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Safety Recommendation Details

Safety Recommendation A-10-025
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: Identify which airplanes operated under 14 Code of Federal Regulations Part 121, 135, and 91K are susceptible to tailplane stalls and then (1) require operators of those airplanes to provide an appropriate airplane-specific tailplane stall recovery procedure in their training manuals and company procedures and (2) direct operators of those airplanes that are not susceptible to tailplane stalls to ensure that training and company guidance for the airplanes explicitly states this lack of susceptibility and contains no references to tailplane stall recovery procedures.
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, Upset Recovery

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/21/2016
Response: We note that you have previously identified airplanes susceptible to ice-contaminated tailplane stalls (ICTS), and that you published Notice N8900.267, “Focused Review of Flightcrew Member Training for Ice-Contaminated Tailplane Stall,” effective June 30, 2014, to require your inspectors to determine whether each airplane make, model, and series being operated or trained on is susceptible to an ICTS using the guidance provided in the notice appendices. For airplanes that are not susceptible to an ICTS, the notice required your inspectors to review the operator’s approved training program and manuals to verify that they do not provide guidance on tailplane icing and ICTS recovery maneuvers. The actions required by the notice satisfy Safety Recommendation A-10-25, which is classified CLOSED—ACCEPTABLE ACTION. Thank you for taking this action.

From: FAA
To: NTSB
Date: 5/23/2016
Response: -From Michael P. Huerta, Administrator: As stated in our last letter dated May 30, 2013, the Federal Aviation Administration (FAA) completed its review of current regulations, policy, and guidance on stall recovery training for pilots and FAA inspectors. In response to the subject safety recommendation, we published Notice N 8900.267, Focused Review of Flight crew Member Training for Ice-Contaminated Tailplane Stall, effective June 30, 2014. A copy of this notice is available at the following Web site: http://www.faa.gov/documentLibrary/media!Notice/ The FAA worked with airplane manufacturers to identify airplane types operating under parts 91 K, 121 , or 135 that may be susceptible to an ICTS. A survey of airplane types operating under part 91 K, 121, or 135 conducted by the FAA and airplane manufacturers found that: • Nearly all airplane types certificated under 14 CFR part 25 have been evaluated for ICTS susceptibility; • A limited number of airplanes certificated under 14 CFR part 23 have been evaluated for ICTS susceptibility; and • The airplane types found susceptible to ICTS had the susceptibility mitigated through design changes, operating limitations, and/or operating procedures. This notice also requires that POIs assigned to a 14 CFR part 91K, 121, and/or 135 operator with authorization to operate airplanes in icing conditions and TCPMs must determine if each airplane make, model, and series being operated or trained is susceptible to an ICTS using the guidance provided in the notice appendices. For airplanes that are not susceptible to an ICTS or that have mitigations in place, POIs and TCPMs must review the approved training program and manuals to verify the following: • The 1998 NASNF AA "Tailplane Icing" video is not incorporated as part of the approved training program; • A tailplane stall recovery procedure is not incorporated as part of the procedures nor included in the approved training program; and • For airplanes whose susceptibility is mitigated by specific Airplane Flight Manual limitations and procedures (such as limiting flaps used for landing), those limitations and procedures are included in the operator's procedures and approved training program. Furthermore, for airplanes that have not been evaluated for ICTS, this notice states that POIs and TCPMs must review the approved training program and manuals to verify that the operator or training center has included any airplane manufacturer recommendations regarding operations in icing conditions. If there are no airplane manufacturer recommendations, current training for operating in icing conditions should be maintained. I believe that the FAA has effectively addressed this safety recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 7/29/2013
Response: We are aware that the FAA has identified airplanes susceptible to tailplane stalls, and we are encouraged that the FAA plans to publish a notice directing all Part 121, 135, and 91 Subpart K principal operations inspectors to review all flight crew training on in-flight icing procedures to ensure that the training and procedures related to icing induced tailplane stalls are appropriate for the aircraft being operated. Pending publication of the notice, Safety Recommendation A-10-25 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/30/2013
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) completed its review of current regulations, policy, and guidance on stall recovery training for pilots and FAA inspectors. In response to this safety recommendation, we are publishing a notice that will direct all part 121, 135, and 91 subpart K (91K) principal operations inspectors (POls) to conduct a focused training program review of all flight crew training on in-flight icing procedures. The FAA expects to publish this notice by January 2014. The notice provides POls with data and procedures to assist in determining aircraft susceptibility to ice-contaminated tailplane stall (ICTS). POIs with carriers operating aircraft not susceptible to ICTS will have to ensure the following items are not incorporated as part of the operator's approved training program: • The NASA/FAA video on ICTS; and • A tailplane stall recovery procedure. If the operator's training program includes either of these items, the POI will request removal. For operators of aircraft that are susceptible to ICTS, POls will ensure any limitation or procedure for icing conditions (such as limiting the amount of flaps used for landing) in the aircraft's flight manual (AFM), is covered in the approved training program. If the AFM includes specific guidance, the POI will ensure: • The operator adopts those limitations and procedures in their training program; and • The operator adds the reason for the applicable limitation/procedure in icing conditions. If the AFM does not include any specific guidance, the POI will ensure current training for icing conditions is maintained. If a POI oversees a part 135 or 91 K operator with airplanes that have not been evaluated and are not known to be susceptible to ICTS, they will verify the operator has included appropriate procedural guidance, based upon the aircraft manufacturer's recommendations or the guidance noted above, in their approved training program. The FAA finds thi.s is an appropriate way to address stall recovery procedures for part 135 and 91 K operators. Since aircraft operated in part 121 can also be operated under parts 13 5 and 91 K, the FAA decided not to conduct a gap analysis on aircraft operated in part 91 K operations as stated in our previous letter. The information and guidance that will be provided in the notice is applicable to all operators under parts 121, 135, and 91K. I will keep the Board infonned of the FAA's progress on this safety recommendation and provide an update by March 31 , 2014.

From: NTSB
To: FAA
Date: 1/25/2011
Response: The FAA indicates that it has completed the identification of airplanes that are susceptible to tailplane stalls. The FAA's plan to review current regulations, policy, and guidance on stall recovery training for pilots and FAA inspectors, focusing on whether any tailplane stall recovery training material is aircraft appropriate, is responsive to this recommendation. After this review, the FAA will need to make any revisions it identifies as needed. Pending completion of the FAA's review and implementation of revisions to training identified as necessary, Safety Recommendation A-I 0-25 is classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/22/2010
Response: MC# 2100243 - From J. Randolph Babbitt, Administrator: Since 1994, FAA airworthiness policy has been to evaluate all new part 23 and part 25 aircraft to ensure they are not susceptible to ice-contaminated tailplane stall (lCTS), which was codified in part 25 in 2007. The charter for a part 23 icing ARC was approved on February 19, 2010. One of the tasks assigned to the ARC is to recommend part 23 regulations that will codify the part 23 certification guidance on ICTS susceptibility. In our September 2009 response to Safety Recommendation A-07-16, we indicated we conducted an ICTS evaluation of existing airplanes (certified prior to 1994) with unpowered flight control systems (of which many are equipped with pneumatic deicing boots) operating under parts 121 or 135 operating rules. The FAA mandated changes to improve tailplane stall margins for airplanes found to be susceptible. These changes were mandated through the following airworthiness directives: Aerospatiale ATR-42 86-20-02 Embraer EMB-I10Pl and EMB-IIOP2 Series 82-20-02 General Dynamics 240 Series, including Model T-29 (Military): 340 and 440 Series, and C-131 96-03-04 Hawker Beechcraft MU-300 99-21-30 Hawker Beechcraft 400, 400A, 400T, and MU-300-1O 99-21-26 Jetstream Aircraft Limited HP137 Mk 1 and Jetstream Series 200 95-15-12 Jetstream Aircraft Limited 3101 95-02-06 Lockheed L-188A L-188C Series 98-24-25 Mitsubishi YS-ll, YS-IIA-200, YS-IIA-300, YS-IIA-500, and YS-IIA-600 Series 91-16-01 Saab SF-340A 86-06-03 Rl