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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: Assess why your existing policies, procedures, and practices resulted in a failure to detect the noncompliant actions of Interstate Helicopters and develop additional methods, measures, or procedures for performing inspections of and following up on complaints about 14 Code of Federal Regulations Part 135 on-demand operators that can successfully detect noncompliant 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
We continue to believe that our investigation of the March 4, 2008, accident that occurred in Oklahoma City clearly demonstrates that the Safety Performance Analysis System (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. We do not believe that use of the Surveillance Priority Index, which uses SPAS data to rank assessed safety risks, would have improved the oversight provided by the FAA in this accident; however, the FAA believes that it has fully responded to this recommendation and plans no further action. Consequently, Safety Recommendation A-09-81 is classified CLOSED—UNACCEPTABLE ACTION.
-From Michael P. Huerta, Administrator: The Federal Aviation Administration's (FAA) policies, procedures, and practices in existence at the time of the March 4, 2008, accident, which resulted in a failure to detect the noncompliant actions of Interstate Helicopters, did not include the beneficial changes now implemented by our inspecting field offices. As stated in our December 23, 2009, letter to the Board, the FAA has been working on long-term revisions to the part 135 surveillance program. Over the last several years, the FAA provided guidance to its Aviation Safety Inspectors (ASIs) with oversight responsibility of part 135 certificate holders. The purpose of the guidance is to enhance aviation safety and to more efficiently use FAA ASI resources. We developed a data-driven work program in the Safety Performance Analysis System (SPAS). When developing an annual work program, or during reassessment of an existing work program, FAA ASIs with oversight responsibility for one or more part 135 certificate holder(s) must use the Surveillance Priority Index (SPI) in SPAS. On August 4, 20 I 0, we published a change to FAA Order 8900.1, Flight Standards Information Management System, volume 6, chapter 2, section 1. This change requires FAA ASIs with oversight responsibility for one or more part 135 certificate holder(s) 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 1800.56L, National Flight Standards Work Program Guidelines. 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 ASIs 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. ASIs will 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, 20]0, letter, the Board expressed concern that modifying SPAS 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 suggested incorporating a module in the ASI initial and recurrent training program that focused on potential illegal charter identification to address components of this recommendation. In this letter, we also said we would work with the National Air Transportation Association (NATA) to establish a hotline to report suspected illegal charter operations. In the Board's May 27, 2010, response, it disagreed that these actions were responsive to this recommendation. Therefore, we decided not to develop and incorporate the training into the ASI initial and recurrent training progran1. However, we did work with NATA to set up the illegal charter hotline, which is still in operation. Finally, we established and implemented the FAA Special Emphasis Investigations Team (SEIT). Under SEIT, all Flight Standards District Offices (FSDO) are tasked with investigating non-compliant charter operations. SETTs have been highly successful in the detection, investigation, and prosecution of non-compliant charter operations by: I. Providing investigative guidance and resources to FSDO investigations of noncompliant and illegal charter operations in their area of geographic responsibility; 2. Investigating or referring for investigation complaints reported to the NATA hotline; 3. Directly detecting and investigating noncompliant and suspected illegal charter operations; 4. Vetting aircraft entering part 135 service and aircraft transitioning between part 135 operators; and 5. Identifying gaps in existing policy and practice that may enable noncompliant and suspected illegal charter operations. The FAA equipped SEIT with methods to track aircraft in-flight and with fast-track enforcement capabilities, which enhances the FAA's ability to provide an effective response to illegal charter operations. I believe that the FAA effectively addressed this recommendation, and I consider our actions complete.
The FAA’s response to this recommendation is not acceptable. Among the findings of the Oklahoma City accident investigation was that, despite reports to the FAA of noncompliant activities of Interstate Helicopters, the FAA did not allow inspectors sufficient time to properly investigate and resolve these activities. The FAA’s proposal to fund the National Air Transportation Association to establish an independent illegal charter hotline for aircraft operators to use for reporting illegal activity and its toll-free telephone number that can be used to file a report of suspected illegal commercial flights do not address the issue. The problem in the Oklahoma City accident was not a lack of reporting of Interstate Helicopter’s activities; rather, the issue was the failure of the FAA to properly respond to these reports. The NTSB believes that the use of SPAS for setting oversight work program priorities, in conjunction with the procedures outlined in Order 1800.56J, was partly responsible for the failure of the FAA to respond to these reports. Although SPAS is a risk-based system for setting priorities, the NTSB is concerned that it may not adequately collect all of the information needed to properly assess the risk and need for oversight associated with a Part 135 carrier. Therefore, responding that the FAA will revise Order 1800.56J to use SPAS to create risk-based work programs for its oversight activities does not constitute an acceptable response. Pending the FAA’s reconsideration of its position and identification of the specific shortcomings in its policies, procedures, and practices that resulted in its failure to detect and address the noncompliant actions of Interstate Helicopters, Safety Recommendation A-09-81 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 1800.565, 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 1800.565 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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