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Safety Recommendation Details

Safety Recommendation A-11-024
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: Revise regulations and policies to permit appropriate use of prescription sleep medications by pilots under medical supervision for insomnia.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable 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: 6/21/2016
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Fatigue,

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/21/2016
Response: We note that your current policy for sleep disorders, other than obstructive sleep apnea (OSA), is that medical certification should not be considered for any airmen with a sleep disorder requiring treatment with medication. You stated that you are not aware of any studies showing that the risk of pharmacological treatment of insomnia is lower than the risk of untreated insomnia. In July 2013, you added a section on sleep aids to your Guide for Aviation Medical Examiners (AME Guide), including a list of required pilot no-fly times following the use of common sleep aid medications. The occasional or limited use of sleep aid medications is acceptable to the FAA, so long as the no-fly times within the AME Guide arc observed. In the Owatonna accident, the co-pilot was using zolpidem, which had been prescribed to his fiancée. Although we did not find that his use of this drug had caused any impairment related to the accident, the co-pilot appears to have suffered from undiagnosed and untreated episodes of insomnia that contributed to his being fatigued at the time of the accident. FAA rules require that a pilot cannot fly sooner than 24 hours after taking zolpidem. We issued this recommendation because we believed that FAA regulations regarding insomnia medications should be revised to be more consistent with US military guidance for aviators regarding similar medications and to the findings of a relevant position paper of the Aerospace Medical Association (AsMA). We were also concerned that the need to wait 24 hours after zolpidem use before flying places the aviator in the position of being subject to fatigue related to the insomnia that prompted his or her use of the drug. Your current policy does not address these concerns. However, you consider your actions complete, and plan no further activity to address Safety Recommendation A-11-24. Accordingly, the recommendation is classified CLOSED—UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 5/5/2016
Response: -From Michael P. Huerta, Administrator: Over the past 3 years, the Federal Aviation Administration (FAA) has focused on the implementation of enhanced screening for Obstructive Sleep Apnea (OS/\), a major cause of chronic fatigue in pilots. In July 2013, we added a section on sleep aids to the FAA's Guide for Aviation Medical Examiners (AME Guide). including a list of required pilot no-fly times following the use of common sleep aid medications. The occasional or limited use of these sleep aid medications is acceptable as long as the no- fly times within the AME Guide arc observed. In March 20 15, the FAA published updated guidance in the AME Guide. As a result of this new guidance, over 313,329 pi lots have received enhanced screening for OSA and over 1.000 pilots have been referred for OSA evaluation and treatment. In January 2016, the FAA incorporated a presentation on the full spectrum of sleep disorders, rather than just OSA, into the AME Refresher Seminar curriculum and plans to do the same for the AME Basic Seminar curriculum. Finally, in order to increase the education of pilots, we are also exploring the possibility of an article in the next Aerospace Medicine themed edition of the FAA Safety Briefing magazine tentatively scheduled for January 2017. As always, we emphasize the importance of sleep disorder evaluation, intervention, and treatment options for pilots. The FAA's current policy for sleep disorders, other than sleep apnea, is that certification should not be considered for any class of airmen with a sleep disorder requiring treatment with medication. We are not aware of any studies showing that the risk of pharmacological treatment of insomnia is lower than the risk of untreated insomnia. In addition, Restless Leg Syndrome may be considered for any class if there is no indication of excessive daytime somnolence. While other conditions are evaluated on a case-by-case basis. We frequently evaluate our medical policies on an ongoing basis in light of advancing technology, medical knowledge, and scientific evidence. The most current version of the AME Guide can be found at the following Web site: http://www.faa.gov/about/office org/headquartersoffices/avs/offices/aam/amc/guide/. I believe the FAA has effectively addressed these safety recommendations and consider our actions complete.

From: NTSB
To: FAA
Date: 11/4/2013
Response: In this letter, the National Transportation Safety Board (NTSB) wishes to clarify our evaluation and classification of the Federal Aviation Administration’s (FAA) responses to Safety Recommendations A-11-24, -26, and -27, stated below. As discussed below, we recently sent the FAA two letters discussing these recommendations, potentially creating confusion. The NTSB issued these recommendations to the FAA on March 29, 2011, as a result of our investigation of the July 31, 2008, crash of East Coast Jets flight 81, a Hawker Beechcraft Corporation 125 800A, while attempting to go around after landing at Owatonna Degner Regional Airport, Owatonna, Minnesota. In our July 29, 2013, letter to the FAA responding to the FAA’s April 8 and 9, 2013, letters regarding Safety Recommendations A-11-23 and -28 (also issued as a result of our investigation of the East Coast Jets flight 81 accident in Owatonna, Minnesota), we stated that our last update from the FAA regarding Safety Recommendations A 11 18 through 20, 24 through 27, 30, and 31 was the FAA’s June 10, 2011, letter. We indicated our concern that, although more than 2 years had passed since then, we had received no additional information regarding the FAA’s efforts to address these recommendations. Our July 29, 2013, letter concluded by stating that pending our timely receipt of an update and completion of the recommended actions, these recommendations remained classified “Open?Acceptable Response.” The inclusion of Safety Recommendations A-11-24, -26, and -27 in that letter was an inadvertent error because, on May 9, 2013, the FAA had sent an update on its actions for these three recommendations. We evaluated and classified the FAA’s actions when we replied to that letter on July 16, 2013. Although the July 29, 2013, letter has a later date than the July 16, 2013, letter, the evaluation and classifications in the earlier letter reflect the NTSB’s current evaluation of the FAA’s actions. To clarify, the following classifications in the July 16, 2013, letter are the current classifications of these recommendations: A-11-24 OPEN—UNACCEPTABLE RESPONSE A-11-26 Open—Acceptable Response A-11-27 Open—Acceptable Response We apologize for any confusion.

From: NTSB
To: FAA
Date: 7/29/2013
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: 7/17/2013
Response: In the Owatonna accident, the co-pilot was using zolpidem, which had been prescribed to his fiancée. Although we did not find that his use of this drug had caused any impairment related to the accident, the co-pilot appears to have suffered from undiagnosed and untreated episodes of insomnia that contributed to his being fatigued at the time of the accident. Current FAA rules require that a pilot cannot fly sooner than 24 hours after taking zolpidem. We issued this recommendation because we believed that FAA regulations regarding insomnia medications should be revised to be more consistent with US military guidance for aviators regarding similar medications, and a position paper of the Aerospace Medical Association (AsMA). We were also concerned that having to wait 24 hours after zolpidem use before flying places the aviator in the position of being subject to fatigue related to the insomnia. The FAA disagrees with this recommendation and does not believe a change in regulations or policies is warranted or safe at this time. On May 16, 2013, at the annual meeting of AsMA, the Manager of the FAA’s Forensic Toxicology Laboratory presented a paper titled “Return to Duty After use of Impairing Medications.” This presentation sought to evaluate what it described as an NTSB recommendation for pilots to avoid flying until twice the recommended dosing interval for a medication had passed. Although we have not issued such a recommendation, we did discuss this topic in support for Safety Recommendation A-00-4, stated below. A-00-4 Establish, with assistance from experts on the effects of pharmacological agents on human performance and alertness, procedures or criteria by which pilots who medically require substances not on the U.S. Dept. of Transportation's list of approved medications may be allowed, when appropriate, to use those medications when flying. In supporting the issuance of Safety Recommendation A-00-4, which was classified “Closed—Reconsidered” on April 24, 2005, we quoted the following statement from an FAA brochure titled “Over-the-Counter Medications and Flying,” regarding the following rule of thumb: “If the label warns of side effects, do not fly until twice the recommended dosing interval has passed.” We found the recent AsMA paper to be very informative and useful. The work it described examined only the drug diphenhydramine, but we believe that, before the FAA makes its decision regarding Safety Recommendation A-11-24, a similar analysis should be performed for the common medications used to treat insomnia. Accordinlgy, pending the FAA’s taking the recommended action using the new tools it developed, Safety Recommendation A-11-24 is classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/9/2013
Response: -From Michael P. Huerta, Administrator: Use of prescription sleep medications by a pilot prior to flying is potentially hazardous, and the effects vary depending on the specific medication used and the time elapsed since the medication was taken. There is also wide variation in the effect a specific medication may have on any one individual. For these reasons, the Federal Aviation Administration (FAA) does not have an individual policy for each one of the many formulations of sleep medications, nor do we have a single policy allowing the "appropriate use" of all prescription sleep medicines, as is called for in this recommendation. The FAA does not believe a change in regulations or policies is warranted or safe at this time. Occasional use of prescription sleep medications is presently allowed. After taking a dose of a prescription sleep medication, an airman must not fly for a period of time equal to 5-times the maximum elimination half-life of the medication. Our requirement for "S-half-lives" allows for a sufficient safety margin after usc of potentially impairing medications before resuming safety related duties. I believe we have effectively addressed Safety Recommendation A-11 -24, and I consider our actions complete.

From: NTSB
To: FAA
Date: 9/6/2011
Response: The NTSB looks forward to reviewing a more detailed response from the FAA with the results of its evaluation of these recommendations and a description of how it plans to respond to them. Pending completion of the recommended actions, Safety Recommendations A-11-24, -26, and -27 are classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/10/2011
Response: CC# 201100245: - From J. Randolph Babbitt, Administrator: We are evaluating this recommendation to determine the best approach to take to address the Board's intent. We will provide an update to our effort by December 2011.