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Safety Recommendation Details

Safety Recommendation A-11-018
Details
Synopsis: On July 31, 2008, about 0945 central daylight time, East Coast Jets flight 81, a Hawker Beechcraft Corporation 125-800A airplane, N818MV, crashed while attempting to go around after landing on runway 30 at Owatonna Degner Regional Airport (OWA), Owatonna, Minnesota. The two pilots and six passengers were killed, and the airplane was destroyed by impact forces. The nonscheduled, domestic passenger flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 135. An instrument flight rules flight plan had been filed and activated; however, it was canceled before the landing. Visual meteorological conditions prevailed at the time of the accident. The National Transportation Safety Board (NTSB) determined that the probable cause of this accident was the captain’s decision to attempt a go-around late in the landing roll with insufficient runway remaining. Contributing to the accident were (1) the pilots’ poor crew coordination and lack of cockpit discipline; (2) fatigue, which likely impaired both pilots’ performance; and (3) the failure of the Federal Aviation Administration (FAA) to require crew resource management (CRM) training and standard operating procedures (SOPs) for 14 CFR Part 135 operators.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require manufacturers of newly certificated and in-service turbine-powered aircraft to incorporate in their Aircraft Flight Manuals a committed-to-stop point in the landing sequence (for example, in the case of the Hawker Beechcraft 125-800A airplane, once lift dump is deployed) beyond which a go-around should not be attempted.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Reconsidered
Mode: Aviation
Location: Owatonna, MN, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA08MA085
Accident Reports: Crash During Attempted Go-Around After Landing East Coast Jets Flight 81 Hawker Beechcraft Corporation 125-800A, N818MV
Report #: AAR-11-01
Accident Date: 7/31/2008
Issue Date: 3/29/2011
Date Closed: 6/3/2019
Addressee(s) and Addressee Status: FAA (Closed - Reconsidered)
Keyword(s): Go Around,Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/3/2019
Response: Previously, you told us that, due to the number of rapidly changing performance and operational considrations during the landing sequence, it was impractical to require manufacturers to incorporate in their AFMs a single CTS point. You argued that operators are in the best position to make this determination for their operation and type aircraft and, as a result, you proposed issuing an information for operators (InFO) bulletin that would allow operators to tailor a CTS procedure for their operation and type aircraft, subject to Federal Aviation Administration approval or acceptance. We told you that issuing such an InFO may constitute part of an acceptable alternate solution to both A-11-18 and -19; however, because InFOs contain guidance for operators, not manufacturers, we do not believe an InFO is an acceptable alternate solution to this recommendation. Instead, because we agree with you that the operational factors are too numerous and varied to require manufacturers to incorporate in their AFM a single CTS point, Safety Recommendation A-11-18 is classified CLOSED--RECONSIDERED.

From: FAA
To: NTSB
Date: 10/3/2018
Response: -From Daniel K. Elwell, Acting Administrator: The Federal Aviation Administration (FAA) recognizes the importance of go-around performance. limitations, and appropriate operational procedures. We agree that the intent of these recommendations should be addressed, although not in the exact manner that is recommended. We further evaluated potential alternative solutions to meet the intent of these recommendations and maintain that an Information for Operators (InFO) on a Committed-To-Stop (CTS) procedure meets the intent of these recommendations. Accordingly, on July 25, 2017, the FAA published JnFO 17009, Committed-to-Stop Point on Landings, which can be found at the following website: https://www.faa.gov/other_visit/aviation_industry/airline operators/airline safety/info/al1_infos/. This InFO informs operators of turbine-powered aircraft about the importance of establishing a point during landing where a go-around or rejected landing procedure will not be initiated and the only option will be bringing the aircraft to a stop. As InFO 17009 states, the FAA investigated the potential benefits and risks associated with incorporating a CTS point in the Aircraft Flight Manual. However, operational fac tors are too numerous and varied to establish a single CTS point. The FAA believes that operators are in the best position to make this detem1ination for their operation and aircraft type. Operators who establish CTS points would eliminate ambiguity for pilots making decisions during time-critical events. InFO 17009 also recommends that operators of turbine-powered aircraft establish Standard Operating Procedures (SOPs) for flightcrcws to detc1mine a point after touchdown where a go-around will not be initiated and the only option would be to bring the aircraft to a stop. This could be accomplished by any single procedure or combination of procedures, such as committing to stop following deployment of reversers or lift-dump, spoilers, or speed brakes (if equipped), and committing to stop below a certain airspeed (e.g., less than 80 knots) and/or runway distance remaining. CTS points should be included in the approach briefing and incorporated into the operators· SOP, flight operations manual, initial and recurrent training, and crew resource management training program. We note that InFO 17009 instructs operators choosing to adopt the procedures discussed therein to notify their principal operations inspector of the procedures and methods adopted via the Safety Assurance System (SAS) External Portal. The SAS External Portal is operational and has been available to operators since August 17, 2017. FAA Order 8900. 1, Volume I 0, Chapter 5, Data Collection, Data Repo11ing, and Data Review, contains guidance for FAA Aviation Safety Inspectors (ASIs) on using SAS Data Collection Tools (OCT) to collect, report, and review data. The OCT information helps the principal inspectors assess the certificate holders· system design and performance. SAS encompasses the certification, routine surveillance, and certificate management processes for certificate holders. It assesses the safety of parts 121, 135, and 145 certificate holders· operating systems using system safety principles, safety attributes, and risk management. SAS also assesses the requirement to provide service at the highest level of safety in the public interest. Finally, 17 AA Order 8000.87 A, Safety Alerts for Operators (SAFO), and r AA Order 8000.9, Information for Operators, encourage ASIs to pay particular attention to any SAFO or InFO applying directly to the operator(s) that the ASI oversees. As such, SAFOs and InFOs are considered FAA guidance, and AS Is are able to verify operator compliance with SAFOs and InFOs during data collection using the appropriate OCT. I believe the FAA has effectively addressed these safety recommendations and consider our actions complete.

From: NTSB
To: FAA
Date: 8/13/2013
Response: We considered the FAA’s plan to address these recommendations in an alternate manner by issuing an Information for Operators (InFO) bulletin that would allow operators to tailor a CTS procedure for their operation and type aircraft, subject to FAA approval or acceptance. Issuing such an InFO may constitute part of an acceptable alternate response to these recommendations, but only if the FAA also takes sufficient action to ensure that all operators, particularly such smaller operators as East Coast Jets, incorporate the guidance provided in the InFO. Simply issuing the InFO without also acting to ensure that all operators incorporate the guidance will not satisfy the recommendation. In the meantime, pending issuance of the InFO and our review of an acceptable plan of action to ensure that all operators incorporate the guidance, Safety Recommendations A 11-18 and -19 are classified OPEN—ACCEPTABLE ALTERNATE RESPONSE.

From: FAA
To: NTSB
Date: 6/10/2013
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) reviewed safety recommendation A-11 -18 and determined that the number of rapidly changing performance and operational considerations during the landing sequence makes it impractical to require a single Aircraft Flight Manual limitation beyond which a go-around should not be attempted. The landing phase is the most dynamic event during a flight which includes configuration changes (e.g., whether lift dumping devices have been deployed), rapid energy state changes, and changing operational factors, such as available runway length and environmental conditions (density altitude, wind conditions, etc.). For these reasons the FAA determined that fully implementing recommendation A-11-18 is impractical. However, we are addressing the Board's concerns by issuing an Information for Operators (InFO) as discussed in Safety Recommendation A-11-19. I believe the FAA has effectively addressed this recommendation, and I consider our actions complete.

From: FAA
To: NTSB
Date: 4/8/2013
Response: Our last update from the FAA regarding these recommendations was its June 10, 2011, letter. We are concerned that, although more than 2 years have passed since then, we have received no additional information regarding the agency’s efforts to address Safety Recommendations A-11-18 through -20, -24 through -27, -30, or -31. Pending our timely receipt of an update and completion of the recommended actions, these recommendations remain classified OPEN—ACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 9/6/2011
Response: The NTSB notes the FAA’s agreement that clear information should be available to the flightcrew when making the decision to execute a go-around and its plan to investigate the benefits and potential risks associated with incorporating a committed-to-stop point in the AFM. Once the FAA determines how it will address Safety Recommendation A-11-18, it will also determine the appropriate action for addressing Safety Recommendation A-11-19. Accordingly, pending completion of the recommended actions, Safety Recommendations A-11-18 and -19 are classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/10/2011
Response: CC# 201100245: - From J. Randolph Babbitt, Administrator: The Federal Aviation Adn1inistration (FAA) agrees with the intended improvement to safety, and we specifically share the Board's concern that clear information should be available to the flightcrew when making the decision to execute a go-around. We will investigate the benefits and potential risks associated with incorporating a committed-to-stop point in the Aircraft Flight Manual (AFM) as well as consider alternative means to prevent an attempted go-around with insufficient runway remaining. I will keep the Board informed of the FAA's progress on this safety recommendation, and I will provide an update by July 2012.