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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.
TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 135 and 91 subpart K operators to establish, and ensure that their pilots adhere to, standard operating procedures.
Original recommendation transmittal letter:
Closed - Unacceptable Action
Owatonna, MN, United States
Crash During Attempted Go-Around After Landing East Coast Jets Flight 81 Hawker Beechcraft Corporation 125-800A, N818MV
Addressee(s) and Addressee Status:
FAA (Closed - Unacceptable Action)
Safety Recommendation History
You stated that little could be gained by developing further guidance or other material on this subject; however, on July 9, 2012, you issued Safety Alert for Operators (SAFO) 12003, which reminds all Part 135 certificate holders and Part 91 subpart K program managers of the criticality of using SOPs during all phases of flight. We remain concerned that, despite the guidance that has been issued, some Part 135 operators still are not establishing, and requiring their pilots to adhere to, SOPs like those required for Part 121 operators. Part 135 operations occur in a higher-risk operating environment than do Part 121 operations, partly as a result of their operating shorter flights; performing more frequent takeoffs and landings (the most dangerous parts of flight); operating with less experienced pilots; flying into smaller airports with no Air Traffic Control services; operating on less familiar routes into less familiar airports (making the flights more vulnerable to terrain and weather obstacles); and operating without the assistance of flight dispatchers. Even though Part 135 on-demand operators have a higher-risk operating environment than Part 121 air carriers have, these operations have less stringent safety requirements, including the lack of required SOPs for such critical safety measures as crew resource management training and strict checklist discipline. This accident shows that, to counter the risk factors listed above, companies like East Coast Jets would benefit from an ongoing emphasis on, and adherence to, SOPs and the resultant development of higher safety margins in the cockpit. We continue to believe that if, as a Part 135 operator, East Coast Jets had been required to develop SOPs and its pilots had been required to adhere to them, many of the deficiencies demonstrated by the pilots during the accident flight might have been corrected by the resultant stricter cockpit discipline. However, because you have indicated that FAA action in response to this recommendation is complete, Safety Recommendation A-11-20 is classified CLOSED—UNACCEPTABLE ACTION.
-From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) has reviewed current and past regulations and policy as they pet1ain to p311 135 and part 91 subpart K (91 K) standard operating procedures (SOPs). Part 135 certificate holders and 91 K program managers are granted some limited regulatory and policy versatility when compared with part 121 air carriers because part 135 and part 9 1 K operational missions are more flexible. Therefore, there is no explicit regulatory requirement that part 135 certificate holders or part 9 1 K program managers develop and employ fom1alized SOPs. However, FAA policy and guidance repeatedly emphasize the use of SOPs, and require all part 135 certificate holders and part 9 1 K program managers to either develop their own SOPs wherever practical or to use those SOPs found in the manufacturer's operating manuals for any equipment the operator is authorized to fly. FAA policy and guidance also state that these SOPs should be employed consistently through all stages of the operator's flight operations. FAA Order 8900.1 Flight Standards Information Management System addresses SOPs in volume 2, chapter 4, section 3; volume 3, chapter 32, section 5: volume 3, chapter 54, section 5; and volume 4, chapter 2, section 5. Additional guidance is available on specific areas of operations and SOPs. For example, the following Advisory Circulars (ACs) address the issue of SOPs while taxiing: • AC 120-74B, Parts 91 , 121 , 125, and 135 Flightcrew Procedures During Taxi Operations, which can be found at the following Web site: www.faa.gov/documentLibrary/media/ Advisory_ Circular/AC%20120-74B.pdf; and • AC 9 1-73B, Parts 91 and 135 Single Pilot, Flight School Procedures During Taxi Operations, which can be found at the following Web site: www.faa.gov/documentLibrary/media/ Advisory_ Circular/ AC%2091-73B.pdf. Any specific standardized procedures that a certificate holder or program manager intends to follow must first be approved by the FAA principal operations inspector who has oversight of that operator. The approved standardized procedures must then be adhered to as approved. These procedures become a recurrent inspection item and must be followed by the operator. AC 120-71 A, Standard Operating Procedures for Flight Deck Crewmembers, provides SOP guidance to operators. FAA Order 8900.1, volume 6, chapter 2, sections 9 and 23 discuss the role of the FAA inspector in SOP compliance and oversight. In light of this review, we believe that little could be gained by developing further guidance or other materials on the subject. However, to help ensure that part 135 certificate holders and part 91 K program managers are reminded of the importance of adhering to SOPs, we issued Safety Alert for Operators (SAFO) 12003 on July 9, 2012 (enclosed). The SAFO reminds all part 135 certificate holders and part 91 K program managers of the criticality of using SOPs during all phases of flight. The FAA has determined that a SAFO is an appropriate action to address this recommendation. SAFOs alert industry about issues of concern that do not rise to the level requiring mandatory corrective action. The responsibility to implement any action recommended in a SAFO rests with the operator. This is the best way to address concerns about SOPs, rather than a rulemaking solution, given all of the regulations and policy that currently exist. While the FAA has no plans to survey compliance with this SAFO, we recognize a SAFO identifies a potential risk to operators and we recommend that operators adjust surveillance to address identified risks. Based on our actions noted above, I believe that the FAA has effectively addressed this safety recommendation and consider our actions complete.
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.
The NTSB notes that the FAA will review existing regulatory and policy requirements, as well as guidance related to operator use of SOPs, and will then determine what changes will be made. Pending completion of the recommended action, Safety Recommendation A-11-20 is classified OPEN—ACCEPTABLE RESPONSE.
CC# 201100245: - From J. Randolph Babbitt, Administrator: The FAA agrees good crew performance is founded on standard operating procedures that are clear, comprehensive, and readily available to the flightcrew. As the Board highlighted in its letter, the FAA has taken n1any actions to encourage the use of standard operating procedures by operators and provided detailed guidance for standard operating procedures development and use. To meet the intent of this recommendation, the FAA will review existing regulatory and policy requirements as well as guidance related to operator use of standard operating procedures. Following that review, the FAA will determine what changes, if any, need to be made. I will keep the Board informed of the FAA's progress on this safety recommendation, and I will provide an update by July 2012.
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