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General Aviation Safety
On March 4, 2008, about 1515 central standard time, a Cessna 500, N113SH, registered to Southwest Orthopedic & Sports Medicine Clinic PC of Oklahoma City, Oklahoma, entered a steep descent and crashed after colliding in flight with a flock of large birds about 2 minutes after takeoff from Wiley Post Airport (PWA) in Oklahoma City.2 None of the entities associated with the flight claimed to be its operator. The pilot, the second pilot,3 and the three passengers were killed, and the airplane was destroyed by impact forces and postcrash fire. The flight was operated under 14 Code of Federal Regulations (CFR) Part 91 with an instrument flight rules (IFR) flight plan filed. Visual meteorological conditions prevailed. The flight originated from the ramp of Interstate Helicopters (a 14 CFR Part 135 on-demand helicopter operator at PWA) and was en route to Mankato Regional Airport (MKT), Mankato, Minnesota, carrying company executives who worked for United Engines and United Holdings, LLC.
TO THE FEDERAL AVIATION ADMINISTRATION: Explore and implement strategies to improve on-site inspector surveillance activities at airports and of flight operations to detect and deter improper charter operations.
Original recommendation transmittal letter:
Closed - Unacceptable Action
Oklahoma City, OK, United States
Crash of Cessna 500, N113SH, Following an In-Flight Collision with Large Birds
Addressee(s) and Addressee Status:
FAA (Closed - Unacceptable Action)
Oversight, Part 135
Safety Recommendation History
On December 23, 2009, the FAA stated that, in response to this recommendation, it intended to develop work programs for its inspectors based on risk determined from data collected by its Safety Performance Analysis System (SPAS). The FAA stated (1) that SPAS provided the foundation for a data-driven approach to safety and (2) that the use of SPAS performance measures to identify trends would allow the FAA to most efficiently use agency resources to ensure safe operations by air carriers. On May 27, 2010, we replied that the use of SPAS as described would not constitute an acceptable response to Safety Recommendation A-09-80. This recommendation was issued because SPAS and Order 1800.56J (the basis for developing inspector work programs using SPAS data) do not adequately address the evaluation of risk when priorities and activities for oversight work programs are being developed. The problem exists because SPAS does not collect necessary data that is available to—and can be collected by—an on-scene inspector. Rather than address these deficiencies, the FAA continues to use the system to define inspector work programs. The FAA developed the Surveillance Priority Index (SPI), which uses SPAS data to rank assessed safety risks, information that is then used to set priorities for surveillance. The FAA now requires its inspectors responsible for the oversight of Part 135 certificate holders to use the SPI when developing or revising annual work programs. In answer to our concerns about SPAS not capturing all of the data needed, the FAA replied that it believes that using the SPI allows it to focus surveillance resources and efforts where they are needed most, thereby leveraging agency resources more efficiently. We continue to believe that our investigation of the March 4, 2008, accident in Oklahoma City clearly demonstrates that SPAS and the inspector work programs based on it cannot adequately evaluate risk because they do not collect sufficient data. In the Oklahoma City accident, aviation safety inspectors needed more time and different priorities to properly investigate reports that the FAA had received concerning the illegal charter activities of Interstate Helicopters, the organization that the NTSB identified as the operator in that accident. We do not believe that use of the SPI would have changed any of the oversight provided by the FAA in this accident; however, the FAA believes that it has fully responded to this recommendation and it plans no further action. Consequently, Safety Recommendation A-09-80 is classified CLOSED—UNACCEPTABLE ACTION.
-From Michael P. Huerta, Acting Administrator: As slated in our December 23, 2009, letter, the Federal Aviation Administration (FAA) has been working on long-term revisions to the part 135 surveillance program. Over the last several years we have developed guidance to our inspectors with oversight responsibility of part 135 certificate holders. The purpose of the guidance is to enhance aviation safety and to more efficiently use FAA inspector resources. Also, we have developed the Surveillance Priority Index (SP!), a data-driven work program in the Safety Performance Analysis System (SPAS). On August 4, 2010, we published a change to FAA Order 8900.1, Flight Standards Information Management Systems, volume 6, chapter 2, section 1. This change required FAA aviation safety inspectors (ASIs) with oversight responsibility for one or more part 135 certificate holders to use the SPI. It also includes a detailed summary of the factors that go into the SPI tool for risk analysis. On August 12, 2010, we issued Notice 8900.132, Work Program Development for 14 CFR Part 135 Certificate Holders, instructing these same ASIs to use the SPI when developing an annual work program or during reassessment of an existing work program. The contents of this notice were incorporated into Order 1800.561., National Flight Standards Work Program Guidance. The SPI is a tool that provides a ranked order of assessed safety risks and is used as the basis for surveillance activities, identifying the amount of oversight, and prioritizing the timing of surveillance required for a particular operator. The SPI allows inspectors to prioritize work functions based upon the SPI ranked score. A higher SPI score provides a preliminary indication of higher inspection priority. The certificate holder's calculated index value is not an absolute measure of safety risk, but rather a tool to assist users in prioritizing certificate holders when considering surveillance. A definitive assessment of individual safety risk can only be determined after conducting surveillance and then analyzing the subsequent surveillance results along with other relevant data. Inspectors can use the SPI as part of a safety analysis to identify increased risk of a particular certificate holder and to increase or redirect surveillance, based on priority. In its May 27, 2010, letter, the Board expressed concern that modifying the SPAS program might not help the FAA's surveillance efforts. For the reasons discussed above, we believe that the mandated use of the SPI tool allows us to leverage resources more efficiently by focusing our surveillance resources and efforts where they are needed most. This targeted surveillance will help effectively detect and deter improper charter operations. In our December 23, 2009, response, we also suggested incorporating a module in the aviation safety inspector initial and recurrent training program that focused on identification of potential illegal charter identification to address components of this recommendation. In the Board's May 27, 2010, response the Board disagreed that adding more training was responsive to this recommendation. Therefore, we have decided not to develop and incorporate this training into the aviation safety inspector initial and recurrent training program. I believe the FAA has effectively addressed this safety recommendation through use of the SPI, and I consider our actions complete.
The NTSB disagrees with the FAA that improving aviation safety inspector (ASI) training by adding more training on the identification of potential illegal charter operations is responsive to this recommendation. In the Oklahoma City accident that prompted Safety Recommendation A-09-80, investigators found no indication that greater training of the ASIs involved would have resulted in any different FAA response. Instead, adequate time and priority in the work programs of the ASIs was needed for them to properly investigate reports the FAA had received concerning the illegal charter activities of Interstate Helicopters, the organization that the NTSB identified as the operator in that accident. Improved training of ASIs would not have made this time available in their work programs. Of even greater concern is the FAA’s belief that greater reliance on its Safety Performance Analysis System (SPAS), the major tool used by the FAA for managing its risk-based work program, and revisions to FAA Order 1800.56J to address oversight activities of Part 135 on-demand carriers constitute an acceptable substitute for the recommended action. This recommendation was issued because SPAS and Order 1800.56J do not adequately address the evaluation of risk when developing oversight work program priorities and activities, because these systems are missing needed data collection associated with an on-airport inspector presence. Accordingly, pending the FAA’s reconsideration of its position and completion of the recommended action, Safety Recommendation A-09-80 is classified OPEN -- UNACCEPTABLE RESPONSE.
Letter Mail Controlled 1/7/2010 3:59:43 PM MC# 2100009: - From J. Randolph Babbitt, Administrator: To address the intent of recommendations A-09-80 and -81, the FAA will incorporate a module in the Aviation Safety Inspector (ASI) initial and recurrent training programs that focuses on identification of potential illegal charter identification. Along with the training module, we are currently developing interim and long-term revisions to the part 135 surveillance program. Surveillance requirements for on-demand operators are currently outlined in FAA Order 1800.56J, Flight Standards National Work Program Guidelines and are intended to be risk-based work programs. They are created and adjusted based on recurring safety assessments. Specifically, Order 1800.56J states: "This order emphasizes the requirement to use the Safety Performance Analysis System (SPAS) for safety assessment, surveillance planning, decision making, certification, and investigation, as appropriate. SPAS is a major tool for managing a risk-based work program and it is the foundation for a data-driven approach to safety. SPAS performance measures help the FAA identify trends to effectively focus resources. Using the results of this assessment, [principal inspectors] (PIS) will create their annual work programs and conduct regular safety reassessments or reviews of their annual work programs. PIS must act upon emerging trends, safety concerns and changes in the aviation environment as they develop." Additionally, the FAA will consider the inherent operational risk factors in on-demand operations as it develops its risk-based part 135 oversight system scheduled for implementation in calendar year 2013. The FAA has also provided funds through a grant to the National Air Transportation Association (NATA) to establish an independent illegal charter hotline whereby certificated aircraft operators may call and make reports regarding illegal activity, which will be forwarded to FAA Headquarters staff for review and investigation. Any employee or agent of a part 135 on-demand certificate holder can call a toll-free number, 888-759-3581 or 888-SKY-FLT1, to file a report of suspected illegal commercial flights, where an aircraft operator without an FAA part 135 certificate is accepting compensation for transportation in violation of both FAA and Department of Transportation regulations. The number is available 24 hours a day and operators may leave a message to receive a call back if the hotline agent is unavailable. Operators are encouraged to compile as much factual data as possible regarding the suspected illegal activity. We will actively pursue information obtained through the NATA illegal charter hotline to revise the ASI training programs as needed to aid in illegal charter operations and to revise the part 135 surveillance program to aid in detecting noncompliant charter activities. I will keep the Board informed of the FAA's progress on these safety recommendations and will provide an update by September 2010.
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