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Safety Recommendation Details

Safety Recommendation A-10-012
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: For all airplanes engaged in commercial operations under 14 Code of Federal Regulations Parts 121, 135, and 91K, require the installation of low-airspeed alert systems that provide pilots with redundant aural and visual warnings of an impending hazardous low-speed condition. (A-10-12) (Supersedes Safety Recommendations A-03-53 and -54)
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
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:
Addressee(s) and Addressee Status: FAA (Open - Acceptable Response)
Keyword(s): Instruments

Safety Recommendation History
From: NTSB
To: FAA
Date: 8/10/2018
Response: Your November 6, 2015, letter to us about this recommendation said that you completed the review necessary to implement a requirement for retrofitting low-airspeed alerting in aircraft certificated under Part 25 and operated under Parts 121 and 129. You anticipated publishing a notice of proposed rulemaking (NPRM) for this requirement by the end of 2016; however, the NPRM is still being developed, and you now anticipate publishing it by the end of 2018. We note that, after you publish this NPRM, you plan to determine if rulemaking for a similar requirement for aircraft certificated under Part 25 and operated under Part 135 and Part 91, subpart K is warranted. We further note that, because you believe a similar requirement for aircraft certificated under Part 23 used in commercial operations is “outside the scope of this recommendation,” you do not plan to develop one. Your decision regarding Part 23 certificated aircraft is also based on your determination that, because of the average age of the relevant fleet, it would be cost prohibitive to retrofit a low airspeed alerting system into Part 23 certificated aircraft used in commercial operations. We point out that Safety Recommendations A-03-53 and -54 resulted from an accident involving a Part 23 certificated aircraft (a Raytheon [Beechcraft] King Air A100) used in a Part 135 commercial operation. Our investigation determined that the probable cause of this accident was “the flight crew’s failure to maintain adequate airspeed.” We do not agree with your determination that addressing Part 23 certificated aircraft used in commercial operations is outside the scope of this recommendation. Therefore, to fully satisfy this recommendation, you must address aircraft used in Part 135 and 91, subpart K operations, as well as in Part 121 operations. We are encouraged that you plan to issue the NPRM to address aircraft used in Part 121 operations by the end of this year. Pending a requirement to retrofit Part 25 and Part 23 certificated aircraft used in commercial operations in Part 121, 135, or 91, subpart K operations with a low-airspeed alerting system, Safety Recommendation A-10-12 remains classified OPEN--ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/27/2018
Response: -From Daniel K. Elwell, Acting Administrator: In our previous letter to the Board dated November 6, 2015, the Federal Aviation Administration (FAA) noted that we completed the review necessary to implement low-speed alerting options applicable to part 25 aircraft operated under parts 121 and 129. And that we anticipated publishing a notice of proposed rulemaking (NPRM) by the end of 2016. Due to personnel and resource constraints, the FAA's pursuit of rulemaking to require retrofit of these aircraft was delayed. The NPRM is still in development. We now anticipate publication by the end of 2018. For part 25 aircraft operated under part 135 and part 91 subpart K, we continue our plan to complete a feasibility study to determine whether rulemaking is warranted. However. we do not expect to complete this evaluation until after publication of the delayed NPRM noted above. We reviewed the Board's comments provided in its letter dated May 12. 2016. on a separate NPRM. which discussed the FAA ·s draft Advisory Circular 23.10. FAA Accepted Means of Compliance Process for Title 14, Code of Federal Regulations Part 23. We acknowledge the Board 's comments on the March 14, 2016, NPRM's proposed section 23. 1500, Flightcrew Interface (now proposed as section 23.2600). However, the NPRM proposed restructuring subpart 0 to relocate aspects that directly affect the pilot's interface with the airplane. such as the throttle shape. to that section. This effort is outside the scope of this recommendation, therefore. The FAA does not plan to pursue rulemaking for part 23 aircraft with low speed alerting systems. The FAA determined that, with the average age or the relevant fleet. it would be cost prohibitive to retrofit this system into part 23 aircraft for commercial operations. As discussed above, we will continue to pursue rulemaking for part 25 aircraft operated under parts 121 and 129, and our feasibility study for part 25 aircraft operated under part 135 and part 91 subpart K. I will keep the Board informed of our progress on this safety recommendation and provide an update by June 2019.

From: NTSB
To: FAA
Date: 5/12/2016
Response: Correspondence control 201600220, Dated May 12, 2016: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) notice of proposed rulemaking (NPRM) titled “Revision of Airworthiness Standards for Normal, Utility, Acrobatic, and Commuter Category Airplanes,” which was published at 81 Federal Register (FR) 13451 on March 14, 2016. The NPRM proposes to amend airworthiness standards for normal, utility, acrobatic, and commuter-category airplanes by removing prescriptive design requirements and replacing them with performance based airworthiness standards. The proposed standards would also replace the current weight and propulsion divisions in small airplane regulations with performance- and risk based divisions for airplanes with a maximum seating capacity of 19 passengers or less and a maximum takeoff weight of 19,000 lbs. or less. In addition, the NPRM proposes to adopt additional airworthiness standards to address certification for flight in icing conditions, enhanced stall characteristics, and minimum control speed to prevent departure from controlled flight for multiengine airplanes. On April 8, 2016, the FAA also published on its website draft Advisory Circular (AC) 23.10 titled “FAA Accepted Means of Compliance Process for 14 [Code of Federal Regulations] CFR Part 23.” The draft AC provides guidance on how to submit a proposed means of compliance (MOC) with Part 23 for acceptance by the Administrator in accordance with proposed section 23.10, “Accepted Means of Compliance,” in the NPRM. This letter provides comments on the NPRM. We will submit separate comments regarding draft AC 23.10. However, we do not agree that proposed section 23.1405 addresses or is relevant to Safety Recommendation A-10-12, which concerns low-airspeed alerting systems. We believe that proposed section 23.1500, “Flightcrew Interface,” is more appropriate for addressing the safety issue identified in this recommendation, which we issued on February 23, 2010: A-10-12 For all airplanes engaged in commercial operations under 14 [CFR] Parts 121, 135, and 91K, require the installation of low-airspeed alert systems that provide pilots with redundant aural and visual warnings of an impending hazardous low speed condition. [Classified “Open—Acceptable Response”]

From: NTSB
To: FAA
Date: 12/21/2015
Response: We note that you completed a preliminary cost effectiveness review for the recommended action, but only for Parts 121 and 129, which was validated by your Aviation Rulemaking Advisory Committee (ARAC) in March 2015. You now have the information needed for the recommended rulemaking for Parts 121 and 129, and you expect to publish a notice of proposed rulemaking in a year. We further note that you also expect to complete your evaluation next year of a retrofit requirement for Part 25 airplanes operated under Parts 135 and 91K. We are encouraged that you continue to make progress in satisfying this recommendation, but we again caution that a fully acceptable response will need to address operations under Parts 135 and 91K as well as those under Part 121. Pending implementation of the recommended requirement for Parts 121, 135, and 91K, Safety Recommendation A-10-12 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 11/6/2015
Response: -From Michael P. Huerta, Administrator: In November 2014, the Federal Aviation Administration (FAA) completed a preliminary cost and effectiveness review for implementing low-speed alerting options applicable to operations under parts 121 and 129, as discussed in our previous letter to the Board dated May 9, 2014. We gave the information from this review to the Aviation Rulemaking Advisory Committee (ARAC) for validation. On March 19, 2015, the ARAC provided a report which confirmed the FAA's review and assumptions. The record of this meeting is available at: http://www.faa.gov/regulations_policies/rulemaking/committees/documents/media/ARAC.Meeting.Minutes.3.19.2015.pdf. We now have the information we need to continue with our low-speed alerting rulemaking project for parts 121 and 129, and expect to publish the notice of proposed rulemaking by the end of 2016. Additionally, the FAA continues to evaluate retrofit requirements for part 25 airplanes operated under part 135 and subpart K of part 91, and we expect to complete our evaluation by December 2016. I will keep the Board informed of the FAA's progress on this recommendation and provide an update by November 2016.

From: NTSB
To: FAA
Date: 6/13/2014
Response: This recommendation superseded Safety Recommendations A 03 53 and 54, which were issued on December 2, 2003. Since then, we have continued to investigate accidents in which an airplane’s airspeed slowed without the pilot’s noticing this dangerous condition until the accident was imminent. We were encouraged that, in February 2013, you received the Aviation Rulemaking Advisory Committee (ARAC) Phase 2 (Revision A) report that addressed scenarios for retrofitting low-speed alerting systems in Part 25 airplanes operating under Part 121, and that you have completed your evaluation of the report recommendations and determined that low speed alerts are a highly effective safety enhancement for airplanes operating under Parts 121 and 129. We note that you may pursue rulemaking pending the results of a cost and effectiveness review you are conducting that should be completed before the end of this year. We also note that you will continue to evaluate retrofit requirements for Part 25 airplanes operated under Parts 135 and 91K. We are encouraged that the FAA is continuing to make progress on this recommendation, but we caution that a fully acceptable response will need to address Part 135 and Part 91K operations as well as those under Part 121. We emphasize that Safety Recommendations A 03 53 and -54 were issued because of our investigation of an accident involving an airplane operating under Part 135. Pending implementation of the recommended requirement for Parts 121, 135, and 91K, Safety Recommendation A-10-12 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/9/2014
Response: -From Michael P. Huerta, Administrator: In February 2013, the Federal Aviation Administration (FAA) received the Aviation Rulemaking Advisory Committee (ARAC) Phase 2 (Revision A) report that addressed scenarios for retrofitting low-speed alerting systems in part 25 airplanes operating under part 12 1. The ARAC recommended that the FAA examine operational and safety data of low-airspeed/low-energy events to help determine whether a low-airspeed alert would be beneficial for existing aircraft. The FAA has completed an evaluation of the ARAC Phase 2 report recommendations and determined that low-speed aler1s are a highly effective safety enhancement for airplanes operating under parts 121 and 129. The FAA is conducting a cost and effectiveness review for implementing low-speed alerts, which is expected to be completed by December 2014. The FAA may pursue rulemaking pending this review and will continue to evaluate retrofit requirements for pat1 25 airplanes operated under pat1s 135 and 91 K. I will keep the Board informed of the FAA's progress on this safety recommendation and provide an update by March 31, 2015.

From: NTSB
To: FAA
Date: 12/2/2013
Response: The NTSB has long been concerned about the FAA’s slow progress in addressing this recommendation. Safety Recommendation A-10-12 superseded Safety Recommendations A 03 53 and 54, which were issued on December 2, 2003. Since then, we have continued to investigate accidents in which an airplane’s airspeed decayed without the pilot’s noticing this dangerous condition until the accident was imminent. We were encouraged to see that, on October 19, 2012, the FAA received a final report from its aviation rulemaking advisory committee regarding a requirement for retrofitting low-speed alerting systems into Part 25 airplanes that are operated under Part 121. We are also encouraged that the FAA is currently reviewing the report and evaluating retrofit requirements and is considering retrofit requirements for airplanes operated under Parts 135 and 91 K. Accordingly, pending implementation of the recommended requirement, Safety Recommendation A-10-12 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/6/2013
Response: -From Michael P. Huerta, Administrator: On October 19, 2012, the FAA received the AR.t\.C final phase 2 report, which addresses scenarios for retrofitting low-speed alerting systems in part 25 airplanes that are operating under part 121. We are currently reviewing the report and evaluating the feasibility of retrofit requirements and arc also considering retrofit requirements for airplanes operated under parts 135 and 91 K. I will keep the Board informed on the FAA's progress on this safety recommendation and provide an updated response by March 30, 2014.

From: NTSB
To: FAA
Date: 3/6/2012
Response: Safety Recommendation A-10-12 superseded Safety Recommendations A-03-53 and -54, which were issued December 2, 2003. We note that the statement for the second phase of the ARAC tasking, addressing potential retrofit requirements for Part 121 operators, was published on March 3, 2011. However, we are concerned that Parts 135 and 91K will not be addressed until later phases. Because timeliness is still of concern, Safety Recommendation A-10-12 remains classified OPEN—UNACCEPTABLE RESPONSE pending substantive action by the ARAC to address the recommendation for Parts 135 and 91K as well as Part 121.

From: FAA
To: NTSB
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
To: FAA
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
To: NTSB
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.

From: NTSB
To: FAA
Date: 2/23/2010
Response: 2/23/2010: During the almost 6 years since the NTSB issued Safety Recommendations A 03 53 and 54, (which were reiterated in July 2006 after another event involving decreasing airspeed and loss of control), accidents and incidents involving a lack of flight crew awareness of decreasing airspeed have continued, indicating that existing stall warnings are not a reliable method for preventing inadvertent hazardous low-speed conditions. The NTSB notes that human factors concerns associated with a low-airspeed alert do not require more than 6 years of study for a solution to be implemented. The NTSB notes that several other airplanes certificated under 14 CFR Part 25, including the Boeing 747-400 and 777, provide pilots with an amber band on the airspeed display above the low-speed cue. This amber band typically represents the airspeed between the stall warning speed and the minimum maneuvering speed. Operations are not normally conducted with airspeeds in the amber band, which, in effect, provides pilots with a visual indication of a developing low speed condition before the onset of the stall warning. AC 25-11A, Electronic Flight Displays, discusses the visual design of low-speed awareness cues and states, the preferred colors to be used are amber or yellow to indicate that the airspeed has decreased below a reference speed that provides adequate maneuver margin, changing to red at the stall warning speed. The speeds at which the low speed awareness bands should start should be chosen as appropriate to the airplane configuration and operational flight regime. For example, low speed awareness cues for approach and landing should be shown starting at Vref with a tolerance of +0 and -5 knots. The NTSB concludes that the Q400 airspeed indicator lacked low-speed awareness features, such as an amber band above the low-speed cue or airspeed indications that changed to amber as speed decrease toward the low-speed cue, which would have facilitated the flight crew’s detection of the developing low-speed situation. Therefore, the NTSB recommends that the FAA require that airspeed indicator display systems on all aircraft certified under 14 CFR 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 AC 25-11A, Electronic Flight Displays. At the public hearing for this accident, an FAA certification specialist testified that current certification rules under 14 CFR 25.1329 indicate that there should be speed protection and/or alerting within the normal speed range while under flight guidance system (autopilot) control. The certification specialist stated, there should be low speed alerting occurring prior to stall warning, if you’re under flight guidance system or autopilot control. And that low speed alerting can take many forms, but it needs to be aural and visual. On July 9, 2009, the FAA issued a notice of proposed rulemaking (NPRM) for flight crew alerting, which included a requirement that alerts necessitating immediate crew awareness be presented using two sensory modalities. For example, a visual alert accompanied by an aural alert can help to capture and focus a pilot’s attention in the event that the pilot is not looking at the alerting cue. In this accident, the pilots did not likely see the rising low-speed cue on the IAS display, the downward pointing trend vector, or the airspeed indications change to red. As a result, the NTSB concludes that an aural warning in advance of the stick shaker would have provided a redundant cue of the visual indication of the rising low-speed cue and might have elicited a timely response from the pilots before the onset of the stick shaker. Therefore, the NTSB recommends that, for all airplanes engaged in commercial operations under 14 CFR Parts 121, 135, and 91K, the FAA require the installation of low-airspeed alert systems that provide pilots with redundant aural and visual warnings of an impending hazardous low-speed condition. Because of the FAA’s inactivity with regard to Safety Recommendations A-03-53 and 54, the NTSB classifies the recommendations Closed Unacceptable Action/Superseded and classifies Safety Recommendation A-10-12 OPEN -- UNACCEPTABLE RESPONSE.