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Safety Recommendation Details

Safety Recommendation A-09-125
Details
Synopsis: On June 4, 2007, about 1600 central daylight time, a Cessna Citation 550, N550BP, impacted Lake Michigan shortly after departure from General Mitchell International Airport, Milwaukee, Wisconsin (MKE).1 The two pilots and four passengers were killed, and the airplane was destroyed. The airplane was being operated by Marlin Air under the provisions of 14 Code of Federal Regulations (CFR) Part 135 and departed MKE about 1557 with an intended destination of Willow Run Airport (YIP), near Ypsilanti, Michigan. At the time of the accident flight, marginal visual meteorological conditions prevailed at the surface, and instrument meteorological conditions prevailed aloft; the flight operated on an instrument flight rules flight plan.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Conduct a detailed review of the oversight provided to Marlin Air to determine why the oversight system failed to detect (before and after the accident) and correct Marlin Air’s operational deficiencies, particularly in the areas of pilot hiring, training, and adherence to procedures.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: Milwaukee, WI, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: CHI07MA160
Accident Reports: Loss of Control and Impact with Water, Marlin Air Cessna Citation 550, N550BP
Report #: AAR-09-06
Accident Date: 6/4/2007
Issue Date: 10/27/2009
Date Closed: 4/30/2012
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Oversight, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 4/30/2012
Response: The FAA conducted a review of the oversight it provided to Marlin Air between June 2005 and June 2007 and found that no major systemic problems existed with the company’s pilot training and checking or adherence to procedures. The FAA believes that, because Marlin Air surrendered its certificate and has been out of business since 2009, the FAA’s actions to satisfy this recommendation are complete. We disagree with the FAA’s position that no major systemic problems existed at Marlin Air. In our report on the accident and in the letter that transmitted this recommendation to the FAA, we discussed findings from our investigation concerning records for the three most recent training flights conducted by the captain (who was the chief pilot for Marlin Air and an FAA-designated check airman). These flights included a company pilot training flight on May 4, 2007, and proficiency checkrides for the accident first officer and another newly hired pilot on May 23 and June 2, 2007, respectively. The training times recorded on the three training records differed significantly from the times recorded by the airplanes’ hour-recording meters. That Marlin Air surrendered its certificate and is now out of business are facts of no relevance to the shortcomings in the FAA’s oversight of Marlin Air before the company surrendered its certificate. We believe that our findings contradict the finding of the FAA’s review that no major systemic problems existed with the company’s pilot training and checking or adherence to procedures. However, because the FAA has made it clear that it considers its actions in response to this recommendation to be complete and it will take no further action, Safety Recommendation A 09 125 is classified CLOSED—UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 1/27/2012
Response: -From Michael P. Huerta, Acting Administrator: The Federal Aviation Administration's (FAA) Great Lakes Region conducted a detailed review of the oversight provided to Marlin Air between June 2005 and June 2007. During this review the FAA consulted all Great Lakes Region Field Office personnel involved with the Marlin Air accident investigation. Based on the information gathered, including observations from FAA inspectors who conducted surveillance of Marlin Air, the FAA finds that there did not appear to be any major systemic problems with the company's pilot training and checking or adherence to procedures. It is also important to note that Marlin Air surrendered its certificate and has been out of business since 2009. Based on our detailed review and the fact that Marlin Air surrendered its certificate, I believe that the FAA has effectively addressed this safety recommendation, and I consider our actions complete.

From: NTSB
To: FAA
Date: 11/17/2010
Response: The NTSB is pleased that the FAA has started the recommended review. Pending completion of that review and implementation of any needed improvements that are identified, Safety Recommendations A-09-125 and -126 are classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 4/28/2010
Response: Letter Mail Controlled 7/29/2010 4:30:29 PM MC# 2100167 - This incoming letter does not address A-09-125.

From: NTSB
To: FAA
Date: 4/8/2010
Response: Notation 8201: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) advance notice of proposed rulemaking (ANPRM) titled “New Pilot Certification Requirements for Air Carrier Operations,” which was published in Federal Register, Volume 75, Number 25, p. 6164 on February 8, 2010. The ANPRM invites comments on possible changes to regulations relating to the certification of pilots conducting domestic, flag, and supplemental operations and seeks to gather information on whether current eligibility, training, and qualification requirements for commercial certification are adequate for engaging in such operations. The ANPRM asks for comments on a large number of questions. The NTSB is seeking similar information related to issues of pilot training and professionalism and has scheduled a Forum on Professionalism in Aviation: Ensuring Excellence in Pilot and Air Traffic Controller Performance in May 2010. The NTSB proposes some general comments on this ANPRM. While the ANPRM focuses on 14 Code of Federal Regulations (CFR) Part 121 pilots, the NTSB believes that the same level of safety and oversight should apply to all revenue air carrier operations and that any substantive changes should include 14 CFR Part 135 pilots, because these pilots also carry members of the paying public. The NTSB believes that careful scrutiny of the eligibility, training, and certification requirements for air carrier pilots is appropriate and supports a comprehensive assessment of the requirements for air carrier crewmember eligibility and qualifications in today’s environment. Significant changes in the airline industry have not been accompanied by changes in crew eligibility, training, and certification requirements. The required number of cockpit crewmembers has, in most cases, decreased from three to two; aircraft have become more complex; airspace has become more restrictive; and domestic and international flight operations have become more challenging. The current trend of major legacy airlines using smaller regional air carriers on a growing number of routes through code-sharing agreements has resulted in the rapid growth of the regional airlines, which have traditionally been, and in most cases still are, entry-level air carriers for pilots. Regional airlines are now operating a substantial number of flights in highly sophisticated and complex aircraft and are carrying a significant number of passengers who expect the same level of safety as the major legacy airlines. Thus, the NTSB is pleased that FAA has taken the initiative to reassess 14 CFR Part 61 requirements of aeronautical knowledge and airman certification requirements. The complex changes in today’s equipment and environment require that pilots enter Part 121 and Part 135 flight operations with a high level of experience, proficiency, and professionalism. Currently, most entry-level air carrier pilots have relatively low operational flight experience and little experience operating in conjunction with other crewmembers. In addition, that experience is generally in less complex aircraft. 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 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. The NTSB is pleased that the FAA is addressing this issue, and the NTSB also intends to explore this issue during its upcoming forum. An issue that the FAA does not address in the ANPRM is that of oversight. The NTSB strongly believes that the development and maintenance of pilot knowledge, proficiency, and professionalism requires a higher level of oversight by FAA inspectors. The current FAA trend of delegating the majority of oversight of flight training, en route line checks, and proficiency checks to airline and flight training vendor designees can lead to poor safety cultures and poorly qualified pilots. For example, the NTSB, in its investigation of the June 4, 2007, accident in Milwaukee, Wisconsin, found that the check airman responsible for training and line checks provided very poor oversight and training of the pilots at the company. As a result, the NTSB made the following recommendation: Conduct a detailed review of the oversight provided to Marlin Air to determine why the oversight system failed to detect (before and after the accident) and correct Marlin Air’s operational deficiencies, particularly in the areas of pilot hiring, training, and adherence to procedures. (A-09-125) The FAA stated that it plans to conduct such a review. While this recommendation was focused on one Part 135 carrier, the NTSB believes that the findings from the review could help shape FAA oversight for all carriers to ensure that the highest levels of pilot knowledge, proficiency, and professionalism are achieved and maintained. Furthermore, the NTSB has found in its investigations that, because of inadequate FAA staffing, many safety critical tasks are delegated to airline or training vendor personnel. In many cases, because of these staffing shortages, some desired oversight tasks may not be accomplished at all. As a result of its investigation of the February 12, 2009, accident in Clarence Center, New York, the NTSB made the following recommendation: Develop more stringent standards for surveillance of 14 Code of Federal Regulations (CFR) Part 121, 135, and 91K operators that are experiencing rapid growth, increased complexity of operations, accidents and/or incidents, or other changes that warrant increased oversight, including the following: (1) verify that inspector staffing is adequate to accomplish the enhanced surveillance that is promulgated by the new standards, (2) increase staffing for those certificates with insufficient staffing levels, and (3) augment the inspector staff with available and airplane-type-qualified inspectors from all Federal Aviation Administration regions and 14 CFR Part 142 training centers to provide quality assurance over the operators’ aircrew program designee workforce. (A-10-26) The NTSB believes that the FAA needs to maintain adequate staffing to provide greater FAA inspector oversight of Part 121 and Part 135 training, proficiency checks, and line flight operations and encourages the FAA to address this issue in future rulemaking. Regarding the ANPRM proposal for a special 14 CFR 61.31 endorsement on a commercial pilot certificate for Part 121 operations, the NTSB believes that a special endorsement for both Part 121 and Part 135 pilots might be beneficial if the requirements for the endorsement are comprehensive, adequate, and effective. The special endorsement requirements need to be well defined, ensure that pilots have the experience and competency in following procedures and handling high performance aircraft, and ensure that pilots achieve and maintain adequate training, experience, and proficiency on the equipment and procedures specific to the pilots’ employers. The special endorsement requirements should also reflect a robust and objective means of determining that pilots demonstrate adequate judgment and professionalism. The appropriate evaluation and processing of such endorsements further necessitates FAA oversight. The NTSB appreciates the opportunity to comment on this ANPRM.

From: FAA
To: NTSB
Date: 2/16/2010
Response: Letter Mail Controlled 2/26/2010 4:02:13 PM MC# 2100071 - From J. Randolph Babbitt, Administrator: The FAA will address this safety recommendation by conducting a detailed review of the oversight provided to Marlin Air as stated in the recommendation. Once the review is complete, we will analyze the results and develop a plan to address any identified issues.