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Safety Recommendation Details

Safety Recommendation A-10-024
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: Define and codify minimum simulator model fidelity requirements to support an expanded set of stall recovery training requirements, including recovery from stalls that are fully developed. These simulator fidelity requirements should address areas such as required angle-of-attack and sideslip angle ranges, motion cueing, proof-of-match with post-stall flight test data, and warnings to indicate when the simulator flight envelope has been exceeded.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
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: 7/21/2016
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Training and Education,

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/21/2016
Response: We note that, in the final rule, Table A1A, QPS Requirements, entry 2.m, “High Angle of Attack Modeling” contains requirements that satisfy Safety Recommendation A-10-24. Accordingly, this recommendation is classified CLOSED—ACCEPTABLE ACTION.

From: NTSB
To: FAA
Date: 12/22/2014
Response: We note that, on July 10, 2014, you published a notice of proposed rulemaking (NPRM), titled “Flight Simulation Training Device (FSTD) Qualification Standards for Extended Envelope and Adverse Weather Event Training Tasks.” This NRPM proposes revisions to Part 60 of FAA regulations that, if implemented, should satisfy Safety Recommendation A-10-24. Accordingly, pending issuance of the final rule as proposed, the recommendation remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 11/14/2014
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration published the Flight Simulation Training Device (FSTD) Qualification Standards for Extended Envelope and Adverse Weather Event Training Tasks'' Notice of Proposed Rulemaking (NPRM) on July l 0, 2014 (79 FR 39462). This NPRM was delayed from its original publication date, which allowed the FAA to further clarify the NPRM's scope. This NRPM proposes to update the FSTD technical standards to improve FSTD fidelity in the stall maneuver and other safety critical training maneuvers. These proposed changes support training requirements mandated in the "Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers Final Rule, which was published on November 12, 2013 (78 FR 67800). We anticipate publication of the FSTD final rule in 2016. I will keep the Board informed of our progress on this recommendation and provide an update by August 31, 2015.

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: 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. Although the draft revised AC does not contain simulator model fidelity requirements, we believe that some of the training recommended in the draft revised AC will depend, in part, on the availability of simulators that comply with the standards specified in Safety Recommendations A-10-24 and A-11-46 and -47.

From: NTSB
To: FAA
Date: 2/11/2013
Response: We are encouraged to learn that the FAA has initiated a rulemaking project to revise Part 60, in which flight simulator training device (FSTD) standards are codified, to update the technical evaluation standards. The revisions would improve FSTD fidelity in the stall maneuver, including aerodynamic stall and stick pusher activation events, and other safety critical training maneuvers. As discussed above, these revisions will be necessary to bring about the full safety improvements proposed in the SNPRM. Pending the completion of final revisions to Part 60 that satisfy Safety Recommendation A-10-24, the recommendation remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 11/6/2012
Response: -From Michael P. Huerta, Acting Administrator: The Federal Aviation Administration (FAA) is taking the necessary steps to best address the intent of this safety recommendation. On August 6, 2012, we published Advisory Circular 120-109, Stall and Stick Pusher Training. On November 1, 2011, the FAA Rulemaking Council approved the 14 CFR part 60 application for rulemaking. On May 1, 2012, the FAA Rulemaking Council approved a rulemaking action plan to develop a notice of proposed rulemaking (NPRM) for the flight simulation training device (FSTD) qualification standards contained in part 60. The proposed changes to part 60 are intended to update the FSTD technical evaluation standards to improve FSTD fidelity in the stall maneuver, including aerodynamic stall and stick pusher activation events, and other safety critical training maneuvers. Some of the interim recommendations from the International Committee for Aviation Training in Extended Envelopes will also be incorporated in the part 60 NPRM. This rulemaking effort will also support the training requirements in the Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers Supplemental Notice of Proposed Rulemaking. The part 60 NPRM is currently being drafted and is expected to be published in 2013. I will keep the Board informed of the FAA's progress on this safety recommendation and provide an updated response by January 2014.

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-10-24 Define and codify minimum simulator model fidelity requirements to support an expanded set of stall recovery training requirements, including recovery from stalls that are fully developed. These simulator fidelity requirements should address areas such as required angle-of-attack and sideslip angle ranges, motion cueing, proof-of-match with post-stall flight test data, and warnings to indicate when the simulator flight envelope has been exceeded.

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 NTSB is pleased to see that the SNPRM proposes to require training for stick shaker and recognition and recovery from full stalls in accordance with the recommendations from the Colgan accident investigation and Public Law 111-216, Sections 208 and 209. The NTSB notes, however, that while the technology now exists to model the correct simulator response to stalls, this technology has not been implemented in many training simulators. It is important that the behavior of the simulator in a stall (often uncommanded roll, reduced roll stability, and reduced roll control authority) be representative of the actual aircraft before training is permitted in these simulators.

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.