Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation A-11-021
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 principal operations inspectors of 14 Code of Federal Regulations Part 135 and 91 subpart K operators to ensure that pilots use the same checklists in operations that they used during training for normal, abnormal, and emergency conditions.
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: 4/7/2014
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s): Checklist

Safety Recommendation History
From: NTSB
To: FAA
Date: 4/7/2014
Response: We previously expressed concern that POIs for Parts 135 and 91 subpart K operators might not be familiar with a company’s out-sourced training and, therefore, we indicated that oversight would be improved if POIs were required to communicate with training schools, including the FAA training center program manager (TCPM), to ensure that the checklists used during training are consistent with those used during operations. We note that, to address this concern, you have included additional information in your “Training Center Program Manager and Authorization” and “Surveillance of Contract Training for Operators” courses, which discuss the requirement for the TCPM to assist the POI with surveillance and evaluation when possible, the appropriate coordination and support functions that are available for POIs from TCPMs, and the necessity for communication between the POI and the TCPM to accomplish continuing surveillance. We believe that including training on these additional topics will increase POI and TCPM awareness of this safety issue and, as a result, will ensure that pilots use the same checklists during operations and training. Because we consider this solution to be an acceptable alternative to the recommended requirement, Safety Recommendation A 11 21 is classified CLOSED—ACCEPTABLE ALTERNATE ACTION. Thank you for your actions to improve the effectiveness of pilot training.

From: FAA
To: NTSB
Date: 1/21/2014
Response: -From Michael P. Huerta, Administrator: In their January 10, 2013, letter to the Federal Aviation Administration (FAA) the Board requested that their staff meet with the FAA to discuss the intent of this recommendation. A teleconference took place on January 23, 2013. During this teleconference, the FAA noted that there were changes in FAA procedures since this recommendation was issued. The Board requested details on these changes to aid in closing this recommendation. This letter contains details on the items that were discussed during the teleconference. The FAA issued Notice 8900.37, Training Centers Special Emphasis Review, on March 12. 2008. This notice provided a special emphasis review for principal operations inspectors (POIs) whose operators are authorized to contract for training, checking, or testing with part 142 training centers. The review focused on each operator's adherence to the specific authorizations granted by the FAA, as well as on the operator• s procedures and practices with respect to quality control over their training program. The notice directed POIs to examine the methods by which operators control training, checking. and testing operations conducted on their behalf: and the process by which the operator conducts surveillance of training centers. Although the notice was issued before the accident that triggered this recommendation. The NTSB indicated at the January 2013 teleconference that the notice was responsive to the safety issues highlighted by this accident. This notice required aviation safety inspectors (AS!s) to document compliance with the notice in the FAA's Program Tracking and Reporting System. The FAA Safety Performance Analysis System (SPAS) shows 773 records in response to Notice 8900.37. The comments contained in SPAS show that AS Is did check on the standardized usage of checklists. Corrective actions were taken when discrepancies were discovered. This accident and the recommendation's safety issues are discussed in the FAA Training Center Program Manager (TCPM) recurrent course. This 3-day course is taught at the FAA Academy in Oklahoma City, Oklahoma. Lesson five of the course specifically discusses the requirement for the TCPM to assist the POI with surveillance and evaluation when possible, and the necessity for communication between the POI and the TCPM to accomplish continuing surveillance. The accident that triggered this recommendation is discussed in detail to graphically illustrate the importance of this communication and surveillance. Additionally, this accident is discussed in detail at the FAA Academy in the Authorization and Surveillance of Contract Training for Operators course. This 3-day course is offered for POIs, assistant POI s, POI selectees, POI supervisors, office managers, and FAA headquarters support personnel. This course discusses the appropriate coordination and support functions that are available from TCPMs, particularly surveillance available to the POIs from the TCPMs. I believe that the FAA has effectively addressed this recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 1/10/2013
Response: The NTSB remains concerned that Parts 135 and 91 subpart K operations may exist in which pilots are trained to use a standard checklist during training, but use a different, nonstandard checklist during actual operations. FAA Order 8900.1, which contains guidance to principal operations inspectors (POI) on outsourced training, emphasizes the importance of including clearly defined standard operating procedures (SOP) that include checklists in the training curriculum. However, the order does not require POIs to communicate with the training school’s or center’s operators or program managers (TCPM) to ensure that the checklists used during training are the same as those used during operations, which is the concern of this recommendation. The POI for East Coast Jets stated that he had assumed that the East Coast Jets Normal Procedures checklist, which he accepted, would be used during training at the training school (Simcom). But the POI did not contact Simcom or the Orlando Flight Standards District Office, which was responsible for the oversight of Simcom, to verify that the approved checklist was being used during training, nor was he required to do so. We remain concerned that POIs for Parts 135 and 91 subpart K operators may not be familiar with a company’s out-sourced training and, therefore, we believe that oversight would be improved if POIs were required to communicate with training schools, including the FAA TCPM, to ensure that the checklists used during training are consistent with those used during operations. Although the FAA has indicated that its actions in response to this recommendation are complete, we request that the FAA reconsider its position. We believe that a meeting between FAA and NTSB staff is needed to discuss the intent of this recommendation. In the meantime, pending the outcome of such a meeting and our review of a plan that is responsive to Safety Recommendation A-11-21, the recommendation is classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/29/2012
Response: -From Michael P. Huerta, Acting Administrator: The Federal Aviation Administration (FAA) has reviewed current and past regulations and policy as they pertain to 14 CFR part 135 and part 91 subpart K (91 K) checklist use and related required training. Section 135.21, Manual Requirements, defines the requirements for part 135 operators to use and maintain a manual or manuals that set forth the certificate holder's procedures acceptable to the FAA Administrator. Those manuals must be used by the certificate holder's flight, ground, and maintenance personnel in conducting its operations. The manuals must be approved by the FAA through the operator's Certificate Holding District Office (CHDO) before a certificate is issued. These manuals are then regularly inspected for compliance. Section 135.323, Training programs: General, and sect ion 135.324, Training programs: Special rules, require that all part 135 operators must have, and comply with, approved training programs. The training may be provided internally by the certificate holder or by a part 142 training center. In either case, all training programs must be specific to the individual operator and be approved by the operator's CHDO before a certificate is issued. The approved training program is then regularly inspected for compliance by the FAA. Initial and recurrent training requirements mandate that standardized documentation and manuals for all phases of normal and non-normal night operations (as described in sect ion 135.21) must be utilized in all phases of flight. These requirements also mandate that these materials must be the same as those that are utilized for pilot training unless otherwise specifically authorized by the operator's principal operations inspector (POI). Standardized checklists constitute a component of a certificate holder's approved manuals and procedures. As such, the checklists must be approved by the certificate holder's CHDO and must be a component of that certificate holder's approved training program. Operators under 91K are subject to training requirements and oversight similar to part 135 operators. Sections 91 .1073, Training program: General, 91.1075, Training program: Special rules, 91.1077, Training program and revision: Initial and final approval, and 91.1079, Training program : Curriculum, and other sections outline the training requirements. Sections 91.503, Flying equipment and operating information, and 91.1033, Operating information required, specifically define the criteria and requirement for checklists and checklist use. FAA Order 8900.1, Flight Standards Information Management System (FSIMS), provides extensive guidance on these issues to field inspectors who oversee part 135 certificate holders and 91 K operators. The FSIMS makes numerous references to inspecting these operators' approved training materials, checklists, and proper checklist usage. Specifically, volume 3, chapter 54, section 6, paragraph 3-4437(F)(4) states: Training centers that are conducting training for certificated air operators are required to follow that operator's SOPs during all training and checking on behalf of that operator. Certificated operators are required to use their approved/accepted checklist for all training and checking and as a result, their checklist policies and procedures are governed by their respective POI and not subject to revision by the operator or training center without specific approval [by their POI]... Paragraph 3•4437(F)(5) states in reference to non-certificated operators, that: a) The operator must provide the training center a copy of the checklist and a written statement indicating that the operator has determined that the submitted checklist meets all the following performance standards: 1. The checklist satisfies the requirements of part 91, § 9 1.503; 2. The checklist is appropriate to the equipment in which the operator's pilots are being trained and/or checked; 3. Areas of differences between the centers approved version of the checklist and the operators checklist arc documented and appropriate training provided to the center personnel ; and 4. The operator certifies that their checklist meets the applicable Airplane Flight manual requirements for the specific equipment. NOTE: Proposals from non-certificated operators to use a checklist that differs from the manufacturer's must also include a copy of a letter of no technical objection to the proposed checklist from the appropriate aircraft manufacturer, FAA Aircraft Evaluation Group office, or FAA Aircraft Certification Office. Certificated operators must use the checklists that are accepted/approved by their POI. Virtually all 91K operators utilize part 142 training centers for their training, therefore, by extrapolation this section applies to them as well. I believe the FAA has effectively addressed this safety recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 9/6/2011
Response: The NTSB notes that the FAA will review existing policy guidance for inspectors and training center program managers concerning outsourced training provided to determine whether additional guidance or a change in policy is necessary. Pending completion of the recommended action, Safety Recommendation A-11-21 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/10/2011
Response: CC# 201100245: - From J. Randolph Babbitt, Administrator: The FAA agrees that the same checklists used in operations should also be used during training. We will review existing policy guidance on outsourced training provided to inspectors and training center program managers to determine if additional guidance or a change in policy is necessary. I will keep the Board informed of the FAA's progress on this safety recommendation, and I will provide an update by July 2012.