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Safety Recommendation Details

Safety Recommendation A-10-010
Details
Synopsis: On February 12, 2009, about 2217 eastern standard time,1 a Colgan Air, Inc., Bombardier DHC-8-400 (Q400),2 N200WQ, operating as Continental Connection flight 3407, was on an instrument approach to Buffalo-Niagara International Airport, Buffalo, New York, when it crashed into a residence in Clarence Center, New York, about 5 nautical miles northeast of the airport. The 2 pilots, 2 flight attendants, and 45 passengers aboard the airplane were killed, one person on the ground was killed, and the airplane was destroyed by impact forces and a postcrash fire. The flight, which originated from Liberty International Airport (EWR), Newark, New Jersey, was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121. Night visual 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 91K operators to review their standard operating procedures to verify that they are consistent with the flight crew monitoring techniques described in Advisory Circular (AC) 120-71A, ?Standard Operating Procedures for Flight Deck Crewmembers?; if the procedures are found not to be consistent, revise the procedures according to the AC guidance to promote effective monitoring.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: Clarence Center, NY, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA09MA027
Accident Reports: Loss of Control on Approach, Colgan Air, Inc., Operating as Continental Connection Flight 3407, Bombardier DHC 8 400, N200WQ
Report #: AAR-10-01
Accident Date: 2/12/2009
Issue Date: 2/23/2010
Date Closed: 1/11/2013
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Flightcrew, Procedures, Procedures: Flightcrew

Safety Recommendation History
From: NTSB
To: FAA
Date: 1/11/2013
Response: On July 15, 2011, the NTSB commented on the FAA’s supplemental notice of proposed rulemaking (SNPRM) titled “Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers,” which was published on May 20, 2011. We noted that the SNPRM contained language that, if retained in the resulting final rule, would have required Part 121 operators to take the action recommended. The FAA indicated, however, that after further reviewing this recommendation, it has determined that changes to guidance, policy, and regulations are not necessary. We recognize that operators are not required to follow the specific standard operating procedures discussed in advisory circulars (AC) and may choose to develop alternate means of compliance for consideration and approval if such procedures result in an equivalent level of safety to those specified in the AC. We point out that Colgan Air’s standard operating procedures at the time of the accident did not promote effective monitoring behavior; however, the FAA approved them as providing an equivalent level of safety. We remain concerned that other air carriers’ standard operating procedures may also be deficient in this area; however, because the FAA has indicated that its actions in response to this recommendation are complete and it will take no further action to address Safety Recommendation A-10-10, this recommendation is classified CLOSED—UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 10/15/2012
Response: -From Michael P. Huerta, Acting Administrator: The Federal Aviation Administration (FAA) reviewed this recommendation and determined that changes to guidance, policy, and regulations are unnecessary. We further note that advisory circulars (ACs) do not mandate that operators follow the specific standard operating procedures discussed in the AC. ACs published by the FAA are guidance material consisting of one way of achieving compliance with FAA regulations and policy. Many operators typically adopt these procedures and recommended practices; however, some choose to develop alternate means of compliance (AMC) for consideration and approval. These AMC result in an equivalent level of safety as compared to the AC. FAA principal operations inspectors (POI) are the direct interface between the operators and the FAA and evaluate AMC with FAA guidance. POIs utilize their training and experience to determine, collaborate, and approve equivalent levels of safety for any AMC. I believe this structure fully meets the intent of this recommendation, and I plan no further action.

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: 7/15/2011
Response: Notation 8106A: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration's (FAA) supplemental notice of proposed rulemaking (SNPRM) titled "Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers," published at 76 Federal Register 29336-29526 on May 20, 2011. The notice proposes to amend the regulations for flight and cabin crewmember and aircraft dispatcher training programs in domestic, flag, and supplemental operations. The proposed regulations are intended to contribute significantly to reducing aviation accidents by requiring the use of flight simulation training devices (FSTD) for flight crewmembers and including additional training and evaluation requirements for all crewmembers and aircraft dispatchers in areas that are critical to safety. The proposal also reorganizes and revises the qualification, training, and evaluation requirements. The SNPRM is based on the FAA's review of comments submitted in response to the January 12, 2009, notice of proposed rulemaking (NPRM) on these issues and its determination that the NPRM did not adequately address or clarify some topics; it is also based on provisions of the Airline Safety and Federal Aviation Administration Extension Act of 2010. The SNPRM contains language that would require Part 121 operators to take the action recommended. If this language is retained in the resulting final rule, it likely will fully address this recommendation for Part 121 carriers. The FAA will need to take similar action for Part 13 5 and Part 91 subpart K operators in order to close this recommendation acceptably.

From: NTSB
To: FAA
Date: 1/25/2011
Response: The NTSB looks forward to receiving the FAA's determination of how best to address this recommendation. Among the options that the FAA described was issuance of an information for operators (InfO) or a safety alert for operators (SAFO) bulletin, but we caution the FAA that, although such action may represent part of an acceptable response to this recommendation, issuance of a SAFO or InFO alone will not satisfy Safety Recommendation A-10-10. When we issued this recommendation, we also issued Safety Recommendation A-10-3l, discussed below, which concerns the need to ensure that guidance provided in documents like SAFOs has been implemented. We encourage the FAA to consider this need in addressing Safety Recommendation A-10-10. In the meantime, pending the FAA's taking the recommended action, Safety Recommendation A-10-10 is classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/22/2010
Response: MC# 2100243 - From J. Randolph Babbitt, Administrator: The Federal Aviation Administration will take this recommendation under consideration and determine the best feasible course of action to meet its intent. This consideration may include policy and regulatory options such as revising guidance material to principal operations inspectors, issuing an Information for Operators (InFO) and Safety Alert for Operators (SAFO), or any combination of these and other programs. The FAA will update the Board on our actions and progress by December 2010.