FAA will need to survey all Part 121, Part 135, and Part 91 subpart K operators to determine that the operators have developed and implemented the written policy recommended. Pending the FAA’s revising Order 8900.1 and completing the survey to ensure that all operators have developed and implemented the recommended written policy, Safety Recommendation A-08-18 is classified OPEN -- ACCEPTABLE RESPONSE.

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: It is critical to flight safety that either flight crew member be able to call for the go-around if either pilot believes that a landing would be unsafe. Although Crew Resource Management principles prescribe that some cockpit decisions can be made by crew consensus, others, including the go-around callout, require immediate action without question due to the close proximity to the ground. To emphasize this, the Federal Aviation Administration Air Transportation Division will publish a SAFO. The SAFO will identify the hazards of cockpit crew members not immediately and instinctively reacting to a go-around callout at any phase of flight while on an approach for landing. We plan to publish the SAFO by November 30, 2008. The Air Transportation Division will also implement a change to FAA Order 8900.1, Flight Standards Information Management System, incorporating guidance to principal operations inspectors to have all part 121, 135, and part 91 subpart K operators, develop written policy emphasizing that either pilot can make a go-around callout and that the response to the callout is an immediate missed approach. We plan to have this change completed by February 28, 2009.