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Safety Recommendation Details

Safety Recommendation A-10-026
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 more stringent standards for surveillance of 14 Code of Federal Regulations (CFR) Part 121 135, and 91K operators that are experiencing rapid growth, increased complexity of operations, accidents and/or incidents, or other changes that warrant increased oversight, including the following: (1) verify that inspector staffing is adequate to accomplish the enhanced surveillance that is promulgated by the new standards, (2) increase staffing for those certificates with insufficient staffing levels, and (3) augment the inspector staff with available and airplane-type-qualified inspectors from all Federal Aviation Administration regions and 14 CFR Part 142 training centers to provide quality assurance over the operators‘ aircrew program designee workforce.
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: 11/2/2015
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Oversight, Staffing

Safety Recommendation History
From: NTSB
To: FAA
Date: 11/2/2015
Response: We note that, on September 13, 2013, you issued Notice 8900.236, “ATOS Resource Management,” which amended policy and procedures specified in FAA Order 8900.1, “Flight Standards Information Management System,” to allow managers of Certificate Management Teams to use personnel from other offices to assist with oversight, as necessary, and to streamline the process for requesting that assistance. In our April 17, 2014, letter to you, we said that, in order to satisfy Safety Recommendation A-10-26, you still needed to incorporate the improved policies and procedures in Notice 8900.236 into your new Safety Assurance System and to incorporate the information contained in Notice 8900.236 into Order 8900.1 before the notice expired on September 13, 2014. We are pleased to learn that you completed the needed revisions in fall 2014. Consequently, Safety Recommendation A-10-26 is classified CLOSED—ACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 9/21/2015
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) has reviewed the Board's response dated April 17, 2014. Since that time, we have incorporated improved policies and procedures into the FAA •s Flight Standards Information Management System (FSIMS) (FAA Order 8900.1 ). FSIMS is the repository of all Flight Standards policy and guidance concerning aviation safety inspector job tasks. Using FSIMS, inspectors have the option to use content pertaining to the Safety Assurance System guidance (SAS content), or to use non-SAS content. These improved policies and procedures, outlined in Notice 8900.236, A TOS Resource Management, have been incorporated into both types of content. Specifically, referring to non-SAS content, we revised Volume 10, Air Transportation Oversight System, Chapter 2, Section 3, Design and Performance Assessment Resource Management, in November 20 I4. Within SAS content, we revised the following sections of Volume I 0, Safety Assurance System, in September 2014: • Chapter I, Section 2: Introduction to SAS Business Process and Tools; • Chapter 1, Section 4: Acronyms, Abbreviations, Terms and Definitions; and • Chapter 4, Section I: Module 3 Resource Management These improvements include amended policies and procedures to allow managers of Certificate Management Teams to use personnel from other offices to assist with oversight as necessary and to streamline the process for requesting that assistance. I believe that the FAA has effectively addressed this safety recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 4/17/2014
Response: Since we issued this recommendation, you have described several management tools you are developing for use in allocating inspection and surveillance oversight resources and personnel. Although these tools have partially addressed the recommendation, we have expressed concern over whether they fully addressed the issue we found in our investigation of the Colgan Continental Connection flight 3407 accident. We found that your principal operations inspector (POI) for Colgan had not previously been qualified in the new equipment (the Q400 aircraft) that Colgan was adding, even though he needed to qualify a number of pilots in this aircraft. Despite his limited Q400 experience at a time when Colgan’s growth imposed a high workload on him in supervising pilot qualifications and other tasks requiring in-depth knowledge of the new aircraft, you did not recognize this problem nor reassign other FAA inspectors who had received appropriate training and who had greater experience with the Q400. In our February 11, 2013, letter, we said that it appeared from the explanations provided in your November 6, 2012, letter that the goals of the systems being developed were (1) to prioritize some carriers over others for oversight and (2) to focus a POI’s attention on particular aspects of a carrier’s current situation. We pointed out that, rather than focusing the POI’s attention on particular aspects of a carrier’s operation, however, this recommendation is focused on FAA management’s (not on the POI’s) recognizing the need for additional oversight resources. We note that, on September 13, 2013, you issued Notice 8900.236, “ATOS Resource Management,” which amends policy and procedures specified in FAA Order 8900.1, “Flight Standards Information Management System,” to allow managers of Certificate Management Teams to use personnel from other offices to assist with oversight as necessary and to streamline the process for requesting that assistance. We also note that you plan to incorporate these improved policies and procedures into your new Safety Assurance System and to incorporate the information contained in Notice 8900.236 into Order 8900.1, Volume 10, Chapter 2, Section 3, before the notice expires on September 13, 2014. Pending completion of these actions, Safety Recommendation A-10-26 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 3/18/2014
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) has reviewed the Board's concerns and questions raised in its response dated February 11, 2013. Since that time, we issued Notice 8900.236, ATOS Resource Management, with an effective date of September 13, 2013. A copy of this notice can be found at: http://www.faa.gov/documentLibrary/media/Notice/N_8900.236.pdf. This Notice, which amends FAA Order 8900.1, Flight Standards Information Management System, revises policy and procedures to allow managers of part 121 Certificate Management Teams (CMT) to use personnel from other offices to assist with oversight as necessary and streamlines the process for requesting that assistance. Requests may address the need for operations, airworthiness specialties, or qualifications deemed necessary for the requisite oversight. both inside and outside of their Regions. If the request cannot be satisfied, the Notice provides for the review of the request by the FAA Regional Managers and, if necessary, the FAA •s Deputy Director of Flight Standards Field Operations, This program will be incorporated into the new Safety Assurance System, which will be implemented in Fiscal Year 2015, and will also include part 135 operations. Short-term staffing requirements can be met (1) within the Region, (2) through the use of the Flight Standards Inspector Resource Program (FSIRP), or (3) by requesting assistance from the Director of the FAA's Flight Standards Service (AFS). If the resource request can be met within the Region, then the divi sion manager will assign the necessary resources. If the resource request cannot be satisfied within the Region, then there are two other options to satisfy a short-term requirement. FSIRP can support the certification or surveillance of aim1en operating large aircraft for certificated entities. Within the FSIRP, there are designated National Resource Inspectors (NRIs) who have been identified by the AFS Flight Program and serve as subject matter experts on large transport category aircraft. This program provides flexibility and efficiency by having these NRIs available for many of the common types of aircraft being operated in the National Airspace System today. For example, whenever a Principal Operations Inspector (POI) is tasked with adding a new aircraft type to an operator's air carrier certificate, for which he or she is not rated or qualified, or there are insufficient Aviation Safety Inspectors (ASI) available to provide oversight, the POI makes a request to the FSIRP for an ASI to assist with the addition of this aircraft. NRIs serve as subject matter experts to observe pilot training, check airmen training and designation, proving and validation testing, and other oversight activities. Another course of action available to the CMT and Region is to request additional resources from outside the Region that may be available on a temporary duty (TOY) assignment. The Region's request for resources is forwarded to the Human Capitol Council (HCC). The HCC reviews the request and provides a recommendation for the TOY assignments to the Director of AFS. For long term staffing needs, AFS uses the Aviation Safety Staffing Tool and Reporting System (AST ARS) to assist management in determining permanent long term staffing requirements. AST ARS uses internal and external data sources to forecast future levels of work activity at each office based on the certificate holder's configuration. Currently, ASTARS is undergoing a two-step revision and modification to improve the modeling accuracy. This process involves an interim and a long-term revision (which is a more detailed analysis). The interim revision was completed on December 3 1, 2013. As part of the long-term revision, the FAA is expanding its efforts to improve future model forecasts through increased data quality review, simplifying databases for easier data collection, and improving guidance for keeping databases current and accurate. We emphasize that AST ARS is only a tool and the results must be refined with the expertise and judgment of subject matter experts, managers, and senior executives when making decisions. Hs application to short-term and highly volatile staffing requirements and requests is very limited. The FAA believes that there are sufficient vehicles in place to identify both short-term and long-term resource requirements. The FAA will review current policy and programs to ensure they are adequate for identifying and meeting the resource needs of the field on both a short- and long-term basis. In addition, we will review guidance to our inspectors, managers, and executives to make sure they are aware of the programs available to them that can identify and satisfy their resource needs. I will keep the Board informed of the progress on this recommendation and provide an updated response by December 2014.

From: NTSB
To: FAA
Date: 2/11/2013
Response: The FAA provided an update on its various initiatives examining and revising its oversight system. Among these revisions is the implementation of the Surveillance Priority Index (SPI) for use by principal operations inspectors (POIs) of Part 135 operators. The SPI considers rapid growth, increased complexity of operations, and accidents and/or incidents as part of a process to prioritize inspection activities. Since before the Colgan 3407 accident, the Air Transportation Oversight System (ATOS) Air Carrier Assessment Tool (ACAT) has included rapid growth, increased complexity of operations, accidents, and incidents (among 25 other risk indicators) to assist Part 121 POIs in focusing on inspection areas where new hazards and increased risk may exist. The FAA is currently developing the Flight Standards Safety Assurance System (SAS) as the FAA’s new safety oversight program. The functionality of the SPI, ACAT, and ATOS data collection tools will be improved and incorporated into SAS. The issue that Safety Recommendation A-10-26 addresses is the need for FAA management to recognize the need for, and provide appropriate resources (particularly personnel) required for, the increased oversight of carriers that are experiencing rapid growth, increased complexity of operations, accidents, incidents, or other changes. In its letter, the FAA discussed the implementation of Safety Management Systems (SMS) at carriers. Although we support the implementation and use of SMS by all organizations in the transportation industry, we do not consider the development and use of an SMS by a carrier to be relevant to FAA decisions regarding the provision of adequate staff to carry out the oversight of a carrier. As we emphasized in our previous letter, Safety Recommendation A-10-26 addresses the issue that the POI involved had not previously been qualified in the new equipment (the Q400 aircraft) that Colgan was adding, yet he needed to qualify a number of pilots. Although the POI had limited Q400 experience at a time when Colgan’s growth imposed a high workload on POIs in supervising pilot qualifications and other tasks requiring in-depth knowledge of the new aircraft, the FAA did not recognize this problem nor reassign other FAA inspectors who had received appropriate training and greater experience with the Q400. Accordingly, in our previous letter, we asked the FAA to describe how the new systems being developed would have (1) detected this specific situation in the flight 3407 accident and (2) prompted the reassignment of inspectors who possessed the needed qualifications. In its current letter, the FAA replied that it uses the AFS [Flight Standards] Staffing Tool and Reporting System to provide a long-term forecast of POI needs. In addition, the SAS Certificate Holder Assessment Tool (CHAT) will be used to identify risks within the certificate holder, allowing the POI to respond in various ways; for example, by increasing oversight, by focusing oversight in areas of risk, or by identifying new hazards. The FAA indicated that CHAT is similar to the ACAT in ATOS. Finally, to further complement the CHAT, the FAA’s National Safety Analysis will assess data on a continuous basis that can alert inspectors to increased risk. Although we recognize the FAA’s efforts to improve the management systems that it uses to prioritize oversight activities, we remain concerned. It appears from the explanations provided in the FAA’s letter that the goal of these systems is to prioritize some carriers over others for oversight, and to focus a POI’s attention on particular aspects of a carrier’s current situation. Yet rather than focusing the POI’s attention on particular aspects of a carrier’s operation, this recommendation is focused on FAA management’s (not on the POI’s) recognizing the need for additional oversight resources. Again, we emphasize that, in the Colgan flight 3407 accident, the POI had limited experience in the new equipment (the Q400 aircraft) that Colgan was rapidly adding, and for which crews needed to be qualified. Although the FAA had a number of other inspectors already on its staff who were experienced with and qualified in the Q400, FAA management neither recognized the need of Colgan’s POI for additional resources, nor did it reassign available inspectors to Colgan during the transition to the new equipment. As it redesigns its oversight system, we ask the FAA to consider this need. In the meantime, pending the FAA’s making revisions in SAS that address Safety Recommendation A-10-26, the recommendation remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 11/6/2012
Response: -From Michael P. Huerta, Acting Administrator: As stated in the Federal Aviation Administration's (FAA) last response, rapid growth, increased complexity of operations, accidents and/or incidents, and other significant changes can introduce risk into an air carrier's operations. A Safety Management System (SMS) can be used by an air carrier to identify and mitigate those risks. The SMS draft final rule remains in executive review at this time. In the interim, we have initiated an SMS pilot project to encourage air carriers to implement voluntary SMSs. Currently there are 162 certificated operators in the SMS pilot project. This includes: 79 14 CFR part 121 air carriers 69 14 CFR part 135 air carriers 4 14 CFR part 141 flight schools 10 14 CFR part 145 repair stations We have also taken steps to implement a Surveillance Priority Index (SPI) that considers rapid growth, increased complexity of operations, and accidents and/or incidents as part of a process to assist part 135 principal operations inspectors (POls) to prioritize their inspection activities. The SPI is continually reviewed and revised to enhance its effectiveness. For example, revised Order 1800.56L, National Flight Standards Work Program Guidelines (http://www.faa. gov/documcntLibrary/media/Order/1800.56L.pdf), was published on July 21 , 2011, to provide surveillance program guidance. The Air Transportation Oversight System (A TOS) Air Carrier Assessment Tool (ACAT) includes rapid growth, increased complexity of operations, and accidents and/or incidents, among 25 other risk indicators, to aid part 121 POls in focusing on inspection areas where new hazards and increased risk may exist. Below is a sample of these risk indicators: Environmental Criticality (EC) - Aspects of the air carrier's surroundings that may lead to or trigger a systemic failure with the potential of creating an unsafe condition. EC-02 Varied Fleet Mix/ Configuration A varied fleet mix and/or mixed fleet configuration can significantly alter an air carrier's safety profile and the potential for failure in its systems. EC-03 Change in Aircraft Complexity Changes to the complexity of an air carrier's fleet can significantly affect an air carrier's safety and the potential for failure in its systems. Operational Stability (OS) - Organizational and environmental factors the air carrier cannot directly control, but can manage effectively to improve system stability and safety. OS-06 Rapid Gorwth/ Downsizing Times of significant change such as rapid expansion or downsizing can impact air carrier operations due to the possible misalignment of resources and operational requirements. We continue our development of the Flight Standards Safety Assurance System (SAS) as the FAA's new safety oversight program. The functionality of the SPI, ACAT, and ATOS data collection tools will be improved and incorporated into SAS. SAS first site initial operational capability is currently planned for February 28, 2014, with completion targeted for September 30, 2014. In the Board's last letter, it asked the FAA to describe how it would detect and respond to the unsafe conditions involved with this accident. First, the FAA uses the AFS Staffing Tool and Reporting System to provide a long-term forecast of POI needs. Second, the SAS Certificate Holder Assessment Tool (CHAT) will be used to identify risks within the certificate holder. The information from the CHAT allows the POI to take several actions (e.g. increase oversight, focus oversight in areas of risk, identify new hazards, etc.); this tool is similar to the ACAT in ATOS. To further compliment the CHAT, the National Safety Analysis will be assessing data on a continuous basis that can alert inspectors to increased risk. I will keep the Board informed of the FAA's progress on this recommendation and provide an update by November 30, 2013.

From: NTSB
To: FAA
Date: 1/25/2011
Response: The NTSB notes that the FAA is developing a new oversight system that will rely on an air carrier's safety management system (SMS) and that the FAA's new system is scheduled for deployment in late 2013. The FAA believes that factors such as rapid growth; increased complexity of operations, accidents, or incidents; and other significant changes shonld be considered by the carrier's SMS. The FAA also indicated that it recently introduced a new staffing tool called the AFS Staffing Tool and Reporting System (ASTARS), which the FAA uses to predict the inspector-staff resources needed for acceptable oversight of a carrier. The FAA indicated that ASTARS will enable it to more effectively monitor factors such as those mentioned in the recommendation and to detennine appropriate, empirically valid staffing levels under changing environmental conditions. The NTSB emphasizes that the oversight issue related to the Colgan flight 3407 accident addressed by this recommendation is that the FAA principal operations inspector (POI) had not previously been qualified in the new equipment (the Q400 aircraft) that Colgan was adding, yet the POI needed to qnalify a number of pilots. Although the POI had limited Q400 experience at a time when Colgan's growth required a high workload associated with the POI supervising pilot qualifications and other tasks requiring in-depth knowledge of the new aircraft, the FAA did not recognize this problem nor reassign other FAA inspectors who had received appropriate training and greater experience with the Q400. Although ASTARS may address this issue, we ask the FAA to describe how it would have detected this specific situation in the flight 3407 accident and reassigned inspectors who possessed the needed qualifications. Pending our receipt of a satisfactory answer to that question and implementation of ASTARS, Safety Recommendation A-10-26 is classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/22/2010
Response: MC# 2100243 - From J. Randolph Babbitt, Administrator: Rapid growth, increased complexity of operations, accidents and/or incidents, and other significant changes can introduce hazards into an air carrier's operations. These hazards and their associated risks must be managed. Safety Management Systems (SMS) are formal processes and standards that air carriers can use for this purpose. The FAA has convened an ARC to consider regulatory requirements for SMS. We have received the ARC recommendations and are reviewing them to determine how to proceed. In the interim, we have initiated an SMS pilot project to encourage air carriers to voluntarily implement SMSs. We are developing a new oversight system that will enable us to leverage our resources against each air carrier's SMS capabilities. The new system is called the Flight Standards (AFS) Safety Assurance System (SAS). It is being developed under the auspices of the Systems Approach to Safety Oversight Program Office and will be deployed by September 30, 2013. We have also taken immediate steps to implement a Surveillance Priority Index (SPI) that considers rapid growth, increased complexity of operations, and accidents and/or incidents as part ofa process to assist part 135 principal inspectors to prioritize their inspection activities. The SPI is currently undergoing further review to enhance it. The Air Transportation Oversight System (ATOS) Air Carrier Assessment Tool (ACAT) already includes rapid growth, increased complexity of operations, and accidents and/or incidents among 25 other risk indicators to aid part 121 principal inspectors in focusing on inspection areas where new hazards and increased risk may exist. Additionally, the ATOS element structure and data collection tools are nearing completion of a major revision. Three of four implementation phases are completed. The fourth phase will be completed in July 2010. The functionality of the SPI, ACAT, and ATOS data collection tools will be further refined and incorporated in the SAS. We recently introduced a new staffing tool called the AFS Staffing Tool and Reporting System (ASTARS). ASTARS enables us to more accurately predict the inspector-staff resources needed to sustain oversight performance at an acceptable level and to distribute available staff resources equitably and effectively. ASTARS will enable us to more effectively monitor factors such as those mentioned in the recommendation and to determine appropriate, empirically valid staffing levels under changing environmental conditions.

From: NTSB
To: FAA
Date: 4/8/2010
Response: Notation 8201: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) advance notice of proposed rulemaking (ANPRM) titled “New Pilot Certification Requirements for Air Carrier Operations,” which was published in Federal Register, Volume 75, Number 25, p. 6164 on February 8, 2010. The ANPRM invites comments on possible changes to regulations relating to the certification of pilots conducting domestic, flag, and supplemental operations and seeks to gather information on whether current eligibility, training, and qualification requirements for commercial certification are adequate for engaging in such operations. The ANPRM asks for comments on a large number of questions. The NTSB is seeking similar information related to issues of pilot training and professionalism and has scheduled a Forum on Professionalism in Aviation: Ensuring Excellence in Pilot and Air Traffic Controller Performance in May 2010. The NTSB proposes some general comments on this ANPRM. While the ANPRM focuses on 14 Code of Federal Regulations (CFR) Part 121 pilots, the NTSB believes that the same level of safety and oversight should apply to all revenue air carrier operations and that any substantive changes should include 14 CFR Part 135 pilots, because these pilots also carry members of the paying public. The NTSB believes that careful scrutiny of the eligibility, training, and certification requirements for air carrier pilots is appropriate and supports a comprehensive assessment of the requirements for air carrier crewmember eligibility and qualifications in today’s environment. Significant changes in the airline industry have not been accompanied by changes in crew eligibility, training, and certification requirements. The required number of cockpit crewmembers has, in most cases, decreased from three to two; aircraft have become more complex; airspace has become more restrictive; and domestic and international flight operations have become more challenging. The current trend of major legacy airlines using smaller regional air carriers on a growing number of routes through code-sharing agreements has resulted in the rapid growth of the regional airlines, which have traditionally been, and in most cases still are, entry-level air carriers for pilots. Regional airlines are now operating a substantial number of flights in highly sophisticated and complex aircraft and are carrying a significant number of passengers who expect the same level of safety as the major legacy airlines. Thus, the NTSB is pleased that FAA has taken the initiative to reassess 14 CFR Part 61 requirements of aeronautical knowledge and airman certification requirements. The complex changes in today’s equipment and environment require that pilots enter Part 121 and Part 135 flight operations with a high level of experience, proficiency, and professionalism. Currently, most entry-level air carrier pilots have relatively low operational flight experience and little experience operating in conjunction with other crewmembers. In addition, that experience is generally in less complex aircraft. 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 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. The NTSB is pleased that the FAA is addressing this issue, and the NTSB also intends to explore this issue during its upcoming forum. An issue that the FAA does not address in the ANPRM is that of oversight. The NTSB strongly believes that the development and maintenance of pilot knowledge, proficiency, and professionalism requires a higher level of oversight by FAA inspectors. The current FAA trend of delegating the majority of oversight of flight training, en route line checks, and proficiency checks to airline and flight training vendor designees can lead to poor safety cultures and poorly qualified pilots. For example, the NTSB, in its investigation of the June 4, 2007, accident in Milwaukee, Wisconsin, found that the check airman responsible for training and line checks provided very poor oversight and training of the pilots at the company. As a result, the NTSB made the following recommendation: Conduct a detailed review of the oversight provided to Marlin Air to determine why the oversight system failed to detect (before and after the accident) and correct Marlin Air’s operational deficiencies, particularly in the areas of pilot hiring, training, and adherence to procedures. (A-09-125) The FAA stated that it plans to conduct such a review. While this recommendation was focused on one Part 135 carrier, the NTSB believes that the findings from the review could help shape FAA oversight for all carriers to ensure that the highest levels of pilot knowledge, proficiency, and professionalism are achieved and maintained. Furthermore, the NTSB has found in its investigations that, because of inadequate FAA staffing, many safety critical tasks are delegated to airline or training vendor personnel. In many cases, because of these staffing shortages, some desired oversight tasks may not be accomplished at all. As a result of its investigation of the February 12, 2009, accident in Clarence Center, New York, the NTSB made the following recommendation: Develop more stringent standards for surveillance of 14 Code of Federal Regulations (CFR) Part 121, 135, and 91K operators that are experiencing rapid growth, increased complexity of operations, accidents and/or incidents, or other changes that warrant increased oversight, including the following: (1) verify that inspector staffing is adequate to accomplish the enhanced surveillance that is promulgated by the new standards, (2) increase staffing for those certificates with insufficient staffing levels, and (3) augment the inspector staff with available and airplane-type-qualified inspectors from all Federal Aviation Administration regions and 14 CFR Part 142 training centers to provide quality assurance over the operators’ aircrew program designee workforce. (A-10-26) The NTSB believes that the FAA needs to maintain adequate staffing to provide greater FAA inspector oversight of Part 121 and Part 135 training, proficiency checks, and line flight operations and encourages the FAA to address this issue in future rulemaking. Regarding the ANPRM proposal for a special 14 CFR 61.31 endorsement on a commercial pilot certificate for Part 121 operations, the NTSB believes that a special endorsement for both Part 121 and Part 135 pilots might be beneficial if the requirements for the endorsement are comprehensive, adequate, and effective. The special endorsement requirements need to be well defined, ensure that pilots have the experience and competency in following procedures and handling high performance aircraft, and ensure that pilots achieve and maintain adequate training, experience, and proficiency on the equipment and procedures specific to the pilots’ employers. The special endorsement requirements should also reflect a robust and objective means of determining that pilots demonstrate adequate judgment and professionalism. The appropriate evaluation and processing of such endorsements further necessitates FAA oversight. The NTSB appreciates the opportunity to comment on this ANPRM.