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General Aviation Safety
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.
TO THE FEDERAL AVIATION ADMINISTRATION: Direct 14 Code of Federal Regulations Part 121, 135, and 91K operators of airplanes equipped with a reference speeds switch or similar device to (1) develop procedures to establish that, during approach and landing, airspeed reference bugs are always matched to the position of the switch and (2) implement specific training to ensure that pilots demonstrate proficiency in this area.
Original recommendation transmittal letter:
Closed - Acceptable Alternate Action
Clarence Center, NY, United States
Loss of Control on Approach, Colgan Air, Inc., Operating as Continental Connection Flight 3407, Bombardier DHC 8 400, N200WQ
Addressee(s) and Addressee Status:
FAA (Closed - Acceptable Alternate Action)
Flightcrew, Procedures, Procedures: Flightcrew, Training and Education
Safety Recommendation History
The NTSB notes that the FAA reviewed the training provided by all U.S. operators (Parts 121, 135, and 91K) of airplanes with reference speed switches and found the following: • Use of the reference speed switch is an item identified in the briefing that each operator is required to complete prior to approach and landing. • The speed bug position confirmation is a before-landing checklist item. • Ground training curricula address the function, characteristics, and capabilities of the reference speed switch systems. • The operators’ simulator training programs reinforce the system function and the criticality of the adherence to appropriate procedures. • The reference speed switch function and use is included in the course completion testing, simulator training program scenarios and evaluations, aircraft checklist, and manuals. In addition, the FAA reviewed its air carrier surveillance policies and confirmed that the appropriate use of the reference speed switch system is addressed in existing surveillance programs. The NTSB is pleased that all U.S. operators took the recommended actions without waiting for the FAA to implement a requirement. We believe that the operators acted quickly, effectively, and responsibly based on the findings of our investigation of the Colgan-Continental Connection flight 3407 accident. The independent actions of the operators have satisfied the recommendation in an alternate manner; consequently, Safety Recommendation A-10-21 is classified CLOSED—ACCEPTABLE ALTERNATE ACTION.
-From Michael P. Huerta, Acting Administrator: The Federal Aviation Administration (FAA) agrees with the Board that Title 14, Code of Federal Regulations, parts 121,135, and 91 subpart K operators should develop training curricula and operational policies and procedures explicitly designed to acquaint flightcrews with the systems operations of their specific aircraft. The FAA determined the following air carriers operate de Havilland DHC-8-402 aircraft that use a reference switch: (1) Horizon Airlines; (2) Colgan Air, Inc.; and (3) Lynx Aviation, Inc. During our review of their training curricula, we found that the planned use of the reference speed switch is an identified item in the briefing that each operator is required to complete prior to approach and landing. Also, the speed bug position confirmation is a before landing checklist item at each operator. The ground training curricula of these operators does stress the function, characteristics, and capabilities of the reference speed switch system. The operators' simulator training programs reinforce the system function and the criticality of the adherence to appropriate procedures. Furthermore, the reference speed switch function and procedural use is incorporated into the course completion testing, simulator training program scenarios and evaluations, aircraft checklist, and manuals. The reference speed switch procedural requirements also are incorporated into the operators' internal operations surveillance program. We have reviewed our air carrier surveillance policies and have confirmed that the appropriate use of the reference speed switch system is addressed in our existing surveillance programs. The operators' surveillance programs will continue to monitor this issue. I believe that the FAA has effectively addressed this recommendation, and I consider our actions complete.
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 includes requirements for training in stalls that are fully developed, the use of reference speed switches, and familiarization with stick pushers. If implemented in the final rule, these proposed requirements likely would be acceptable actions in response to these recommendations for Part 121 carriers. The FAA will need to take similar actions for Part 135 and Part 91 subpart K operators before these recommendations can be closed acceptably.
The NTSB notes the FAA's planned review of (1) its air carrier and operator surveillance policies, to determine whether any changes are needed to ensure that training curricula and operational policies and procedures acquaint flight crews with the systems operation of their specific aircraft, and (2) of operators' approved training programs, to ensure that they adequately stress systems operational capabilities and characteristics unique to their aircraft. The NTSB is concerned, however, that the FAA's planned reviews may miss problems associated with procedures that are used on airplanes equipped with a reference speed switch or similar device unless the FAA emphasizes this check as part of its review. Accordingly, we encourage the FAA to consider this issue before conducting its review. In the meantime, pending the FAA's taking the recommended action, Safety Recommendation A-10-21 is classified OPEN – ACCEPTABLE RESPONSE.
MC# 2100243 - From J. Randolph Babbitt, Administrator: We agree with the Board that 14 CFR parts 121, 135, and 91K operators should develop training curricula and operational policies and procedures explicitly designed to acquaint flightcrews with the systems operation of their specific aircraft. We will review our air carrier and operator surveillance policies to determine if any changes need to be made. We also plan to review operators' approved training programs to ensure they have developed and implemented flightcrew training syllabi and operational procedures stressing systems operational capabilities and characteristics unique to their aircraft. We will keep the Board informed of the progress on this safety recommendation and provide an update by March 2011.
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