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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 pilots to receive initial and recurrent education and training on factors that create fatigue in flight operations, fatigue signs and symptoms, and effective strategies to manage fatigue and performance during operations.
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
In your letter, you stated that current FAA regulations fully address this recommendation, and that, as a result, you will take no further action. We reviewed the final rule concerning crew resource management in Part 135 operations. This rule, issued in January 2011, contains in 14 CFR Section 135.330 (a)(6) a requirement for the recommended training for Part 135 operators. However, Sections 91.1057(h) and 91.13(a) do not address the recommended training needed by Part 91, subpart K pilots; rather, those sections make it a violation of the regulations for a fatigue-impaired pilot to operate a flight. Because you have made it clear that FAA action to address Safety Recommendation A 11 25 is complete and no further action will be taken, the recommendation is classified CLOSED—UNACCEPTABLE ACTION.
-From Michael P. Huerta, Administrator: As stated in our June 10, 2011, response to the Board on this recommendation, the preamble to the Flightcrew Member Duty and Rest Requirements Notice of Proposed Rulemaking for part 121 operators included a statement that part 135 certificate holders should anticipate a similar fatigue related rule. However, upon further review, the FAA believes that Title 14, Code of Federal Regulations (14 CFR) section 135.330, Crew Resource Management Training, fully addresses the part 135 portion of this recommendation. The FAA issued this final rule on January 21, 2011, and it is available at the following Web address: http://www.gpo.gov/fdsys/pkg/FR-20 11 -01-21 /pdf/2011-1211.pdf This final rule created 14 CFR section 135.330 and requires each part 135 certificate holder to have an approved crew resource management training program. The training program must include initial and recurrent training on the effects of fatigue on performance, avoidance strategies and countermeasures, and the effects of stress and stress reduction strategies. Section 135.330 applies to both dual and single pilot operations conducted under part 135. We also previously stated that we would evaluate the appropriateness of extending a regulatory framework similar to that in the Flightcrew Member Duty and Rest Requirements rule to part 91 subpart K operations. The FAA has decided that current regulations appropriately address fatigue under part 91 subpart K. During the 2003 drafting of final rules for part 91 subpart K operations, the FAA considered the existing issues and research surrounding flight duty, and rest time requirements. Section 91.1 057(h) states that, "a flight crewmember may decline a flight assignment if, in the flight crewmember's determination, to do so would not be consistent with the standard of safe operation required under this subpart, this part, and applicable provisions of this title. With the rule, the FAA has already established a regulatory safety standard within part 91 subpart K meeting a high level of safety. Furthermore, Advisory Circular 120-51 E, Crew Resource Management Training, encourages operators to recognize and develop training policies and procedures addressing crew performance and fatigue. Additionally, part 91 subpart K program managers and their flight crewmembers are subject to the regulatory provisions of 14 CFR section 9 1.1 3(a), Careless or reckless operation. Both the program manager and flight crewmember would violate regulations if it were determined that a crewmember operated an aircraft when the crewmembers • lack of rest endangered others. Individual program managers are responsible for developing policies that: • Allow flight crewmembers to decline assignments or remove themselves from duty if they were impaired by a lack of sleep; and • Include the administrative implications of fatigue calls. Principal operations inspectors work closely with program managers to ensure program operating manuals support regulatory compliance. The FAA exercises oversight responsibility to ensure fractional ownership programs comply with the regulations and maintain a high level of safety. The FAA believes 14 CFR sections 91. 1 057(h) and 9 1.1 3(a) provide sufficient regulatory structure to meet the intent of this recommendation without requiring additional training on fatigue. We believe the FAA has full y addressed this recommendation for 14 CFR parts 135 and 91 subpart K. and we plan no further action.
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 FAA indicated that it had reviewed some additional training material it has recently developed in addition to other FAA-developed training material discussed in the letter that transmitted this recommendation to the FAA. The NTSB believes that the FAA needs to ensure that Part 135 and Part 91 subpart K pilots receive training based on this material. The FAA will shortly issue a final rule addressing flightcrew duty and rest requirements, which will address fatigue education and training for Part 121 operations. The notice of proposed rulemaking (NPRM) for this rule indicated that a similar NPRM and final rule would be developed for Part 135. In its current letter, the FAA indicated that it is considering similar regulations for Part 91 subpart K operations. Pending issuance of an NPRM and final rule addressing fatigue education and training for Part 135 and Part 91 subpart K operations, Safety Recommendation A-11-25 is classified OPEN—ACCEPTABLE RESPONSE.
CC# 201100245: - From J. Randolph Babbitt, Administrator: The FAA agrees with the Board on the importance of fatigue education and training. The FAA has done a tremendous amount of work on pilot fatigue, some of which the Board highlighted in its letter. One publication that was not listed that is applicable to this recommendation is Safety Alert for Operators (SAFO) 09014, Flight Crewmember Fatigue: Concepts for the Development of Fatigue Countermeasures Relative to Part 121 and 135 Short-Haul Operations, published on September 11, 2009 (enclosure 3). This SAFO provides insight to operators and crew for mitigating fatigue in short-haul flight operations. The FAA also issued AC 120-100, Basics of Aviation Fatigue, published June 7, 2010 (enclosure 4), which is applicable to parts 135 and 91 subpart K operators. This AC summarizes the content of the FAA international symposium on fatigue, describes fundamental concepts of human cognitive fatigue and how it relates to safe performance of duties by employees in the aviation industry, it provides information on conditions that contribute to cognitive fatigue, and provides information on how individuals and aviation service providers can reduce fatigue and/or mitigate the effects of fatigue. The FAA is currently working on the Flightcrew Member Duty and Rest Requirements final rule, which will address fatigue education and training for part 121 operations. We anticipate publishing the final rule in August 2011. As noted in the notice of proposed rulemaking (NPRM), the part 135 community should expect to see an NPRM and final rule very similar to those of part 121. Additionally, we are evaluating the appropriateness of extending this regulatory framework to part 91 subpart K operations. 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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