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Safety Recommendation Details

Safety Recommendation A-10-015
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: Develop, and distribute to all pilots, multimedia guidance materials on professionalism in aircraft operations that contain standards of performance for professionalism; best practices for sterile cockpit adherence; techniques for assessing and correcting pilot deviations; examples and scenarios; and a detailed review of accidents involving breakdowns in sterile cockpit and other procedures, including this accident. Obtain the input of operators and air carrier and general aviation pilot groups in the development and distribution of these guidance materials. (Supersedes Safety Recommendation A-07-8)
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable 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 - Unacceptable Response)
Keyword(s): Professionalism

Safety Recommendation History
From: NTSB
To: FAA
Date: 1/4/2017
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) notice of proposed rulemaking (NPRM) titled, “Pilot Professional Development,” which was published at 81 Federal Register 69908 on October 7, 2016. The NPRM proposes to modify requirements primarily applicable to 14 Code of Federal Regulations (CFR) Part 121 air carriers conducting domestic, flag, and supplemental operations to enhance the professional development of pilots in those operations. The proposal includes requirements for air carriers to provide leadership and command and mentoring training for all pilots in command (PICs), provide new-hire pilots with an opportunity to observe flight operations (operations familiarization) to become familiar with procedures before serving as a flight crewmember in operations, and establish pilot professional development committees (PPDC). The NTSB notes that, although the NPRM identified Safety Recommendation A-10-15 as relevant, neither the proposed rule nor the draft AC addresses the content or the intent of this recommendation. Specifically, this recommendation called for multimedia guidance materials to be distributed to all pilots, “on professionalism in aircraft operations that contain standards of performance for professionalism; best practices for sterile cockpit adherence; techniques for assessing and correcting pilot deviations; examples and scenarios; and a detailed review of accidents involving breakdowns in sterile cockpit and other procedures,” including the Colgan Air flight 3407 accident. Neither the actions proposed in the NPRM nor the draft AC’s instructional outline on leadership and command training provides pilots with an integrated and comprehensive source of information about best practices for professionalism with a review of relevant accidents. In addition, the NPRM’s scope of applicability does not address all pilots (see below). Finally, the draft AC should include in its list of related FAA guidance the safety alerts for operators (SAFO) and information for operators (InFO) messages relevant to the topic as cited in the NPRM.

From: NTSB
To: FAA
Date: 1/11/2013
Response: We remain concerned that the FAA continues to delay its efforts to respond to this recommendation until after the AC and NPRM have been published. Although an AC can provide useful guidance, we point out that the intent of this recommendation is not for the development and distribution of an AC, but for the development and distribution of multimedia guidance materials that address professionalism in aircraft operations. The FAA has not yet indicated a plan that addresses our concerns. Accordingly, pending our timely receipt and review of a plan that does so, Safety Recommendation A-10-15 remains classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/24/2012
Response: -From Michael P. Huerta, Acting Administrator: Public Law (P.L.) 111-216, section 206, titled Flight Crewmember Mentoring, Professional Development and Leadership, required that the Federal Aviation Administration (FAA) initiate rulemaking with a notice of proposed rulemaking (NPRM) issued by August 1, 2011. In response to the P.L., the FAA chartered the Flight Crewmember Mentoring, Leadership and Professional Development Aviation Rulemaking Committee (ARC). The ARC consisted of several members of academia, industry, pilots, and the FAA. The ARC's recommendations were used to draft the Flight Crewmember Mentoring, Leadership and Professional Development NPRM. The NPRM entered executive level review on May 17, 2011, and the FAA anticipates publication of the NPRM in late 2012. The FAA believes the NPRM will address Safety Recommendations A-I 0-13 through -15 for part 121 operators. Along with the NPRM, an Advisory Circular (AC) on mentoring, leadership, and professional development will be written and published in the docket for public comment. The FAA's current rulemaking effort is focused on pilot mentoring and professionalism for part 121 operations. While part 135 and 91 K operators could elect to comply with the rule or AC. the FAA has no immediate plans to include part 135 and 91 K operators in this rulemaking effort. After the NPRM is published, the FAA will consider developing multimedia guidance materials beyond what the draft AC will provide in response to Recommendation A-10-15. I will keep the Board informed of the FAA's progress on this safety recommendation and provide an update by July 2013.

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: 4/25/2012
Response: The NTSB has not received an update from the FAA regarding its efforts to address this recommendation since its initial response in 2010. The Department of Transportation’s (DOT) Annual Report on Air Carrier Safety Recommendations for calendar year 2010 reported that the FAA’s Flight Crewmember Mentoring, Leadership and Professional Development notice of proposed rulemaking (NPRM) and planned advisory circular (AC) on mentoring, leadership, and professional development address this recommendation. However, neither of these initiatives directly responds to this recommendation. In addition, the DOT reported that these initiatives only focus on Part 121 operations and that the FAA has not yet determined how it will address Part 135 or Part 91K. Although an AC can provide useful guidance, we point out that the intent of this recommendation is to develop and distribute multimedia guidance materials that address professionalism in aircraft operations. For example, to address the increasing problem of runway incursions, the FAA distributed to all pilots a multimedia presentation and printed guidance on the issue. The presentation addressed runway safety, discussed accidents and operating rules, and offered best practices and techniques. We believe that this approach would also be effective in addressing breakdowns in pilot professionalism and sterile cockpit discipline, especially if examples of accidents are included with standard operating procedures and best practices to help focus attention on the reasons for the standards and the potential results of not following them. Safety Recommendation A-10-15 superseded A-07-8, which was classified “Closed—Unacceptable Action” because the FAA had not taken any action in 3 years to address the recommendation. Although 5 years have now passed since the issuance of Safety Recommendation A-07-8, the FAA has still not yet indicated a plan that addresses our concerns. Accordingly, pending our timely receipt and review of a plan that does so, Safety Recommendation A-10-15 is classified OPEN—UNACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 3/14/2012
Response: Correspondence Control #201200089 was closed administratively, no letter was mailed using this correspondence control number and pertaining to A-10-15.

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. This recommendation asks for the development and distribution of guidance on professionalism, which may be beyond a rulemaking project. However, the NTSB's review of the SNPRM did not find any mention of standards of performance, sterile cockpit procedures, or associated breakdowns. The NTSB believes this rulemaking to be an appropriate platform to include discussion of these topics and urges the FAA to do so.

From: NTSB
To: FAA
Date: 1/25/2011
Response: The NTSB notes that the FAA agrees with this recommendation and is reviewing how best to address it. Pending receipt of additional information once the FAA determines how it will proceed and completion of the recommended action, Safety Recommendation A-10-15 is classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/22/2010
Response: MC# 2100243 - From J. Randolph Babbitt, Administrator: The FAA agrees that providing effective and usable information to pilot groups is an essential component in preventing accidents. The FAA is reviewing this recommendation to determine how best to address it in a timely and effective manner. The FAA will update the Board on our progress in December 2010.