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Safety Recommendation Details

Safety Recommendation A-09-016
Details
Synopsis: On July 10, 2007, about 0835 eastern daylight time, a Cessna Aircraft Company 310R, N501N, part of the fleet operated by the National Association for Stock Car Auto Racing (NASCAR) corporate aviation division, crashed while performing an emergency diversion to Orlando Sanford International Airport (SFB), Orlando, Florida. The two pilots on board the airplane (a commercial pilot and an airline transport pilot [ATP]) and three people on the ground were killed. Four people on the ground received serious injuries. The airplane and two homes were destroyed by impact forces and a postcrash fire. The personal flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Develop a safety alert for operators encouraging all 14 Code of Federal Regulations Part 91 business operators to adopt Safety Management System programs that include sound risk management practices.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Sanford, FL, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: NYC07MA162
Accident Reports: In flight Fire, Emergency Descent and Crash in a Residential Area Cessna 310R, N501N
Report #: AAR-09-01
Accident Date: 7/10/2007
Issue Date: 2/18/2009
Date Closed: 9/12/2011
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Safety Management Systems

Safety Recommendation History
From: NTSB
To: FAA
Date: 9/16/2016
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) supplemental notice of proposed rulemaking (SNPRM) titled, “Safety Management System [SMS] for Certificated Airports,” which was published at 81 Federal Register 45871 on July 14, 2016. The SNPRM amends an October 7, 2010, notice of proposed rulemaking (NPRM) that was to require an SMS for all airports certificated under 14 Code of Federal Regulations (CFR) Part 139. Based on comments received and further internal analysis, the FAA now proposes (among other amendments) to require SMS only for those 14 CFR Part 139 certificated airports that are classified as a small, medium, or large hub airport in the National Plan of Integrated Airport Systems, serve international traffic, or have more than 100,000 total annual operations. As noted in the SNPRM, both the NTSB and the International Civil Aviation Organization support SMS as a means to prevent future accidents and improve safety. SMS includes an organization-wide safety policy, formal methods of identifying hazards, control and continual assessment of risk, and promotion of safety culture. SMS stresses not only compliance with technical standards but also increased emphasis on the overall safety performance of the organization. The NTSB has long recognized the benefits of SMS for a variety of aircraft operations. For example, on January 23, 2007, we issued Safety Recommendation A-07-10, which asked that the FAA require all Part 121 operators to establish SMS programs. In response, the FAA published its final rule on January 8, 2015, that established SMS requirements for all Part 121 operators; as a result, on December 1, 2015, we classified Safety Recommendation A 07 10 “Closed—Acceptable Action.” We also issued safety recommendations addressing the need for SMS for business operations conducted under Part 91 and for helicopter emergency medical services (HEMS) operations, some of which are operated under Part 135. In response to these recommendations, the FAA took action to encourage all Part 91 business operators to adopt SMS programs but did not take action to require SMS for HEMS operators. On February 18, 2009, we issued Safety Recommendation A-09-16, which asked the FAA to develop a safety alert for operators encouraging all Part 91 business operators to adopt SMS programs that include sound risk management processes. In response, on April 11, 2011, the FAA issued Information for Operators 11010, “[FAA SMS] Developments for General Aviation (GA) Operators”; as a result, Safety Recommendation A-09-16 was classified “Closed—Acceptable Action.” On September 24, 2009, we issued Safety Recommendation A-09-89, which asked the FAA to require HEMS operators to implement an SMS program that includes sound risk management practices. Safety Recommendation A-09-89 was classified “Closed—Unacceptable Action” on September 11, 2014, after the FAA responded that its rulemaking activity did not address HEMS operations. In followup correspondence dated September 24, 2014, the FAA stated that its goal was to require SMS for all Part 135 operators, including HEMS, but that, due to staffing limitations, it could not address a HEMS-specific rule at that time. The full text and correspondence history for Safety Recommendations A-07-10, A-09-16, and A-09-89 can be accessed from the Safety Recommendations link on the NTSB’s web page at www.ntsb.gov.

From: NTSB
To: FAA
Date: 9/12/2011
Response: The April 11, 2011, issuance of Information for Operators (InFO) message 11010, “Federal Aviation Administration (FAA) Safety Management System (SMS) Developments for General Aviation (GA) Operators” satisfies Safety Recommendation A-09-16, which is classified CLOSED—ACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 7/8/2011
Response: CC# 201100279: - From J. Randolph Babbitt, Administrator: The Federal Aviation Administration (FAA) supports the Board's recommendation to encourage 14 CFR part 91 operators to implement a safety management system program that includes sound risk management practices. In our last response we stated e would issue a Safety Alerts for Operators (SAFO) to highlight Advisory Circular 120-92, introduction to Safety Management Systems (SMS) for Operators. The Board asked the FAA to clarify that the SAFO would be focused on part 91 business operators. To address this recommendation the FAA determined that issuing an Information for Operators (InFO) was more appropriate for part 91 business operators. On April 11, 2011, the FAA issued InFO 11010, Federal Aviation Administration (FAA) Safety Management System (SMS) Developments for General Aviation (GA) Operators (enclosure). I believe the FAA has effectively addressed this safety recomn1endation, and I consider our actions complete.

From: NTSB
To: FAA
Date: 2/3/2011
Response: Notation 8278: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) notice of proposed rulemaking (NPRM) titled “Safety Management Systems for Part 121 Certificate Holders,” which was published at 75 Federal Register 68224 (November 5, 2010). The notice proposes to require 14 Code of Federal Regulations (CFR) Part 121 certificate holders to develop a safety management system (SMS). According to the NPRM, an SMS is a comprehensive, process-oriented approach to managing safety throughout an organization. An SMS includes an organization-wide safety policy, formal methods of identifying hazards, control and continual assessment of risk, and promotion of a safety culture. SMS stresses not only compliance with technical standards but also increased emphasis on the overall safety performance of the organization. The NPRM cited four reasons for the proposed SMS rulemaking: (1) the FAA’s desire to improve safety through proactive hazard identification and improved safety management practices among Part 121 operators; (2) existing International Civil Aviation Organization (ICAO) standards for SMS; (3) NTSB Safety Recommendation A-07-10, which asked the FAA to require all 14 CFR Part 121 operators to implement an SMS; and (4) a statutory requirement under Public Law 111-216 for issuance of a final rule on SMS by July 30, 2012. The NTSB recognizes the benefits of an SMS and supports the proposed rule, which, if adopted, would likely meet the intent of Safety Recommendation A-07-10. The proposed rule would require 14 CFR Part 121 operators to provide SMS implementation plans to the administrator for approval within 6 months of the effective date of the rule and to have a fully operational SMS within 3 years. The NTSB believes that this graduated implementation plan is justified because of (1) the complexity and breadth of SMS processes and (2) the criticality for operators and their FAA principal inspectors to ensure that the SMS components (safety policy, safety risk management, safety assurance, and safety promotion) both function together as a system and are incorporated into the operating practices of the airlines. Although the NPRM only addresses SMS for 14 CFR Part 121 operators, it states that the general requirements for SMS defined in the NPRM could be applied to other FAA-regulated entities in subsequent rulemaking. Following the 2007 issuance of Safety Recommendation A 07-10 concerning SMS in Part 121 operations, the NTSB has since issued safety recommendations addressing SMS for some operations conducted under Parts 91 and 135. For example, Safety Recommendation A-09-16 asks the FAA to develop a safety alert for operators encouraging all 14 CFR Part 91 business operators to adopt SMS programs that include sound risk management practices. In addition, Safety Recommendation A-09-89 asks the FAA to require helicopter emergency medical services operators to implement an SMS program that includes sound risk management practices. The NTSB firmly believes that aviation safety can be improved through the adoption of SMS by these operators and is encouraged that the FAA and the aviation rulemaking committee supporting the subject NPRM are also broadly considering the benefits of SMS for a variety of operations affecting the safety of the National Airspace System. Specifically, such operations include commuter and on-demand operations under 14 CFR Part 135, fractional ownership operations under 14 CFR Part 91 subpart K, training providers under 14 CFR Parts 141 and 142, maintenance repair stations under 14 CFR Part 145, and product manufacturers under 14 CFR Part 21. The NTSB looks forward to commenting on subsequent rulemaking efforts that support a phased implementation of SMS beyond Part 121 operations. The NPRM discusses the challenges associated with mandating voluntary programs—such as aviation safety action programs (ASAP), flight operational quality assurance (FOQA), line operations safety audits (LOSA), and advanced qualification programs (AQP)—as part of an SMS. Although the NPRM states that operators can use these programs to comply with the proposed rule’s provisions, the rule, if adopted, would not require operators to implement these programs as part of their SMS. The NPRM cites concerns regarding protection of voluntarily submitted safety data if such programs were FAA-mandated. Although the NTSB understands these concerns, it also recognizes that the effectiveness of the safety assurance component of SMS is predicated on operators having robust tools in place to conduct safety performance monitoring and measurement and that existing voluntary programs have proven invaluable in this area. In a January 22, 2008, letter to the administrator regarding Safety Recommendation A-07-9, the NTSB stated that a required LOSA program should be part of an SMS. The NTSB encourages the FAA to reconsider its position regarding the need to require programs such as FOQA, LOSA, ASAP, and AQP in the final rule. The NPRM also describes the SMS record-keeping requirements as a necessity “for certificate holders to conduct a meaningful analysis under safety risk management, to review safety assurance activities, and for the FAA to review for compliance during inspections.” The NTSB is encouraged that these data are being retained for a 5-year period and made available for FAA review. However, the NPRM does not make clear how data collected as part of an SMS will be protected from disclosure so that employees are not discouraged from providing important safety information. If these SMS data are not anticipated to be protected under current statutory/regulatory structures, the FAA should seek the appropriate authority to do so, as proposed in Safety Recommendation A-10-28. As noted in the NPRM, an SMS at the operator level does not replace active oversight efforts by the FAA, and the FAA is still responsible for setting safety standards, conducting inspections, and maintaining oversight. However, standardizing the SMS concept, through advisory and guidance information produced by the FAA, and specifying the requirements for a mature SMS will provide operators with the tools and framework to potentially manage safety proactively; these actions can also provide the FAA with a systematic approach for evaluating the effectiveness of operators’ management of safety. This approach will help raise the bar on safety in this industry. The NTSB appreciates the opportunity to comment on this NPRM.

From: NTSB
To: FAA
Date: 3/9/2010
Response: The FAA replied that it will issue a SAFO to highlight AC 120-92, Introduction to Safety Management Systems for Air Operators, and encourage operators to develop an SMS. AC 120-92 contains guidance for SMS development. The FAA’s plan to issue the SAFO is responsive to this recommendation, but the NTSB is concerned that the title of the AC indicates that it is focused on SMS programs for air operators, while this recommendation addresses SMS programs for Part 91 business operators. The NTSB asks the FAA to clarify that the SAFO is for Part 91 business operators. Pending issuance of a SAFO addressing SMS for Part 91 business operators, Safety Recommendation A-09-16 is classified OPEN -- ACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 10/20/2009
Response: Notation 8153: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration's (FAA) Advance Notice of Proposed Rulemaking (ANPRM) titled "Safety Management System," which was published in 74 Federal Register 140 on July 23,2009. The advance notice solicits public comments on a potential rulemaking requiring certain 14 Code of Federal Regulations (CFR) Part 21, 119, 121, 125, 135, 141, 142, and 145 certificate holders, product manufacturers, applicants, and employers to develop safety management system (SMS) programs. According to the ANPRM, an SMS is a comprehensive, process-oriented approach to managing safety throughout an organization. An SMS includes an organization-wide safety policy; formal methods of identifying hazards, mitigating risks, and continually assessing risks; and promotion of a safety culture. SMS programs not only stress compliance with technical standards but also place increased emphasis on the organizational aspects and processes that ensure risk management and safety assurance. The ANPRM solicits input on 17 questions; although most of the questions are directed towards certificate holders and service providers who would likely be affected by an SMS rule, the NTSB is providing general input at this time. The NTSB recognizes the benefits of SMS programs and supports rulemaking in this area. As a result of its investigations, the NTSB has issued three safety recommendations since 2007 addressing the importance of SMS programs in 14 CFR Part 121 operations and in some operations conducted under Parts 91 and 135. For example, Safety Recommendation A-07-10 asked the FAA to "require that all 14 Code of Federal Regulations Part 121 operators establish Safety Management System programs." On January 22, 2008, this recommendation was classified "Open-Acceptable Response" pending the FAA's requirement that all Part 121 operators establish SMS programs. Also, Safety Recommendation A-09-162 asked the FAA to "develop a safety alert for operators encouraging all 14 Code of Federal Regulations Part 91 business operators to adopt Safety Management System programs that include sound risk management practices." In addition, on September 24, 2009, in response to the increase in fatal accidents involving helicopter emergency medical services (HEMS) operations in 2008, the NTSB issued Safety Recommendation A-09-89 asking that the FAA require HEMS operators to implement SMS programs that include sound risk management practices. The ANPRM states that potential rulemaking may affect a broad range of certificate holders and service providers. The NTSB is encouraged that the FAA is considering requirements for SMS implementation not only for 14 CFR Part 121 operators (which would be consistent with the action desired in Safety Recommendation A-07-10) but also for commuter and on-demand operators under 14 CFR Part 135, training providers under 14 CFR Parts 141 and142, maintenance repair stations under 14 CFR Part 145, and product manufacturers under 14 CFR Part 21. However, the ANPRM does not specifically address corporate operations under 14 CFR Part 91 or fractional ownership operations under 14 CFR Part 91 subpart K, even though the FAA notes in the ANPRM that some 14 CFR Part 91 operators have used Advisory Circular 120-92, "Introduction to Safety Management Systems for Air Operators," for voluntary SMS development. As discussed above, Safety Recommendation A-09-16 noted the need for all 14 CFR Part 91 business operators to adopt SMS programs. Therefore, the NTSB encourages the FAA to include these operations in SMS rulemaking to allow them to benefit from the proactive management of safety by implementing SMS programs that incorporate safety policy, safety risk management, safety assurance, and safety promotion. In question 12, the FAA specifically requests comments on the role of voluntarily submitted safety data through programs such as the Aviation Safety Action Program (ASAP) and how these programs would fit within an SMS framework. The NTSB considers programs such as ASAP and the Flight Operational Quality Assurance (FOQA) program to be fundamental tools for operators to realize the safety assurance component of SMS programs. The NTSB has had a longstanding interest in programs such as ASAP and FOQA and has issued safety recommendations encouraging the adoption of these programs. The FAA states in its ANPRM that SMS "is not a substitute for compliance with FAA regulations or FAA oversight activities. Rather, an SMS would ensure compliance with safety related statutory and regulatory requirements." The NTSB agrees that this important distinction must be overtly stated. A mature SMS can help to provide an operator with the tools and framework to proactively manage safety. It can also help to provide the FAA with a systematic approach for evaluating the effectiveness of an operator's management of safety. However, as the FAA moves forward with rulemaking activities in this area, it must ensure that SMS programs facilitate and do not subjugate the FAA's essential responsibility to provide direct and active oversight of operators and service providers in this industry. The NTSB appreciates the opportunity to comment on this advance notice of proposed rulemaking.

From: FAA
To: NTSB
Date: 5/4/2009
Response: Letter Mail Controlled 5/12/2009 12:11:59 PM MC# 2090293: - From Lynne A. Osmus, Acting Administrator: FAA Comment. The FAA will issue a SAFO to highlight AC 120-92, Introduction to Safety Management Systems (SMS) for Air Operators, and encourage operators to develop an SMS. AC 120-92 contains a clear message as to the benefits of SMS, as well as guidance for SMS development. We anticipate issuing this SAFO by December 2009.