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Safety Recommendation Details

Safety Recommendation A-11-026
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: Review the policy standards for all common sleep-related conditions, including insomnia, and revise them in accordance with current scientific evidence to establish standards under which pilots can be effectively treated for common sleep disorders while retaining their medical certification.
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: 6/21/2016
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Fatigue,

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/21/2016
Response: We note that you continually evaluate your medical certification policies, including those concerning sleep-related conditions, in light of advancing technology, medical knowledge, and scientific evidence. We also note that, in July 2013, you revised the AME Guide by adding a section on sleep aids and, in March 2015, you published updated guidance in the AME Guide on screening for OSA. These actions satisfy Safety Recommendation A-11-26, which is classified CLOSED—ACCEPTABLE 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: 7/17/2013
Response: The FAA is responding to this recommendation through its current review and evaluation of policies related to the diagnosis and treatment of sleep disorders. We point out that this recommendation was issued to ensure that all sleep disorders, not only obstructive sleep apnea (OSA), are addressed. We believe OSA to be a serious medical condition with important safety consequences, and we have separately issued recommendations addressing the diagnosis and treatment of OSA in aviators. The FAA appears to be addressing OSA, but we caution that an acceptable response to this recommendation will address other sleep disorders as well. Pending completion of the FAA’s review and evaluation, and appropriate revisions being made to the policy standards, Safety Recommendation A-11-26 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/9/2013
Response: -From Michael P. Huerta, Administrator: The FAA reviews and evaluates all medical policy standards on a regular and continuing basis in light of ever advancing medical knowledge and technology. Current FAA policy allows for airmen with appropriately diagnosed and treated sleep conditions to receive special issuance medical certification if the airman is determined not to be a safety risk to the national air space. Over the last 12 months, we have been evaluating current scientific data related to the evaluation and treatment of sleep disorders, particularly obstructive sleep apnea, in an effort to modify current policy, streamline the process, and make it easier for an airman to safely receive special issuance medical certification. We anticipate publishing an updated policy in 2013. I will keep the Board informed of our progress on Safety Recommendation A-11-26 and will provide an update once the policy has been published.

From: FAA
To: NTSB
Date: 4/8/2013
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: 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 these recommendations to determine the best approach to take to address the Board's intent. We will provide an update to our effort by December 2011.