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On February 12, 2009, about 2217 eastern standard time,1 a Colgan Air, Inc., Bombardier DHC-8-400 (Q400),2 N200WQ, operating as Continental Connection flight 3407, was on an instrument approach to Buffalo-Niagara International Airport, Buffalo, New York, when it crashed into a residence in Clarence Center, New York, about 5 nautical miles northeast of the airport. The 2 pilots, 2 flight attendants, and 45 passengers aboard the airplane were killed, one person on the ground was killed, and the airplane was destroyed by impact forces and a postcrash fire. The flight, which originated from Liberty International Airport (EWR), Newark, New Jersey, was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121. Night visual meteorological conditions prevailed at the time of the accident.
TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to incorporate explicit guidance to pilots, including checklist reminders as appropriate, prohibiting the use of personal portable electronic devices on the flight deck.
Original recommendation transmittal letter:
Closed - Unacceptable Action
Clarence Center, NY, United States
Loss of Control on Approach, Colgan Air, Inc., Operating as Continental Connection Flight 3407, Bombardier DHC 8 400, N200WQ
Addressee(s) and Addressee Status:
FAA (Closed - Unacceptable Action)
Safety Recommendation History
Notation 8476 (dated 3/12/2013): The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) notice of proposed rulemaking (NPRM), titled “Prohibition on Personal Use of Electronic Devices on the Flight Deck,” which was published at 78 Federal Register 2912 on January 15, 2013. The NPRM proposes to prohibit flight crewmembers in operations under 14 Code of Federal Regulations (CFR) Part 121 from using a personal wireless communications device or laptop computer for personal use while at their duty station on the flight deck while the aircraft is being operated. According to the NPRM, the prohibition would begin “at taxi (movement of the aircraft under its own power) and end when the aircraft is parked at the gate at the end of the flight segment.” The FAA is proposing this rule in response to a legislative mandate in the FAA Modernization and Reform Act of 2012 to prohibit personal use of electronic devices on flight decks in specific air transportation operations. The NTSB has previously addressed the importance of providing explicit guidance to pilots prohibiting the use of personal portable electronic devices (PEDs). As a result of the NTSB’s investigation of the February 12, 2009, crash of Colgan Air (operating as Continental Connection) flight 3407 while on approach to Buffalo Niagara International Airport, Buffalo, New York, the NTSB issued Safety Recommendation A-10-30 on February 23, 2010. The recommendation asked the FAA to “require 14 Code of Federal Regulations Part 121, 135, and 91K operators to incorporate explicit guidance to pilots, including checklist reminders as appropriate, prohibiting the use of personal portable electronic devices on the flight deck.” On April 26, 2010, the FAA issued Information for Operators (InFO) 10003, “Cockpit Distractions,” which emphasized that using PEDs was a safety risk. On March 7, 2012, the FAA stated that it did not plan to take any further action because current regulations prohibited the use of PEDs. The FAA believed that issuance of the InFO provided the appropriate information to Part 121, 135, and 91 subpart K operators about these regulations and that checklist reminders were not necessary. On June 14, 2012, the NTSB replied that regulations, as well as company policy, in effect at the time of the Colgan Air flight 3407 accident prohibited the use of PEDs; however, InFO 10003 contained no mention of checklist reminders, as specified in the recommendation, and an InFO is a guidance document, not a regulation. Because the FAA indicated that its actions were complete and that it did not plan to take any additional action, the NTSB classified Safety Recommendation A-10-30 “Closed—Unacceptable Action.” Section 307 of the FAA Modernization and Reform Act of 2012 prohibits the use of personal wireless communications devices and laptop computers by flight crewmembers during all phases of flight in Part 121 operations. The NTSB is pleased that the FAA is proposing to amend current regulations as required by this legislation. However, contrary to the broad scope of the NTSB’s Safety Recommendation A-10-30, the proposed rule would only affect pilots operating under 14 CFR Part 121. Pilots using PEDs while operating under Parts 135 and 91 subpart K are equally susceptible to the potentially catastrophic consequences of distraction, and their passengers are all placed at risk. Therefore, the FAA’s proposal only partially addresses the problem of distraction caused by PEDs on the flight deck. The NTSB believes that the FAA should expand the proposed rule to Part 135 and 91 subpart K operations to more broadly and effectively address this issue within the industry. The NTSB appreciates the opportunity to comment on this proposed rule.
The NTSB is aware that current regulations prohibit the use of personal PEDs as did Colgan’s policy at the time of this accident. However, we remain concerned that the FAA’s issuance of InFO 10003, “Cockpit Distractions,” contains no mention of checklist reminders, as specified in the recommendation. We are also concerned because InFOs, which are guidance documents only and not regulations, cannot require the oversight or documentation of an operator’s response and may therefore leave critical safety issues unaddressed. However, because the FAA indicated that its actions are complete and it will take no additional action to address Safety Recommendation A-10-30, this recommendation is classified CLOSED—UNACCEPTABLE ACTION.
-From Michael P. Huerta, Acting Administrator: As mentioned in our letter dated June 22, 2010, the Federal Aviation Administration (FAA) issued Information for Operators (InFO) 10003, Cockpit Distractions, on April 26. 2010. The InFO emphasizes that using personal electronic devices (PEDs) constitutes a safety risk. The Board's January 25, 2011, letter stated that an InFO was not an appropriate vehicle for transmitting safety-critical information and asked the FAA to document that all operators had taken the action recommended in the InFO. The FAA does not plan to take this course of action as current regulations prohibit the use of PEDs. Sections 121.306 and 135.144, Portable Electronic Devices, state. "... [N]o person may operate, nor may any operator or pilot in command of an aircraft allow the operation of, any portable electronic device on any U.S.-registered civil aircraft operating under this parl." Additionally, section 9 J .21 , Portable Electronic Devices, applicable to part 91 subpart K (91 K) program managers, restricts the use of these devices when the flights are conducted under instrument night rules. The issuance of the InFO provided the appropriate information to parts 121, 135, and 91 K operators about these regulations. The FAA believes that checklist reminders arc not necessary. FAA surveillance programs me designed to ensure compliance with all existing regulations, including those cited above. I believe that the FAA has addressed this recommendation, and I consider our actions complete.
The NTSB disagrees with the FAA that its April 26, 2010, issuance of InFO 10003, "Cockpit Distractions," effectively addresses this recommendation. Among the findings from the Colgan flight 3407 accident investigation was this: The current use of safety alerts for operators [SAPO] to transmit safety-critical information is not effective because oversight and documentation of an operator's response are not required and critical safety Issues may not be effectively addressed. In the context of Safety Recommendation A-10-30, an InFO is not substantially different from a SAFO in that both are advisory only, and oversight and documentation by the FAA of operators' response to these documents is needed. Therefore, issuance of the InFO may represent the first step in an acceptable alternate response to this recommendation, provided that the FAA documents that all operators have taken the actions recommended. The NTSB points out that, although this recommendation explicitly mentions inclusion of a checklist reminder where appropriate, the InFO contains no mention of checklist reminders. Accordingly, pending documentation by the FAA that all operators have taken the recommended action, including checklist reminders where appropriate, Safety Recommendation A-10-30 is classified OPEN – ACCEPTABLE ALTERNATE RESPONSE.
MC# 2100243 - From J. Randolph Babbitt, Administrator: On April 26, 2010, we issued Information for Operators (InFO) 10003, Cockpit Distractions (enclosed), to emphasize to crewmembers and operators that engaging in tasks not directly related to required flight duties, including using personal electronic devices (PED), constitutes a safety risk. In the recommended actions, we advise operators to create a safety culture that clearly establishes guidance, expectations and requirements to control cockpit distractions, including use of PEDs, during flight operations. I believe that the FAA has effectively addressed this safety recommendation, and I consider our actions complete.
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