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Safety Recommendation Details

Safety Recommendation A-10-031
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: Implement a process to document that all 14 Code of Federal Regulations Part 121, 135, and 91K operators have taken appropriate action in response to safety-critical information transmitted through the safety alert for operators process or another method.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable 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: 2/21/2018
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Oversight

Safety Recommendation History
From: NTSB
To: FAA
Date: 2/21/2018
Response: We note that, on January 13, 2015, you published the “Safety Management Systems for Domestic, Flag, and Supplemental Operations Certificate Holders” final rule, which implements a new Part 5 that requires Part 121 operators to have a safety management system (SMS). You believe that the rule addresses Safety Recommendation A-10-31 because section 5.93, Safety Communication, requires the certificate holder to develop and maintain a means for communicating safety information. Issuing this final rule does satisfy other recommendations that we have issued, and we believe that SMS adoption and implementation by Part 121 carriers will improve aviation safety. Although we recognize the benefits of an SMS, we believe that transmitting safety-critical information to operators without the FAA measuring results is inconsistent with the basic principles of an SMS. We note that you developed the safety assurance system (SAS) for your inspectors to use to assess initial certification, routine surveillance, and certificate management for Part 121 and Part 135 certificate holders. Because SAFOs are nonregulatory, they are not part of an inspector’s formal work program unless the information from a SAFO becomes a notice. For those SAFOs that do not generate a notice, an inspector’s preparation for inspecting an operator includes completing the preinspection checklist contained in FAA Order 8900.1, “Flight Standards Information System.” This checklist includes a review of applicable regulations and other FAA guidance, and your November 17, 2017, letter indicates that SAFOs would be reviewed here. Including SAFOs in the preinspection checklist would satisfy Safety Recommendation A 10-31; however, our review of the checklist shows that only “item e” pertains to this issue, which reads “Review FAA guidance.” This is not sufficiently detailed to ensure that relevant SAFOs are included in an inspector’s preparation for an inspection; therefore, it does not satisfy the recommendation. Simply adding some additional text, such as “for example, Safety Alerts for Operators,” immediately after “review FAA guidance” would satisfy the recommendation; however, we note that you consider your actions to satisfy the recommendation complete and you plan no further action. Consequently, Safety Recommendation A-10-31 is classified CLOSED--UNACCEPTABLE ACTION. We encourage you to consider making a minor addition to the preinspection checklist that will satisfy this recommendation. If you inform us that you have made, or plan to make, this revision, we may consider changing the classification of Safety Recommendation A-10-31.

From: FAA
To: NTSB
Date: 11/17/2017
Response: -From Michael P. Huerta, Administrator: On January 13. 2015, the Federal Aviation Administration (FAA) published the Safety Management Systems for Domestic. Flag. and Supplemental Operations Certificate Holders Final Rule (80 FR 1584). effective March 9. 2015. This final rule, which implements a new Part 5, requires part 121 operators to have a Safety Management System (SMS) in place by March 9, 2018. SMS is a comprehensive. process-oriented approach to managing safety throughout an organization. SMS includes an organization-wide safety policy. formal methods for identifying hazards and controlling and continually assessing risk and safety performance. and promotion of a safety culture. SMS stresses not only compliance with technical standards but also increased emphasis on overall safety. The air carrier's SMS must contain the following four major components: safety policy. safety risk management. safety assurance. and safety promotion. The FAA believes the new Part 5 ensures part 121 operators have taken appropriate action in response to safety-critical information. In particular, §5. 93, Safety communication. requires the certificate holder to develop and maintain a means for communicating safety information that. at a minimum: (a) Ensures that employees are aware of the SMS policies, processes. and tools that are relevant to their responsibilities: (b) Conveys hazard information relevant to the employee's responsibi lities: (c) Explains why safety actions have been taken; and (d) Explains why safety procedures are introduced or changed. To meet the safety assurance component of SMS. the FAA developed the Safety Assurance System (SAS). SAS is the process FAA inspectors use to assess initial certification. Routine surveillance. and certificate management for part 121. 135. and 145 certificate holders or applicants. It is based on system safety principles. safety attributes. risk management. and a structured, system-engineered approach to identify hazards and prevent loss of equipment and other property. A key foundational component of SAS is the National Safety Analysis (NSA). NSA is a national level function providing analytical support to meet the following objectives: • Identify national-level safety hazards: • Perform risk analysis associated with identified national-level safety hazards: and • Develop recommendations and strategies to address national-level hazards and risks. In the planning module of SAS, the principal inspector (PI) or certification program manager (CPM) is tasked with developing a risk-based data collection plan. To do this, the PI/CPM is provided with a chart of Certificate Holder Performance History Risk Indicators (as contained in FAA Order 8900.1. Vol. I 0. Chap. 3, Sec. I. Figure I 0.3. 1.C). Data on accidents, incidents. And occurrences. and the certificate holder's response to them. is considered here. If any of them generated a Safety Alert for Operators (SAFO). the certificate holder’s response to it would be considered at this stage. SAFOs contain helpful information and are written for certificate holders. They are non-regulatory. and not part of an inspector's forma l work program. If the information from a SAFO becomes a Notice. it is included in an inspector's work program immediately (via data collection tools) for those SAFOs that do not generate a Notice. an inspector" s preparation for an inspection of an operator includes completing a --Pre-Inspection .. checklist. This checklist includes a review of applicable regulations and other FAA guidance. SAFOs would be reviewed here. In summary. the FAA considers SMS as another method of verifying that operators have taken appropriate action in response to safety-critical information transmitted for part 121 operators. The SAS component of SMS will accomplish this for part 135 operators. The FAA has no plans to introduce SMS or SAS for part 91 subpart K operators. I believe the FAA has effectively addressed this safety recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 2/10/2014
Response: Although, after evaluating operators’ speedbrake procedures and training methods, you believe that issuing a Safety Alert for Operators (SAFO) is the most appropriate action for addressing this recommendation, we do not agree that issuing a SAFO will be sufficient to close this recommendation. We have previously expressed concern that a SAFO is not an effective substitute for a requirement. In past and current investigations, we have frequently found that neither the operator nor regional FAA personnel providing oversight of the operator were aware of, let alone following, guidance contained in relevant SAFOs. For example, as a result of our investigation of the February 12, 2009, crash in Clarence Center, New York of Colgan Continental Connection flight 3407, a Bombardier DHC 8 400, while on approach to Buffalo Niagara International Airport, Buffalo, New York, on February 23, 2010, we issued Safety Recommendation A-10-31: A-10-31 Implement a process to document that all 14 Code of Federal Regulations Part 121, 135, and 91K operators have taken appropriate action in response to safety-critical information transmitted through the safety alert for operators process or another method. Your September 24, 2012, letter regarding Safety Recommendation A-10-31 stated that the intent of a SAFO was to disseminate directly to operators important safety information that is often critical, but the responsibility to implement any action recommended in a SAFO rests with the operator. The FAA did not intend to develop its own process for tracking operator action in response to safety-critical information, as recommended. At that time, you proposed that a coming requirement for Part 121 operators to develop and implement safety management systems (SMS) would address operators’ responding appropriately to guidance in SAFOs. On February 7, 2013, we replied that a mature SMS would (1) provide operators with the tools and framework to potentially manage safety proactively and (2) provide the FAA with a systematic approach for evaluating the effectiveness of operators’ management of safety?including actions taken in response to safety-critical information transmitted through the SAFO process or another method. Although we recognized the benefits of an SMS, we emphasized that transmitting safety-critical information to operators without measuring results was inconsistent with the basic principles of SMS. Accordingly, on February 7, 2013, Safety Recommendation A-10-31 was classified “Open—Unacceptable Response.” In our accident and incident investigations, we have found and continue to find that operators and FAA regional staff providing oversight of the operator are frequently not aware of the existence of relevant SAFOs. This calls into question whether SAFOs are effective at disseminating important safety information, let alone bringing about an appropriate response from operators. Were a SAFO effective in bringing about the needed action, it might constitute an acceptable alternate response to Safety Recommendation A-12-44. But issuance of the SAFO does not constitute an acceptable response without any follow-up to ensure that the safety information is actually being disseminated, and appropriate responses are resulting. Therefore, although development of the SAFO is an acceptable alternate response for the moment, it will not be a basis for closure of Safety Recommendation A-12-44 without acceptable action to address Safety Recommendation A-10-31. Accordingly, pending development of the SAFO, and action that satisfies Safety Recommendation A 10 31, Safety Recommendation A-12-44 is classified “Open—Acceptable Alternate Response.”

From: NTSB
To: FAA
Date: 2/7/2013
Response: The FAA stated that a notice of proposed rulemaking (NPRM), titled “Safety Management Systems (SMS) for Part 121 Certificate Holders,” includes a requirement for Part 121 operators to develop and implement an SMS. The NTSB believes that a mature SMS will (1) provide operators with the tools and framework to potentially manage safety proactively and (2) provide the FAA with a systematic approach for evaluating the effectiveness of operators’ management of safety—including actions taken in response to safety-critical information transmitted through the Safety Alert For Operators process or another method. Although we recognize the benefits of an SMS, we believe that transmitting safety-critical information to operators without measuring results is inconsistent with the basic principles of SMS. In addition, we are concerned that Part 135 and 91K operators are not included in the FAA’s SMS rulemaking and that the FAA described no plan to address these operators. At the public hearing about this accident, the FAA indicated that it was considering the establishment of a new transmittal method for safety-critical information, referred to as an operational directive, which would be similar to an airworthiness directive. Operators would be responsible for complying with the operational directive, and FAA inspector surveillance would be required to determine whether the recommended actions had been accomplished. We point out that the same safety benefit could also be achieved if the FAA were to revise Order 8000.87A so that the SAFO process would incorporate FAA follow-up. We are interested in learning more about these methods for documenting the response to safety-critical information by Part 121, 135, and 91K operators. In the meantime, pending our review of a plan that is responsive to Safety Recommendation A-10-31, the recommendation is classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/24/2012
Response: -From Michael P. Huerta, Acting Administrator: The Federal Aviation Administration (FAA) first indicated that it would explore options for enhancing or modifying various oversight programs for the purpose of documenting operator response to safety-critical information transmitted through Safety Alerts for Operators (SAFOs) and other methods. The intent of a SAFO is to disseminate important safety information that is often critical directly to operators. The responsibility to implement any action recommended in a SAFO rests with the operator. On occasion, the FAA assesses industry's follow-up to a SAFO, but this is not a normal practice. The FAA does not intend to develop its own process for tracking operator action to safety-critical information. As an alternative approach to meeting the intent of this recommendation, the FAA proposed a part 5 Safety Management System (SMS) for 14 CFR part 121 operations. An SMS is a comprehensive, process-oriented approach to managing safety throughout an organization. SMS is becoming a standard throughout the aviation industry worldwide, and is recognized by the Joint Planning and Development Office, International Civil Aviation Organization, civil aviation authorities (CAA) and product and service providers as the next step in the evolution of safety in aviation. To that end, the FAA published the Safety Management Systems for Part 121 Certificate Holders Notice of Proposed Rulemaking in November 2010. The proposed rule will require 14 CFR part 121 operators to develop and implement an SMS to improve the safety of their aviation related activities and communicate safety information throughout their organization. We anticipate publishing a final rule by the end of2012. The FAA has no immediate plans to initiate similar rulemaking for 14 CFR part 135 or 91K operators. We consider our actions complete with regard to 14 CFR parts 135 and 91K. I will keep the Board informed of the FAA's progress on this safety recommendation by providing an update on the SMS rule by May 31, 2013.

From: NTSB
To: FAA
Date: 1/25/2011
Response: The FAA's plan to explore options for enhancing or modifying oversight programs for the purpose of documenting operator response to safety-critical information transmitted through SAFOs, InFOs, and other methods is responsive to this recommendation. Accordingly, pending completion of the recommended action, Safety Recommendation A-10-31 is classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/22/2010
Response: MC# 2100243 - From J. Randolph Babbitt, Administrator: We are exploring options for enhancing or modifying various oversight programs for the purposes of documenting operator response to safety-critical information transmitted through SAFO and other methods. We will provide an update to this recommendation by December 2010.