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Safety Recommendation Details

Safety Recommendation A-10-022
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 (CFR) Part 121, 135, and 91K operators and 14 CFR Part 142 training centers to develop and conduct training that incorporates stalls that are fully developed; are unexpected; involve autopilot disengagement; and include airplane-specific features, such as a reference speeds switch.
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): Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 10/2/2014
Response: We have reviewed the Federal Aviation Administration’s (FAA) notice of proposed rulemaking (NPRM) titled “Flight Simulation Training Device Qualification Standards for Extended Envelope and Adverse Weather Event Training Tasks,” published at Federal Register 39462-39753 on July 10, 2014. The NPRM proposes requirements in the QPS for FSTDs that will satisfy Safety Recommendation A-10-24, though as currently phrased, only for aircraft not equipped with stick pushers. In attachment 7 on page 39632, the NPRM states: “For full (aerodynamic) stall training tasks, model validation and/or analysis should be conducted through at least 10 degrees beyond the critical angle of attack. In cases where training is limited to the activation of a stall identification system (stick pusher), model validation may be conducted at a lower angle of attack range, but the FSTD Sponsor must specify and restrict the use of the FSTD to those maneuvers that have been appropriately validated.” (emphasis added) We disagree with the idea that effective stick pusher training can be limited to the activation of the stick pusher. We have investigated several accidents in which the crew “fought” the stick pusher and entered a situation where the “stick pusher response dynamics” caused the angle of attack to grow each time the pilot pulled back in response to the stick pusher. This dynamic behavior is a critical cue to a stall, which pilots must be trained to recognize. Peak angle of attack growth of about ten degrees beyond stall is typical for most accidents/incidents we have investigated, though the “stick pusher response dynamics” led to an angle of attack 13 degrees beyond stall for the Colgan Continental Connection Flight 3407 accident. Endeavor Air does stick pusher training and reports that essentially all pilots initially fight the pusher. Endeavor Air lets the pilots respond naturally to the pusher so they can recognize the cue, then trains until the pilots will relax back pressure after their first instinctive pull. Such training will be enhanced if the simulation modeling includes the changes in roll behavior we have noted in our accident and incident investigations as the aircraft goes in and out of stall. The text from the NPRM emphasized above, suggesting that training can be limited to the activation of a stall identification system (stick pusher), should be eliminated. Any concern for the safety of flight of aircraft that have dangerous stall characteristics could likely be addressed by replacing the text emphasized above with: For an aircraft equipped with a stall identification system (a stick pusher) where safety of flight beyond the stick pusher is a concern, collecting additional flight test data for validation is not required. Validation should be done with available flight test data and any data available from incidents and accidents, but the FSTD Sponsor must specify and restrict the use of the FSTD to those maneuvers that have been appropriately validated. The November 13, 2013, crewmember and dispatcher training final rule requires the training discussed in Safety Recommendations A-10-22 and A-10-23, though only for Part 121 operators. Safety Recommendations A 10-22 and A-10-23 are currently classified “Open—Unacceptable Response,” and A-10-24 is currently classified “Open—Acceptable Response.” In order to conduct the training described in Safety Recommendations A-10-22 and A-10-23, FSTDs compliant with requirements in the NPRM will be needed.

From: NTSB
To: FAA
Date: 7/11/2014
Response: The November 12, 2013, final rule on training addressed these recommendations in Sections 121.423, “Pilot: Extended Envelope Training” and 121.424, “Pilots: Initial, Transition, and Upgrade Flight Training.” Although these requirements satisfy the recommendations, they apply only to Part 121 operations. We were disappointed to learn that you do not plan to pursue similar rulemaking for Part 135 or 91K, or to take any other action. These recommendations specifically include Parts 135 and 91K because we continue to investigate accidents for flights conducted under these operating rules in which the pilot encountered a stall and did not respond appropriately. In our February 11, 2013, letter about these recommendations, we emphasized that, during the period from early 2001 through the end of 2011, we had investigated 37 accidents in which an aircraft was being operated under Part 135 rules and for which the investigation revealed a stall to be a prominent factor in the accident. Of these 37 accidents, 15 involved fatalities; a total of 38 people were killed and 19 others were seriously injured. An acceptable response to these recommendations must address Parts 135 and 91K as well as Part 121. Given this data clearly demonstrating a safety problem, we request that you reconsider your decision not to act to address the training of Parts 135 and 91K pilots to appropriately respond to fully developed stalls and to stick pusher activation. Pending issuance of requirements for Parts 135 and 91K similar to those included in Sections 121.423 and 121.424 for Part 121, Safety Recommendations A-10-22 and -23 are classified OPEN—UNACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 5/12/2014
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) draft Advisory Circular (AC) 120-109A, “Stall Prevention and Recovery Training,” which was posted for comment on the FAA’s website on March 12, 2014, and proposes revisions to AC 120-109. The purpose of the draft revised AC is to provide guidance and best practices for training, testing, and checking pilots to ensure correct responses to impending and full stalls. (For air carriers, the applicable regulatory requirements are contained in 14 Code of Federal Regulations [CFR] Part 121.) Although the draft revised AC is directed to air carriers, the FAA encourages all airplane operators, pilot schools, and training centers to use this guidance for conducting stall prevention training, testing, and checking because many of the principles apply to all airplanes. The guidance was created based on a review of recommended practices developed by major airplane manufacturers, labor organizations, air carriers, training organizations, simulator manufacturers, and industry representative organizations. Draft revised AC 120-109A provides an update to reflect new Part 121 regulatory terms and also incorporates the full stall training requirement of Public Law 111-216. The AC proposes the development and inclusion of training that incorporates stalls that are unexpected, involve autopilot disengagement, and include airplane-specific features, such as a reference speeds switch, as recommended. Although elements of the AC are applicable to fully developed stalls, we recognize that this element of Safety Recommendation A-10-22 cannot be implemented until simulator fidelity in the stall and stall recovery regimes has been improved. The draft revised AC, in conjunction with the final rule, is responsive to this recommendation for Part 121 operations. We encourage the FAA to provide similar guidance for Part 135 and Part 91 subpart K operators and are pleased that you have indicated your plans to do so.

From: FAA
To: NTSB
Date: 5/6/2014
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) proposed to revise crewmember and aircraft dispatcher qualification, training, and evaluation requirements in the existing subparts N and 0 of part 121 through a notice of proposed rulemaking (NPRM), titled Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers published on January 12, 2009 (74 FR 1280) and a supplemental notice of proposed rulemaking (SNPRM) published on May 20, 20 II (76 FR 29335). After reviewing the changes proposed in the NPRM and the SNPRM, the FAA determined it was necessary to move forward with a final rule to address certain safety-critical provisions proposed in the SNPRM that enhance pilot training for rare, but high-risk scenarios that provide the greatest safety benefit. The tina! rule was published on November 12, 20 13 (78 FR 67799). Safety Recommendations A-96-120 and A-1 0-22 and -23 are addressed in the final rule by § 121.423, Pilot: Extended Envelope Training and § 121.424, Pilots: Initial. transition, and upgrade flight training. In its comments to the SNPRM, the Board stated that the provisions in the SNPRM were responsive to these recommendations. Additionally. as discussed in our previous letters on these recommendations, the FAA reconvened the Stick Pusher Adverse Weather (SPAW) Aviation Rulemaking Committee (ARC). The FAA received the reconvened SPAW ARC's recommendations on February 13, 2013. These recommendations have been incorporated into a draft advisory circular (AC), which will be published for public comment in Spring 2014 and will provide best practices and guidance for academic and flight simulation training devices for pilots. This training will prevent developing upset conditions and ensure correct and consistent recovery responses. While this training is a requirement in the final rule, the AC is only meant to provide additional guidance on upset training. In previous letters to the FAA on A-96-120 and in response to the SNPRM the Board commented on whether the rule provisions would give principal operations inspectors (POIs) the authority to require changes to training programs that do not adequately address the topics in the new§ 121.423. If a training program does not adequately address the topics in.§ 121.423, the POI would be able to require changes to the program. Section 121.405 (b) and (d), which covers training program approval, includes the correction of deficiencies in training programs. FAA Order 8900.1, volume 3, chapter 19, section 2 contains guidance, direction, and in formation on the training program approval process. Additionally, paragraphs 3- 111 2, 3-11 14, and 3-1 11 5 of the Order address the process to withdraw approval due to an ineffective or noncompliant training curriculum. Order 8900.1 can be found at: htlp://fsims.faa.gov/. Due to other rulemaking priorities, an expressed commitment cannot be made at this time to pursue rulemaking to address recommendations A-96- I 20, A-1 0-22, and -23 for parts 135 and 91 K. I believe that the FAA has effectively addressed these safety recommendations as they pertain to part 121 operations. I consider our actions complete and plan no further action on these recommendations.

From: NTSB
To: FAA
Date: 2/11/2013
Response: The FAA is responding to these recommendations with its August 6, 2012, publication of advisory circular (AC) 120-109, “Stall and Stick Pusher Training,” and its continued development of a final rule based on the May 20, 2011, supplemental notice of proposed rulemaking (SNPRM) titled “Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers.” The AC, which offers guidance to training providers operating under Parts 121, 135, and 142 on stall event and stick pusher demonstration training, including recommendations and best practices for academic training, job performance training, and instructor training, is substantially unchanged from a draft that the FAA published in December 2011. On January 12, 2012, in comments about the draft AC, we stated that the AC is a significant improvement in FAA guidance to operators on stall and stick pusher training philosophy, stall prevention training, and stall recovery training. The AC includes the development and inclusion of training that incorporates stalls that are unexpected, involve autopilot disengagement, and include airplane-specific features, such as a reference speeds switch. Though elements of the AC are applicable to fully developed stalls, this element cannot be implemented until simulator fidelity in the stall and stall recovery regimes has been improved, as recommended in Safety Recommendation A-10-24, discussed below. The AC includes stick pusher familiarization in flight crew training on stalls. The AC is only advisory, however. The FAA included requirements that address stall and stick pusher training in the SNPRM; the FAA anticipates publishing a final rule in late 2013. On July 15, 2011, in comments about the SNPRM, we stated that implementation of the requirements proposed in the SNPRM would satisfy Safety Recommendations A-10-22 and 23, but only for Part 121 carriers. The FAA needs to take similar action for Part 135 and 91K operators and for Part 142 training centers before these recommendations can be closed acceptably. In its current letter, the FAA indicated that it would pursue rulemaking activity similar to the SNPRM for operating rules other than Part 121 only if the compliance costs for such rules show they are justified. The NTSB believes, however, that the accident experience shows that the training improvements are needed in operating rules in addition to Part 121. We reviewed our accident data for the period 2001 through the end of 2011, during which we investigated 37 accidents in which an aircraft was being operated under Part 135 rules, and for which the investigation revealed a stall to be a prominent factor in the accident. Of these 37 accidents, 15 involved fatalities; a total of 38 people were killed and 19 others were seriously injured. Accordingly, pending issuance of a final rule based on the SNPRM, and similar action being taken for Parts 135, 91K, and 142, Safety Recommendations A-10-22 and -23 remain classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 11/6/2012
Response: -From Michael P. Huerta, Acting Administrator: The Federal Aviation Administration (FAA) plans to partially adopt the intent of these recommendations for operators that are required to train under part 121 through the Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers Final Rule. The FAA will consider introducing this requirement to additional rule parts as they become cost justified. Section 208 of Public Law 111 -216, Airline Safety and Federal Aviation Administration Extension Act of2010, requires the FAA to initiate rulemaking on stall and upset recognition and recovery for part 121 operators. This section states that part 121 operators need to provide flight crewmembers with ground and flight training, or flight simulator training, to recognize and avoid or recover from a stall. The FAA included requirements that address stall and stick pusher training in the Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers Notice of Proposed Rulemaking (NPRM) published on January 12, 2009, and the supplemental NPRM published on May 20, 201 I. The final rule is anticipated to be released in late 2013. As a result of Public Law 111 -216, the FAA chartered the Stick Pusher Adverse Weather (SPAW) Aviation Rulemaking Committee (ARC) in 2010 to identify the best procedures and training practices that will enable air carrier pilots to accurately and consistently respond to unexpected stick pusher activations, icing conditions, and microburst and windshear events. The SPA WARC provided its recommendations to the FAA in July 2011. The FAA continues to evaluate the ARC's recommendations prior to determining if full adoption of the ARC's recommendations is appropriate. The FAA provided a report to Congress based on the SPAW ARC's work on March 7, 2012; the report is available at: http://www.faa.gov/about/office_org/headquarters_offices/agi/reports/media/Report%20to%20Congress%20on%20Stick%20Pusher%20Icing%20Microburst%20and%20Windshear%20Panel%20Recommendations.pdf The FAA reconvened the SPAW ARC in January 2012 and tasked it with specific de1iverables on upset recovery training in flight simulator training devices. The FAA will review the ARC's report, which is scheduled to be released by the end of2012. Following the report's release, the FAA will make its determination on how to proceed. Additionally, the FAA convened an FAA/Industry Stall Working Group in March 2010 that provided recommendations for an advisory circular (AC) for stall and stick pusher training. The FAA published AC 120-109, Stall and Stick Pusher Training, on August 6, 2012; the AC is available at: http://www.faa.gov/docurnentLibrary/media/Advisory_Circular/AC%20120-109.pdf I will keep the Board informed of the FAA's progress on these recommendations and provide an updated response by November 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: 1/12/2012
Response: Notation 8370: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) draft Advisory Circular (AC) 120-STALL, “Stall and Stick Pusher Training,” and the notice announcing its availability for comment, which was published at 76 Federal Register 77542 on December 13, 2011. According to the notice, the draft AC offers guidance to training providers operating under 14 Code of Federal Regulations (CFR) Parts 121, 135, and 142 on stall event and stick pusher demonstration training, including recommendations and best practices for academic training, job performance training, and instructor training. The NTSB recognizes the significant improvement in FAA guidance to operators on stall and stick pusher training philosophy, stall prevention training, and stall recovery training provided by the draft AC. The draft AC covers several important issues revealed during NTSB investigations related to pilot training for avoidance of and recovery from stalls. Among the issues are: 1. Emphasis on Angle-of-Attack: The importance of reducing the angle-of-attack in response to an encounter with a stall, stall warning, or approach to stall. 2. Energy Management: The importance of effective use of available energy (both altitude and speed), rather than minimal altitude loss, for stall recovery. 3. Stick Pusher Training: The importance of pilots experiencing the sudden forward movement of the control wheel during stick pusher events in training. 4. Crew Concept: The importance of good crew coordination in stall recognition and recovery. 5. Realistic Training Environment: The importance of pilots experiencing the startle effect, which can accompany an unexpected stall warning and the pitch changes, stick shakers, and alarms associated with autopilot disconnect during stall training. 6. Full Flight Simulator Use and Limitations: The importance of using full flight simulators (level C or D) to provide appropriate motion sensation to pilots during stall training while recognizing the fidelity limitations of particular simulators. The NTSB found in its investigation of Colgan Air, Inc., operating as Continental Connection flight 3407, a DHC-8-400, which crashed in Clarence Center, New York, on February 12, 2009, that the air carrier’s approach-to-stall training did not fully prepare the flight crew for an unexpected stall in the Q400 and did not address the actions needed to recover from a fully developed stall. The NTSB found the FAA’s practical test standards required pilots to recover from an approach to stall with minimal altitude loss, but altitude loss standards were not appropriate for responding to a fully developed stall. The FAA has since issued Safety Alert for Operators 10012, “Possible Misinterpretation of the Practical Test Standards (PTS) Language ‘Minimal Loss of Altitude’,” dated July 6, 2010, which stated that the reduction of angle of attack during a stall recovery would likely result in altitude loss; however, the draft AC goes much further in explaining the importance of angle-of attack reduction and acceptance of altitude loss and, as an AC, it will have a lasting effect on safety. The NTSB also found in its investigation of the crash of Colgan Air flight 3407 that the circumstances of the accident and other similar accidents demonstrated the continuing need to train pilots on the actions of the stick pusher and the airplane’s initial reaction to the pusher. The accident captain did not recognize the stick pusher’s action to decrease the angle-of-attack as a proper step in a stall recovery, and his improper flight control inputs to override the stick pusher exacerbated the situation. The captain might have received simulator training on the pusher, but the operator did not provide consistent stick pusher training to its Q400 pilots. The draft AC addresses the need for air carrier pilots to experience the sudden forward movement of the control wheel during a pusher event in a full flight simulator. The NTSB found that both pilots of Colgan Air flight 3407 failed to detect the impending onset of the stick shaker due to a significant breakdown in their monitoring responsibilities and workload management. The draft AC addresses crewmember roles and responsibilities, including cross-checking, standard phraseology, and good situational awareness in stall training. In addition, the NTSB found in the Colgan Air flight 3407 accident that following the automatic autopilot disconnect, the captain’s response to the stick shaker activation was consistent with startle and confusion. The draft AC addresses stall training with and without autopilot use and provides guidance for creating stall training scenarios where stall onset may be unexpected, which should provide pilots with skills to manage startle and surprise while implementing recovery techniques. The draft AC recommends that, whenever available, the highest level full flight simulators should be used in stall training programs, and the NTSB agrees. However, the draft AC cautions that the FAA does not recommend post-stall training unless the simulator is tested and validated for this. The NTSB found in the Colgan Air flight 3407 investigation that pilots could have a better understanding of an airplane’s flight characteristics during the post-stall flight regime if realistic (fully developed) stall models were incorporated into simulators used for such training. The NTSB strongly encourages the FAA to improve simulator fidelity in the stall and stall recovery regimes. The NTSB notes the statement in the forward of the AC that “The FAA recognizes that the content of this draft AC explains in further detail concepts proposed in the supplemental notice of proposed rulemaking (SNPRM), entitled Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers, FAA Docket FAA-2008-0677, and corresponding flight crewmember training AC, regarding stall and stick pusher training.” The NTSB believes the draft AC provides additional needed detail to support the proposed requirements in the SNPRM, and many of the comments here reflect comments we provided on July 15, 2011, concerning the SNPRM. The NTSB also notes that the draft AC addresses the following open safety recommendations to the FAA. A-10-22 Require 14 Code of Federal Regulations (CFR) Part 121, 135, and 91K operators and 14 CFR Part 142 training centers to develop and conduct training that incorporates stalls that are fully developed; are unexpected; involve autopilot disengagement; and include airplane-specific features, such as a reference speeds switch. This recommendation is currently classified “Open—Acceptable Response.” The draft AC proposes the development and inclusion of training that incorporates stalls that are unexpected, involve autopilot disengagement, and include airplane-specific features, such as a reference speeds switch as recommended. Though elements of the AC are applicable to fully developed stalls, the NTSB recognizes that this element of Safety Recommendation A-10-22 cannot be implemented until simulator fidelity in the stall and stall recovery regimes has been improved. The draft AC, in conjunction with the appropriate requirement in the SNPRM is also responsive to this recommendation for Part 121 operations. As with Safety Recommendation A 07-3, because the SNPRM only applies to Part 121 operators, the FAA will need to take similar action for Part 135 operators, as it has indicated it plans to do, before this recommendation can be closed acceptably.

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 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.

From: NTSB
To: FAA
Date: 1/25/2011
Response: The convening of an FAA/industry committee to explore and develop options to address stall training is a positive first step in responding to these recommendations. Accordingly, pending completion of the recommended actions, Safety Recommendations A-10-22, -23, and -24 are classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/22/2010
Response: MC# 2100243 - From J. Randolph Babbitt, Administrator: An FAA/industry committee has been convened to explore and develop options to address stall training for parts 121, 135, and 91K operators and part 142 training centers. The first meeting was held on March 11, 2010, with additional meetings planned this year. The committee intends to have its recommendations for addressing stall training, which will include stick-pusher training, in October 2010. We will then review those recommendations and determine the most appropriate course of action to address these safety recommendations.