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Safety Recommendation Details

Safety Recommendation A-11-030
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: Require that 14 Code of Federal Regulations Part 135 pilot-in-command line checks be conducted independently from other required checks and be conducted on flights that truly represent typical revenue operations, including a portion of cruise flight, to ensure that thorough and complete line checks, during which pilots demonstrate their ability to manage weather information, checklist execution, sterile cockpit adherence, and other variables that might affect revenue flights, are conducted.
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: 11/7/2013
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Checklist,

Safety Recommendation History
From: NTSB
To: FAA
Date: 11/7/2013
Response: We issued this recommendation because, in our investigation of the East Coast Jets flight 81 accident, we had found that the accident captain’s most recent line check was a flight of only about 32 miles that took a total of only about 1.5 hours. Although it adhered to the line check requirements because the captain had flown on an airway route to a representative airport, the line check was too short to be representative of a typical flight (customers do not typically charter flights for such short distances), and the airplane would not have reached a typical cruise altitude in that amount of time. Performing part of the line check during the cruise portion of flight is critical, because it allows the inspector to see how a pilot responds to situations in real time and under conditions representative of a typical revenue flight. During the cruise portion of flight, the inspector can discuss such issues as flight planning, diversions, alternates, and weather dynamics. When line checks are not conducted in an environment truly representative of operations, the inspector has a limited opportunity to evaluate the pilot’s practical application of his or her knowledge to company operations and to identify and address any performance issues with the pilot. The check airman who conducted the captain’s last line check would not have had sufficient time to conduct a thorough and complete inspection or to adequately address all of the inspection items. If the check airman had conducted the line check on a truly representative revenue flight, using the full checklist provided in FAA Order 8900.1, he might have been able to provide feedback to the captain about how to properly conduct checklists and how to properly accomplish a missed approach—two areas the captain handled inadequately during the accident flight. The accident captain also would have benefitted from a more thorough knowledge and awareness of convective weather and the use of forecasts and related reports; a line check conducted on a truly representative flight would have been an appropriate means to reinforce that knowledge and awareness and to improve the captain’s overall performance as a PIC. We concluded that the FAA’s current guidance, allowing multiple checks to be combined into one, allowed the accident captain to operate without adequate oversight. His errors in weather information management, use of checklists, sterile cockpit, and adherence to standard operating procedures likely would have been caught and corrected on a Part 121?type line check. The FAA replied that it had reviewed existing policy and guidance to principal operations inspectors (POI) regarding PIC line checks, and that the implications of the recommended action on inspector workload would be logistically problematic and would increase the FAA’s workload. We believe that our findings contradict the FAA’s belief that, because current guidance to POIs on line checks makes it mandatory for POIs to verify that the PIC is capable of performing the duties and responsibilities associated with the conduct of a revenue flight, there would be no improvement to safety. We further believe that, as currently implemented by the FAA for Part 135, line checks of pilots represent a burden on pilots and operators with much less safety benefit than is possible. Because the FAA has indicated that it does not plan to take any action in response to Safety Recommendation A-11-30, it is classified CLOSED—UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 8/8/2013
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) reviewed existing policy and guidance regarding pilot-in-command (PIC) line checks, and the implications on inspector workload of requiring all PIC line checks to be independent from other required checks. Title 14, Code of Federal Regulations part 135 encompasses a wide variety of aircraft and operations that are usually on-demand, and lack the '•hub and spoke" route structure that part 121 airlines often use. This means that part 135 flights can be sporadic and often take place long distances from FAA facilities. Due to these impediments, the FAA believes requiring all part 135line checks, including those done by FAA inspectors, to be conducted independent from other required checks would be logistically problematic and would increase the FAA workload without a corresponding improvement in safety. Current guidance to principal operations inspectors (POIs) on line checks makes it mandatory for POIs to verify that the PIC is capable of performing the duties and responsibilities associated with the conduct of a revenue flight. This includes managing weather information, checklist execution, sterile cockpit adherence, and other variables that might affect revenue flights. The FAA believes that current guidance regarding part 135 line checks is appropriate and plans no further action.

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 notes that the FAA will review existing policy and guidance regarding PIC line checks and that, once the review is complete, it will determine the specific actions to take in response to this recommendation. Pending completion of the recommended action, Safety Recommendation A-11-30 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/10/2011
Response: CC# 201100245: - From J. Randolph Babbitt, Administrator: As the Board described in its letter, the applicable pilot-in-command (PIC) line check regulation does not prohibit it fron1 being combined with other required flight checks. Current regulations only require that the PIC line check consist of at least one flight over one route segment, include takeoffs and landings at one or more representative airports, and if the pilot is instrument qualified, the check must be conducted over a civil airway, an approved off airway route, or a portion of either of then1. While these requirements are prescriptive they do not restrict air carriers from combining the required line check with other flight events. The FAA will review existing policy and guidance in this area in addition to considering the implications of requiring the PIC line check to be independent fron1 other required checks. Once that review is complete we can determine a plan to address this recommendation. I will keep the Board informed of the FAA's progress on this safety recommendation, and I will provide an update by July 2012.