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Safety Recommendation Details

Safety Recommendation A-11-019
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 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators and Part 142 training schools to incorporate the information from the revised manufacturers’ Aircraft Flight Manuals asked for in Safety Recommendation A-11-18 into their manuals and training.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
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 - Acceptable Alternate Action)
Keyword(s): Flightcrew,Go Around,Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/3/2019
Response: We note that, on July 25, 2017, you published InFO 17009, “Committed-to-Stop Point on Landings,” which informs turbine-powered aircraft operators 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 stopping the aircraft. We note that the InFO encourages operators to include a CTS point in the approach briefing and in the operator’s standard operating procedures, the flight operations manual, initial and recurrent training, and the crew resource management training program. We are also pleased to learn that the InFO requests that operators notify their principal operations inspector of the procedures and method they have adopted via the Safety Assurance System External Portal. We believe these actions constitute an acceptable alternative solution to Safety Recommendation A-11-19, which is classified CLOSED--ACCEPTABLE ALTERNATE ACTION.

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 FAA has evaluated potential alternative solutions to meet the intent ofthis recommendation and concluded that an InFO on a committed-to-stop procedure is the most appropriate way to alert operators of this issue. The InFO will allow operators to tailor a procedure for their operation and type aircraft, subject to FAA approval or acceptance. We are currently working on a draft InFO that addresses the Board's concerns and anticipate publication of the InFO by July 2013. I will keep the Board informed of the FAA's progress on this safety recommendation and provide an update by December 2013.

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: NTSB
To: FAA
Date: 7/15/2011
Response: Notation 8106A: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration's (FAA) supplemental notice of proposed rulemaking (SNPRM) titled "Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers," published at 76 Federal Register 29336-29526 on May 20, 2011. The notice proposes to amend the regulations for flight and cabin crewmember and aircraft dispatcher training programs in domestic, flag, and supplemental operations. The proposed regulations are intended to contribute significantly to reducing aviation accidents by requiring the use of flight simulation training devices (FSTD) for flight crewmembers and including additional training and evaluation requirements for all crewmembers and aircraft dispatchers in areas that are critical to safety. The proposal also reorganizes and revises the qualification, training, and evaluation requirements. The SNPRM is based on the FAA's review of comments submitted in response to the January 12, 2009, notice of proposed rulemaking (NPRM) on these issues and its determination that the NPRM did not adequately address or clarify some topics; it is also based on provisions of the Airline Safety and Federal Aviation Administration Extension Act of 2010. The NTSB notes that Safety Recommendation A-11-18 recommends that the FAA require manufacturers to develop for newly certificated and in-service aircraft a committed-to-stop point in the landing sequence. Safety Recommendation A-11-19 recommends that pilots be trained to use this information. Although the SNPRM would be an appropriate rulemaking to include such a requirement, the NTSB acknowledges that manufacturers need to develop this information before it can be included in required training.

From: FAA
To: NTSB
Date: 6/10/2011
Response: CC# 201100245: - From J. Randolph Babbitt, Administrator: The FAA agrees with the philosophy that flightcrew men1bers should be trained and aware of their aircraft's go-around performance, limitations, and appropriate operational procedures. As indicated in our response to Safety Recommendation A-II-I8, we will evaluate the benefits and risks associated with incorporating a committed-to-stop point in the AFM. We will also evaluate potential alternative solutions to meeting the intent of Safety Recommendation A-11-I8, including guidance to operators on go-around decision-making. Once a determination is made on how to address A-II-I8, appropriate action to address A-11-19 can be determined. I will keep the Board informed of the FAA's progress on this safety recommendation, and I will provide an update by July 2012.