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Safety Recommendation Details

Safety Recommendation A-11-027
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: Increase the education and training of physicians and pilots on common sleep disorders, including insomnia, emphasizing the need for aeromedically appropriate evaluation, intervention, and monitoring for sleep-related conditions.
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 have taken the following actions: 1. As stated above, in July 2013, you added a section to the AME Guide discussing sleep aids. 2. As stated above, in March 2015, you published updated guidance in the AME Guide regarding OSA. 3. In January 2016, you incorporated a presentation on the full spectrum of sleep disorders, rather than just OSA, into the aviation medical examiner (AME) Refresher Seminar curriculum; you are also making a similar revision to the AME Basic Seminar curriculum. 4. You plan to include an article in the next Aerospace Medicine themed edition of the FAA Safety Briefing magazine, scheduled for January 2017, that will emphasize the importance of sleep disorder evaluation, intervention, and treatment options for pilots. 1) In 2007 you published “Fatigue in Aviation,” which defines fatigue, describes its physiologic effects, describes ways that it can be prevented, and addresses types of sleep disorders. Although the brochure was published before this recommendation was issued, it partially satisfies the recommendation. These combined actions satisfy Safety Recommendation A-11-27, 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: 7/29/2013
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: As Safety Recommendation A-11-26 does, this recommendation addresses all sleep disorders, not only OSA. The activities described by the FAA in its letter, some of which were developed before this recommendation was issued, partially satisfy this recommendation, particularly the aviation medical examiner (AME) seminars and the FAA’s brochure “Fatigue in Aviation.” However, our review of the Aeronautical Information Manual (AIM) and the 2013 AME Guide revealed no discussion in these documents of sleep disorders other than OSA. We emphasize that OSA is a serious medical issue affecting aviation safety, and we commend the FAA for including this information. However, to fully satisfy Safety Recommendation A-11-27, the FAA will need to revise the AIM and the AME guide to discuss other sleep disorders, such as insomnia, as well. Pending the FAA’s taking such action, Safety Recommendation A-11-27 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/9/2013
Response: -From Michael P. Huerta, Administrator: The FAA concurs that Aviation Medical Examiners (AMEs) and pilots should have a basic understanding of common sleep disorders, their evaluation and diagnosis, and how the effects relate to the performance of safety-related duties. We initiated an educational program for AMEs in September 2009, making this topic a part of the regular curriculum in all Basic and Specialty AME Seminars. Since initiating this program, more than 3,400 AMEs have been trained. This training is updated regularly, keeping up with the changing medical understanding of these conditions and their evaluation and treatment. Insomnia, as one facet of sleep disorders in general, is discussed in the training, as are narcolepsy and the various types of sleep apnea. In addition to keeping up with current medical knowledge, the lectures provide the latest information and any applicable modifications ofF AA medical policy. AMEs arc educated regarding the requirements for aeromedically appropriate evaluation, intervention, and monitoring for sleep-related conditions. The training emphasizes that a medical certificate should not be issued for any class to airmen with a sleep disorder requiring treatment with medication. A full explanation of the condition including the definitive diagnosis is required. Further evaluation may be required in specific cases and eligibility for aeromedical certification will be determined on an individual basis. We modified the AME Guide in 2011 to stress the importance of detection and evaluation of airmen with possible sleep disorders such as obstructive sleep apnea. We also published a Pilot Safety Brochure, "Obstructive Sleep Apnea," in January 2010, for distribution to pilots, employers, AMEs and other interested physicians. We also published "Fatigue in Aviation" in 2007. This brochure defines fati~:,TUe and describes the physiologic effects of fatigue, and describes ways that fatigue can be prevented, and addresses types of sleep disorders. While we published "Obstructive Sleep Apnea" and "Fatigue in Aviation" before the Board made this recommendation, we feel these brochures are relevant to the issue and continue to use them as educational tools. These brochures may be accessed at: http://www.faa.gov/pilots/safety/pilotsafetybrochures/. In addition, we initiated a revision to the Aeronautical Information Manual, chapter 8, Medical Facts for Pilots, section 1, Fitness for Flight, which includes a new section on obstructive sleep apnea. It describes the importance of an obstructive sleep apnea diagnosis as well as other sleep disorders and their effective treatment. We published this revision in 2011. I believe we have effectively addressed Safety Recommendation A-11-27, 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 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.