Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation A-11-022
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 and 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to design new, or revise existing, checklists to require pilots to clearly call out and respond with the actual flap position, rather than just stating, “set” or “as required.”
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable 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: 8/23/2017
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Checklist

Safety Recommendation History
From: NTSB
To: FAA
Date: 8/23/2017
Response: We note that the March 15, 2016, revision of FAA Order 8900.1, Flight Standards Information Management System, Volume 3, Chapter 32, “Manuals, Procedures and Checklists for Parts 91 subpart K, 135, and 121,” section 12, “Safety Assurance System: Aircraft Checklists,” 3 3407 “Checklist Terminology,” paragraph C says that operators should have a consistent policy concerning responses to items with variable settings. That paragraph further states that although “as required” may be printed on the checklist, it should not be an authorized response, and that a response that gives the actual setting is normally appropriate. The current version of this part of Order 8900.1 satisfies Safety Recommendation A-11-22, which is classified CLOSED--ACCEPTABLE ACTION.

From: NTSB
To: FAA
Date: 10/28/2013
Response: We look forward to reviewing the revised Order 8900.1, which should require that the aircraft checklist state that both pilots must verify and verbalize the actual flap setting rather than responding with such generic terms as “set” or “as required.” Pending this review, Safety Recommendation A-11-22 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 7/24/2013
Response: -From Michael P. Huerta, Administrator: As previously stated, the Federal Aviation Administration (FAA) reviewed existing policy on checklist design and approval and determined that a change to the guidance in FAA Order 8900.1 , Flight Standards Information Management System (FSIMS), volume 3, chapter 32, is appropriate. The draft changes to FSIMS are designed to clarify that crewmembers should verify and verbalize the actual flap setting rather than using generic terms such as "set" or "as required." The revisions to FSIMS are currently in FAA internal coordination. We will provide a copy of the changes to the Board once they are published, which is expected to occur by November 30, 2013. I will keep the Board informed of the FA~A.'s progress on this recommendation and provide an update by June 30, 2014.

From: NTSB
To: FAA
Date: 11/6/2012
Response: The NTSB notes that the FAA plans to revise Order 8900.1 to require that the aircraft checklist state that the flap setting must be confirmed by both pilots before being approved by a principal operations inspector. Pending our review of the revised approval guidance and policy, Safety Recommendation A-11-22 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/2/2012
Response: -From Michael P. Huerta, Acting Administrator: The Federal Aviation Administration (FAA) reviewed the checklist guidance available in FAA Order 8900.1 , Flight Standards Information Management System (FSIMS). The FAA will change FSIMS to clarify the necessity for the aircraft checklist to state that the flap setting must be confirmed by both pilots before a principal operations inspector approves it. The FAA is currently working on drafting the new language. I will keep the Board informed of the FAA's progress on this recommendation and provide an update by June 30, 2013.

From: NTSB
To: FAA
Date: 9/6/2011
Response: The NTSB notes that the aircraft procedures and checklists found in the AFM are established by manufacturers as a part of the initial certification of an aircraft, but they are not approved by the FAA as part of the aircraft’s certification, and the operational checklists and the crew coordination aspects of executing the AFM procedures is the responsibility of each operator. We agree with the FAA that requiring manufacturers to make the recommended revisions to AFMs would not produce the results needed to resolve the safety issue addressed by this recommendation, because the operator is not required to use the exact phrasing used in the AFM procedures. An operator’s checklists and procedures used with the checklists must be reviewed and approved by the FAA principal operations inspector (POI) assigned to oversee the carrier. The guidance used by POIs for checklist approval is found in FAA Order 8900.1. We note that the FAA plans to review existing policies on checklist design and approval to determine how to address this recommendation. The NTSB agrees that revising the guidance to POIs on the approval of checklists, and procedures used with the checklist, will constitute an effective response to this recommendation. We also believe that making appropriate revisions to Order 8900.1 will encourage manufacturers developing AFMs for new aircraft designs to include the revised procedures. Accordingly, pending completion of the FAA’s review and appropriate revisions to checklist design and approval guidance and policy, Safety Recommendation A-11-22 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/10/2011
Response: CC# 201100245: - From J. Randolph Babbitt, Administrator: The use of aircraft checklists and operator's policies are one means by which operators can structure and define flight crewmember roles. Aircraft checklists are used to verify that the correct aircraft configuration has been established in specified phases of flight. The aircraft procedures and checklists found in the AFM are established by manufacturers as a part of the initial certification of an aircraft, but they are not approved by the FAA Aircraft Certification Office because they are considered operational. The operational checklists and the crew coordination aspects of executing the AFM procedures is the responsibility of each operator, therefore requiring manufacturers to make such a change would not produce the results the Board was intending because the operator is not required to use the exact verbiage in the AFM procedures. For an operator to obtain FAA approval of its customized checklists, it must provide them to its FAA principal operations inspector (POI) for approval. The guidance to POIs for checklist approval can be found in FAA Order 8900.1, volume 3, chapter 32, section 2 (enclosure 1). The FAA does not require operators to design a checklist a specific way. However, it provides options to operators to custon1ize. Additional guidance to POIs on checklist design can be found in FAA Order 8900.1, volume 3, chapter 32, section 12 (enclosure 2). We will review existing policy on checklist design and approval as well as the potential impact on operators on requiring such a change to determine how best to address this recommendation. We will keep you informed of our progress on this safety recommendation. I will keep the Board informed of the FAA's progress on this safety recommendation, and I will provide an update by July 2012.