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Safety Recommendation Details

Safety Recommendation A-11-028
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: Actively pursue with aircraft and avionics manufacturers the development of technology to reduce or prevent runway excursions and, once it becomes available, require that the technology be installed.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate 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: 9/25/2018
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s): Runway Safety

Safety Recommendation History
From: NTSB
To: FAA
Date: 9/25/2018
Response: We previously said that your efforts to support avionics and transport airplane manufacturers in developing technology that reduces runway excursions and protects aircraft from runway overruns satisfied the first part of this recommendation. We also said that your plan to facilitate voluntary equipage of the technology might be an acceptable alternative to the second part of the recommendation (to require that the technology be installed). You previously said that such a requirement was not warranted because industry was sufficiently motivated to install the technology voluntarily. In our previous letter to you about this recommendation, we asked for information on how industry has adopted the technology (which aircraft makes/models/derivatives) and how the new tools and procedures were being applied. Based on information in your August 8, 2018, letter, we note that major airplane manufacturers such as Airbus, Boeing, Embraer, and Gulfstream have developed, certified, and are installing technology to reduce or prevent runway excursions in newly manufactured aircraft. We further note that Honeywell has developed a system that can be installed on in-service airplanes, and its Smart Runway/Smart Landing systems, or similar, are being used in a variety of in-service airplanes from a number of manufacturers. This information demonstrates that industry is voluntarily adopting the technology, which is an alternative that satisfies this recommendation. Accordingly, Safety Recommendation A-11-28 is classified CLOSED--ACCEPTABLE ALTERNATE ACTION.

From: FAA
To: NTSB
Date: 8/8/2018
Response: -From Daniel K. Elwell, Acting Administrator: In the Board's letter dated February 13. 2017, the Board acknowledged that the Federal Aviation Administration (FAA) has responsively addressed the first part of this safety recommendation. The FAA has been working with avionics vendors and transport manufacturers to develop technology that reduces runway excursions and protect aircraft from runway overruns. The Board requested further information on how industry has adopted the technology to date and how industry is using the new tools and procedures in their operations. Examples of industry adoption of Runway Overrun Awareness and Alerting Systems CROAAS) are provided below for several aircraft manufacturers. Runway Overrun Prevention System CROPS) Airbus: As of September 2017, Airbus had installed their version of RO AAS, named Runway Overrun Preventions System (ROPS), on 781 aircraft with 54 operators. ROPS was installed on the following aircraft models: A320 (451); A380 (I 79); A350 (I 02); and A330 (49). ROPS is available for retrofit and line-fit on Model A320, A330, A380 aircraft, and is included as a basic feature on the Model A350 type design. The latest version of ROPS, Step 3, also provides landing distance calculation capability, which allows the crew to see the worst braking action that can be accepted for the landing and a notification if the braking action is worse than anticipated. Boeing: Received FAA certification approval for their ROAAS on the Model 737NG as well as the Model 737 Max aircraft. It is available as an option. Embraer: Developing a RO AAS system, targeting entry into service in 2019. Gulfstream: In the process of integrating and certifying Honeywell's Smart Runway/Smart Landing system in conjunction with a jointly developed ROAAS into an existing product, with the intent to implement the system in future products. Honevwell Smart Runway The Honeywell Smart Runway (formerly known as Runway Awareness and Alerting System) or Smart Landing system has been installed on--Airbus Model A300, A3 I 0, A320, A330 and A340 aircraft, -Boeing Model 727-200. 737-400, 737 NG, 747-400, 757-200, 767-300, 777-2/300, DC-9, MD-I 0, MD-11 F and MD-80 aircraft, the Tupolev TU-204, Tlyushin 96-300. and various business jets. On December 18, 2017, the European Organization for Civil Aviation Equipment (EUROCAE) released Minimum Operational Performance Standards for ROAAS. The working group members included seven manufacturers, two certification agencies, and numerous avionics vendors and industry groups. Regarding the Board’s request for information on how industry is using the ROAAS tools, the various RO AAS share the common objective of providing the flight crew advisory and warning information intended to inform the flight crew as to how and when they should take action to eliminate or reduce the consequences of overruns. The alerting systems provide callouts that guide the flight crew to e ither abort the landing if it determines the runway available is too short to support the landing or, if the airplane is already on the runway, alerting the crew to ensure all deceleration devices have been deployed and are used to their maximum effectiveness. The industry has undertaken broad efforts to create standards for ROAAS, to develop and certify increasingly mature ROAAS, and to install them in many different models of transport aircraft. The FAA has been actively involved in these efforts. I believe the FAA has effectively addressed this safety recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 2/13/2017
Response: We believe that your efforts to support avionics and transport manufacturers in developing technology that reduces runway excursions and protects aircraft from runway overruns are responsive to the first part of this recommendation. You indicated, however, that a requirement to install runway excursion advisory systems is not warranted because you believe industry is sufficiently motivated and will apply for certification and install these systems voluntarily. We believe that your efforts to work with industry to develop the technology, along with manufacturers voluntarily installing it, could be an acceptable alternate solution to the recommended requirement. However, we would like to know (1) how industry has adopted the technology (which aircraft makes/models/derivatives) and (2) how industry is applying the new tools and procedures that are discussed in your letter in their operations (Part 121, 135, 91K, 125, 91). Pending our receipt and review of this additional information, Safety Recommendation A 11 28 is classified OPEN--ACCEPTABLE ALTERNATE REPSONSE.

From: FAA
To: NTSB
Date: 5/5/2016
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) has been working with avionics vendors, third parties, and transport airplane manufacturers who are conducting research and developing technology to reduce runway excursions and protect aircraft from runway overruns. In addition, the Runway Excursion Joint Safety Analysis and Implementation Team (RE JSAIT) has been evaluating the effectiveness of these technologies using runway excursion accident data to determine the appropriate utilization and implementation requirements for operators. The current efforts to reduce runway excursion can be separated into three areas: 1) The on-board systems intended to alert and advise the flightcrew regarding the current landing status and whether it is appropriate to go around or use additional stopping force, if available, after landing; 2) The FAA-funded research and cooperation with industry to evaluate the feasibility of using information available on airplanes to quantitatively measure braking capability in order to improve decision-making processes for flightcrews of following aircraft, airport runway maintenance personnel, and Air Traffic Control (A TC) during active winter events; and 3) The FAA collaboration with Team Eagle, a Canadian effort intended to verity friction measurements by airport personnel using an aircraft tire and anti-skid system in a friction measuring device utilized by airport ground personnel. The device, called the Braking Availability Tester, is similarly intended to quantitatively measure braking capability in order to improve decision-making processes for flightcrews, airport runway maintenance personnel, and ATC. Industry development of Runway Awareness Advisory Systems was described in our April 8, 2013, letter to the Board, which included the previously operational Situational Awareness and Alerting for Excursion Reduction System. Since that time, the Airbus Runway Overrun Prevention System and a related Runway Overrun Warning System have been certified on the A320, A330, and A350 as basic equipment. Also of note since our previous response, Honeywell's SmartLanding was certified and is now installed in over 2,500 aircraft. Boeing is also developing features such as Overrun Warnings (during approach and landing rollout), Perspective Runway on the Heads-up Display, and Speedbrake alerting, and is evaluating these features for integration into its future fleet of aircraft. The RE JSAIT reviewed runway excursion accident data and concluded that runway overrun awareness systems provide considerable benefit, especially when installed in newer airplanes. Using Commercial Aviation Safety Team (CAST) methodology, the RE JSAIT estimated that approximately one quarter of runway excursion events can be prevented by use of such systems. Based on these findings, CAST approved the following RE JSAJT recommendations: • Manufacturers should provide this functionality in all new type designs, major type design derivatives, and current production airplanes; • Operators should have such systems installed by manufacturers in their new type design purchases; and • Operators should assess the cost-benefit value of installing the systems when they purchase new, current production airplanes and retrofit existing in-service airplanes when feasible. CAST has taken a proactive role in addressing and mitigating the risk associated with runway excursions by developing safety enhancements concerning the airplane systems, as well as modified policies, procedures, and training programs that entail specific courses of action. These safety enhancements are expected to reduce future runway excursion occurrences and combat lapses of situational awareness by the flightcrew. The FAA has been consistently working with industry and operators to enhance technological development, promote innovatio'1, and create awareness to the hazards of runway excursions. Through our support of funding, research, participation in studies, and creating plans of action for operators, we have been proactive in reducing the risk associated with operating in the airport environment and creating a compelling landscape for technological improvements. Industry is taking ownership and is advancing current systems to heighten awareness and effectively reduce risk that accompanies operating in and around the runway environment. Industry has proven itself sufficiently motivated to develop and apply for certification of increasingly more mature systems as they are developed, and our current rules are sufficient to allow the FAA to certify these systems without revision. For these reasons, development of new airworthiness standards requiring installation of runway excursion advisory systems is not warranted. I believe the FAA has effectively addressed this recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 3/4/2015
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) draft Advisory Circulars (AC) 25-X, “Takeoff Performance Data for Operations on Contaminated Runways,” and AC 25-X, “Landing Performance Data for Time-of-Arrival Landing Performance Assessments,” which were posted for comment on the FAA’s website on January 21, 2015. Both of these draft ACs provide guidance and standardized methods that data providers, such as type certificate (TC) holders, supplemental type certificate (STC) holders, applicants, and airplane operators can use when developing performance data for transport category airplanes for operations on contaminated runways. The AC also promotes the use of consistent terminology for runway surface conditions used among data providers and FAA personnel. The NTSB has investigated several accidents within the last 10 years that involve issues addressed by these ACs. As a result of these investigations, the NTSB issued Safety Recommendations A 07 57 through 64, A 08 17, A 08 41 through 43, and A 11 28 and 29.

From: NTSB
To: FAA
Date: 7/29/2013
Response: We are encouraged by the coordinated efforts of the FAA, avionics manufacturers, and transport manufacturers thus far to develop technology that reduces runway excursions and protects aircraft from runway overruns. We are interested in learning more about the FAA’s plan to require the installation of this technology on transport category aircraft, once the technology becomes available. Pending our receipt and review of such a plan, Safety Recommendation A 11-28 remains classified OPEN—ACCECPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 4/8/2013
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) is working with avionics and transport airplane manufacturers that are conducting research and developing technology to reduce runway excursions and protect aircraft from runway overruns. These efforts have so far resulted in several Runway Awareness and Advisory Systems (RAAS) that arc currently available and installed on an increasing number of aircraft types that use advanced avionics systems. As these technologies demonstrate their practicality and provide a measurable reduction in incidents resulting from runway excursions, the FAA may pursue the best regulatory approach to install these new systems on transport category aircraft in the future. Currently, there are three RAAS systems in various stages of development and approval: 1) Situational Awareness and Alerting for Excursion Reduction (SAAFER) SAAFER is an FAA-certified software developed by Boeing that provides a suite of tools to help a pilot make an effective, timely decision that supports safe approaches and landings. It also provides the pilot with enhanced awareness and guidance from the approach planning phase through landing, rollout, and deceleration. SAAFER will be made available for installation on newer Boeing aircraft models and is currently operational on certain aircraft. 2) SmartLanding® Honeywell, Inc., developed and manufactured SmartLanding®, which was FAA certified and is available for installation on properly equipped aircraft; it is currently installed on many Boeing and Airbus aircraft. SmartLanding is a software enhancement to Honeywell's Enhanced Ground Proximity Warning System (EGPWS). Through a simple software upgrade to EGPWS, coupled with the installation of an enhanced Display Unit, SmartLanding® improves pilot situational awareness by providing auditory and visual alerts. Additionally, associated caution and warning alerts are broadcast if the aircraft has not met established safe approach parameters. 3) Runway Overrun Prevention System (ROPS) Airbus Industrie developed and manufactured ROPS, which has not yet been FAA certified, but is in operation on some Airbus aircraft. ROPS is integrated with an aircraft's flight management and navigation systems and provides the pilots with a real•time picture in the navigation display of where the aircraft will stop on the runway, regardless of runway conditions. If the approach profile or the braking conditions vary, the stopping point changes proportionately. If ROPS detects that the aircraft will not be able to stop on the available runway remaining, the system provides the crew with a Crew Alerting System message and an auditory "runway too short" warning. Airbus is planning for FAA ROPS certification on all Airbus A350 aircraft during the aircraft certification phase in 2014. ROPS is currently installed on more than 60 percent or the in•service A380 fleet and is now installed on all new A380 aircraft during production. As none of the Airbus A380 aircraft currently in service are on the U.S. aircraft registry, no FAA certification or evaluation is being performed. Starting next year, ROPS will be available on all new-build and retrofit Airbus aircraft and will be certified and evaluated on a fleet-type basis. I will keep the Board informed of the FAA's progress on this recommendation and provide an update by February 28, 2014.

From: NTSB
To: FAA
Date: 9/6/2011
Response: The NTSB notes that the FAA has been working with both avionics and transport airplane manufacturers who are conducting research and developing technology to reduce runway excursions and protection from runway overruns. We further note the FAA’s expectation that some of these early technologies will become available for incorporation and initial certification within the next 2 years. The FAA stated that, if these technologies prove to be practical and provide a measureable reduction in runway excursions, it will pursue requirements to implement the new capabilities on future transport category aircraft. Accordingly, pending the development of technology to reduce or prevent runway excursions and, once it becomes available, its installation on transport category aircraft, Safety Recommendation A-11-28 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/10/2011
Response: CC# 201100245: - From J. Randolph Babbitt, Administrator: The FAA agrees with the intent of this recommendation. We have been working with both avionics and transport airplane manufacturers who are conducting research and developing technology to reduce runway excursions and protection from runway over-runs. We anticipate son1e of these early technologies will become available for incorporation and initial certification on transport aircraft flight decks within the next two years. Should these technologies prove to be practical and provide a measureable reduction in incidents resulting from runway excursions, we will pursue the best regulatory approach to implement these new capabilities on transport category aircraft in the future. I will keep the Board informed of the FAA's progress on this safety recommendation, and I will provide an update by July 2012.