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Safety Recommendation Details

Safety Recommendation A-10-011
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 that airspeed indicator display systems on all aircraft certified under 14 Code of Federal Regulations Part 25 and equipped with electronic flight instrument systems depict a yellow/amber cautionary band above the low-speed cue or airspeed indicator digits that change from white to yellow/amber as the airspeed approaches the low-speed cue, consistent with Advisory Circular 25-11A, "Electronic Flight Displays."
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Clarence Center, NY, United States
Is Reiterated: No
Is Hazmat: 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: 12/3/2013
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Instruments, Personal Floatation Device

Safety Recommendation History
From: NTSB
Date: 12/2/2013
Response: We reviewed the information provided in the FAA’s letter concerning the results of its review and evaluation of current design standards requirements for flight guidance systems (Section 25.1329 adopted in Amendment 25-119 on May 11, 2006) and flight crew alerting (Section 25.1322 adopted in Amendment 25-131 on January 3, 2011). The NTSB agrees with the FAA’s review, which found that these standards address the recommendation for new designs. Consequently, Safety Recommendation A-10-11 is classified CLOSED—ACCEPTABLE ACTION.

From: FAA
Date: 9/6/2013
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) tasked the Aviation Rulemaking Advisory Committee (ARAC) with examining the subject of low speed alerting and providing information that could be used to formulate new regulations. On March 15, 2011, the FAA received the final phase 1 report which addressed low speed alerting for new designs. Our review of the report and evaluation of current requirements confirmed that design standards for flight guidance systems (§25.1329 adopted in Amendment 25-1 19 on May 11 , 2006) and flight crew alerting (§25.1322 adopted in Amendment 25-131 on January 3, 2011) satisfactorily address this recommendation for new designs. Section 25.1 329 now includes paragraph (h), which states that "a means must be provided to avoid excursions beyond an acceptable margin from the speed range of the normal flight envelope. If the airplane experiences an excursion outside this range, a means must be provided to prevent the flight guidance system from providing guidance or control to an unsafe speed." If a caution-level alert is used to meet section 25.1329(h), section 25.1322(e)(l )(ii) requires the use of amber or yellow indications. I believe that these amendments effectively address this safety recommendation and consider our actions complete.

From: NTSB
Date: 3/6/2012
Response: We note that the Aviation Rulemaking Advisory Committee (ARAC) working group completed reports on the first phase of its tasking (establishing new Part 25 design requirements) in response to Safety Recommendation A-10-11. We appreciate having this new information. Pending the FAA’s completion of the recommended action, Safety Recommendation A-10-11 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
Date: 11/30/2011
Response: -From J. Randolph Babbitt, Administrator: The Federal Aviation Administration (FAA) tasked the Aviation Rulemaking Advisory Committee (ARAC) on May 18, 20 I0 (75 FR 27858), to provide information that will be used to develop standards and guidance material for low airspeed alerting systems that complement existing stall warning system requirements. The ARAC working group includes participants from regulatory authorities and airplane manufacturers. The working group completed the reports (enclosed disc) on the first phase of that ARAC tasking (establishing new part 25 design requirements) in March 2011. On March 3, 2011, we published the tasking statement for the second phase (76 FR 11844). The second phase addresses potential retrofit requirements for part 121 operators. We plan to address parts 135 and 91K in subsequent phases. I will keep the Board informed of the FAA's progress on these safety recommendations and provide an updated response by January 31, 2013.

From: NTSB
Date: 1/25/2011
Response: The NTSB notes the FAA's plan to task the Aviation Rulemaking Advisory Committee (ARAC) with developing recommendations for performance-based regulatory standards to address Safety Recommendation A-10-11 and potential retrofit requirements to address Safety Recommendation A-10-12. The tasking to develop a performance-based standard for a warning system is of concern to the NTSB, because we believe that either the standard will be ineffective or it will be difficult and onerous for a manufacturer to show compliance with the new standard. A valid performance-based standard is likely to require a statistically valid sampling of pilots performing their normal duties during the phase of flight when the alarm would activate in either an aircraft or a simulator with appropriate lighting and background noise conditions present and then measuring the time it takes a pilot to notice the alarm and take appropriate action. Although we have doubts about whether an effective and practical performance standard is possible, referral to the ARAC to develop a standard, whether a performance standard or a design standard, is the first step in responding to Safety Recommendation A-10-11 , which is classified OPEN – ACCEPTABLE RESPONSE. Safety Recommendation A-10-12 superseded Safety Recommendations A-03-53 and -54, which were issued December 2, 2003. The FAA did not provide a substantive response to these recommendations until October 3, 2006, when the NTSB reiterated these recommendations. At that time, the FAA stated (1) that it was forming an internal team of experts to assess the feasibility of new low airspeed alerting systems and (2) that the FAA would provide us with a status update by November 17, 2006; however, no update was ever received. In its current letter, the FAA indicates that it is asking an ARAC to supply a response to the issue of low airspeed alerting systems. Although this may represent the first step in an acceptable response, in view of the long period of inactivity in this area, Safety Recommendation A-10-12 remains classified “Open – Unacceptable Response” pending substantive action by the ARAC to address the recommendation.

From: FAA
Date: 6/22/2010
Response: MC# 2100243 - From J. Randolph Babbitt, Administrator: The FAA agrees with the intent of these recommendations. This year we will task the Aviation Rulemaking Advisory Committee to develop recommendations regarding performance-based regulatory standards responsive to A-10-11 and recommendations regarding potential retrofit requirements to address A-10-12. We expect to provide a status update by March 2011.