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Safety Recommendation Details

Safety Recommendation A-11-046
Details
Synopsis: On January 27, 2009, about 0437 central standard time, an Avions de Transport Régional (ATR) Aerospatiale Alenia ATR 42-320 (ATR 42), N902FX, operating as Empire Airlines flight 8284, was on an instrument approach when it crashed short of the runway at Lubbock Preston Smith International Airport (LBB), Lubbock, Texas.2 The captain sustained serious injuries, and the first officer sustained minor injuries. The airplane was substantially damaged. The airplane was registered to FedEx Corporation and operated by Empire Airlines, Inc., as a 14 Code of Federal Regulations (CFR) Part 121 supplemental cargo flight. The flight departed from Fort Worth Alliance Airport, Fort Worth, Texas, about 0313. Instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed. The National Transportation Safety Board (NTSB) determined that the probable cause of this accident was the flight crew’s failure to monitor and maintain a minimum safe airspeed while executing an instrument approach in icing conditions, which resulted in an aerodynamic stall at low altitude. Contributing to the accident were (1) the flight crew’s failure to follow published standard operating procedures (SOP) in response to a flap anomaly, (2) the captain’s decision to continue with the unstabilized approach, (3) the flight crew’s poor crew resource management (CRM), and (4) fatigue due to the time of day in which the accident occurred and a cumulative sleep debt, which likely impaired the captain’s performance.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Define and codify minimum simulator model fidelity requirements for aerodynamic degradations resulting from airframe ice accumulation. These requirements should be consistent with performance degradations that the National Transportation Safety Board and other agencies have extracted during the investigations of icing accidents and incidents.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Lubbock, TX, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: CEN09MA142
Accident Reports: Crash During Approach to Landing Empire Airlines Flight 8284 Avions de Transport Regional Aerospatiale Alenia ATR 42-320, N902FX
Report #: AAR-11-02
Accident Date: 1/27/2009
Issue Date: 5/19/2011
Date Closed: 7/21/2016
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Icing,

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/21/2016
Response: We note that, in the final rule, Table A1A, QPS Requirements, entry 2.j, “Engine and Airframe Icing” contains requirements that satisfy Safety Recommendation A-11-46. Accordingly, the recommendation is classified CLOSED—ACCEPTABLE ACTION.

From: NTSB
To: FAA
Date: 12/8/2015
Response: NOTE: Correspondence controls numbers 201500886 and 201500898 were combined. We note that the FAA’s National Simulator Program has evaluated the Stick Pusher and Adverse Weather Aviation Rulemaking Committee’s recommendations and is making the appropriate revisions to Part 60, “Flight Simulation Training Device [FSTD] Initial and Continuing Qualification and Use.” In our October 2, 2014, comments on the notice of proposed rulemaking (NPRM) titled “Flight Simulation Training Device Qualification Standards for Extended Envelope and Adverse Weather Event Training Tasks,” we stated that the requirements proposed in the NPRM respond to Safety Recommendation A-11-46. However, we expressed concern with the sources of information that would be used as the basis for validating FSTDs. We emphasize that using information we and other agencies have extracted during the investigations of icing accidents and incidents would provide a very good basis for the conditions that an FSTD needs to simulate in order to train pilots to recognize and recover from encounters with these conditions. FSTDs that comply with the proposed requirements in the NPRM would have to be available before the training recommended in Safety Recommendation A 11 47 could be required. Pending our receipt and review of a final rule that addresses the concerns described above, Safety Recommendations A-11-46 and 47 remain classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/2/2015
Response: -From Michael P. Huerta, Administrator: As previously mentioned, the Federal Aviation Administration (FAA) chartered the Stick Pusher and Adverse Weather Aviation Rulemaking Committee (ARC) to identify best procedures and training practices that would enable pilots to accurately and consistently respond to unexpected stick pusher activations, icing conditions, and microburst and windshear events. The FAA's National Simulator Program evaluated the recommendations provided by the ARC and is moving forward with rule changes to part 60, Flight Simulation Training Device Initial and Continuing Qualification and Use. The proposed changes to part 60 are intended to update the flight simulation training device (FSTO) technical standards to improve FSTD fidelity in the stall maneuver. as well as other safety-critical training maneuvers that support training requirements in the part 121, Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers rulemaking. The Flight Simulation Training Device Qualification Standards for Extended Envelope and Adverse Weather Event Training Tasks notice of proposed rulemaking (NPRM) was published in the Federal Register on July I 0, 2014 (79 FR 39462), and publication of the final rule is anticipated in 2016. We will keep the Board informed of the FAA's progress on these safety recommendations and provide an updated response by March 2016.

From: NTSB
To: FAA
Date: 10/2/2014
Response: We have reviewed the Federal Aviation Administration’s (FAA) notice of proposed rulemaking (NPRM) titled “Flight Simulation Training Device Qualification Standards for Extended Envelope and Adverse Weather Event Training Tasks,” published at Federal Register 39462-39753 on July 10, 2014. The proposed requirements in the NPRM, if implemented in a final rule, will satisfy Safety Recommendation A-11-46. There is considerable discussion within the NPRM on sources of data that may be used to provide a validation basis for FSTDs. We note that Safety Recommendation A-11-46 specifically mentions using information that we and other agencies have extracted during the investigations of icing accidents and incidents, though the NPRM did not discuss this source of information. We continue to believe that this information is a very good basis for the conditions that an FSTD needs to simulate in order to train pilots to recognize and recover from encounters with these conditions. This recommendation is currently classified “Open—Acceptable Response.”

From: NTSB
To: FAA
Date: 5/12/2014
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) draft Advisory Circular (AC) 120-109A, “Stall Prevention and Recovery Training,” which was posted for comment on the FAA’s website on March 12, 2014, and proposes revisions to AC 120-109. The purpose of the draft revised AC is to provide guidance and best practices for training, testing, and checking pilots to ensure correct responses to impending and full stalls. (For air carriers, the applicable regulatory requirements are contained in 14 Code of Federal Regulations [CFR] Part 121.) Although the draft revised AC is directed to air carriers, the FAA encourages all airplane operators, pilot schools, and training centers to use this guidance for conducting stall prevention training, testing, and checking because many of the principles apply to all airplanes. The guidance was created based on a review of recommended practices developed by major airplane manufacturers, labor organizations, air carriers, training organizations, simulator manufacturers, and industry representative organizations. Draft revised AC 120-109A provides an update to reflect new Part 121 regulatory terms and also incorporates the full stall training requirement of Public Law 111-216. Although the draft revised AC does not contain simulator model fidelity requirements, we believe that some of the training recommended in the draft revised AC will depend, in part, on the availability of simulators that comply with the standards specified in Safety Recommendations A-10-24 and A-11-46 and -47.

From: NTSB
To: FAA
Date: 2/11/2013
Response: We note that, in response to the aviation rulemaking committee’s (ARC) final report, which included recommendations for revisions to Part 121 and other associated regulations regarding minimum flight simulator fidelity requirements and icing training, the FAA approved a rulemaking effort for Part 60. We look forward to reviewing the notice of proposed rulemaking (NPRM), which the FAA plans to publish in the fall of 2013. We also look forward to hearing about the FAA’s plan for expanding training requirements for flying in icing conditions, as recommended in Safety Recommendation A-11-47, once such a plan is developed. Pending our receipt and review of the NPRM and a plan for expanding training requirements as described above, Safety Recommendations A-11-46 and -47 remain classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 11/6/2012
Response: -From Michael P. Huerta, Acting Administrator: As we reported in our August 22, 2011, letter, the Federal Aviation Administration (FAA) chartered the Stick Pusher and Adverse Weather Aviation Rulemaking Committee (ARC) in September 2010 to address stick pusher and adverse weather event training as defined in section 208(b) of Public Law 111-216. On July 11,2011, the ARC recommended changes to the minimum flight simulator fidelity requirements, as defined in 14 CFR part 60. Flight simulation is an integral component of pilot training including training for in flight icing conditions. The FAA believes that by modifying part 60 the quality and realism of training in the simulator will improve and be translated into improved training. With improved simulator fidelity, pilots will be better prepared to recognize airframe icing as it develops, monitor and maintain appropriate airspeeds in icing conditions, and respond to decaying airspeed situations. The FAA approved the part 60 rulemaking effort on May 1, 2012. We anticipate publishing a notice of proposed rulemaking in 2013. I will keep the Board informed of the FAA's progress on these recommendations and provide an update by September 30, 2013.

From: NTSB
To: FAA
Date: 1/12/2012
Response: Notation 8370: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) draft Advisory Circular (AC) 120-STALL, “Stall and Stick Pusher Training,” and the notice announcing its availability for comment, which was published at 76 Federal Register 77542 on December 13, 2011. According to the notice, the draft AC offers guidance to training providers operating under 14 Code of Federal Regulations (CFR) Parts 121, 135, and 142 on stall event and stick pusher demonstration training, including recommendations and best practices for academic training, job performance training, and instructor training. The NTSB recognizes the significant improvement in FAA guidance to operators on stall and stick pusher training philosophy, stall prevention training, and stall recovery training provided by the draft AC. The draft AC covers several important issues revealed during NTSB investigations related to pilot training for avoidance of and recovery from stalls. Among the issues are: 1. Emphasis on Angle-of-Attack: The importance of reducing the angle-of-attack in response to an encounter with a stall, stall warning, or approach to stall. 2. Energy Management: The importance of effective use of available energy (both altitude and speed), rather than minimal altitude loss, for stall recovery. 3. Stick Pusher Training: The importance of pilots experiencing the sudden forward movement of the control wheel during stick pusher events in training. 4. Crew Concept: The importance of good crew coordination in stall recognition and recovery. 5. Realistic Training Environment: The importance of pilots experiencing the startle effect, which can accompany an unexpected stall warning and the pitch changes, stick shakers, and alarms associated with autopilot disconnect during stall training. 6. Full Flight Simulator Use and Limitations: The importance of using full flight simulators (level C or D) to provide appropriate motion sensation to pilots during stall training while recognizing the fidelity limitations of particular simulators. The draft AC recommends that, whenever available, the highest level full flight simulators should be used in stall training programs, and the NTSB agrees. However, the draft AC cautions that the FAA does not recommend post-stall training unless the simulator is tested and validated for this. The NTSB found in the Colgan Air flight 3407 investigation that pilots could have a better understanding of an airplane’s flight characteristics during the post-stall flight regime if realistic (fully developed) stall models were incorporated into simulators used for such training. The NTSB strongly encourages the FAA to improve simulator fidelity in the stall and stall recovery regimes. The NTSB notes the statement in the forward of the AC that “The FAA recognizes that the content of this draft AC explains in further detail concepts proposed in the supplemental notice of proposed rulemaking (SNPRM), entitled Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers, FAA Docket FAA-2008-0677, and corresponding flight crewmember training AC, regarding stall and stick pusher training.” The NTSB believes the draft AC provides additional needed detail to support the proposed requirements in the SNPRM, and many of the comments here reflect comments we provided on July 15, 2011, concerning the SNPRM. The NTSB also notes that the draft AC addresses the following open safety recommendations to the FAA. A-11-46 Define and codify minimum simulator model fidelity requirements for aerodynamic degradations resulting from airframe ice accumulation. These requirements should be consistent with performance degradations that the National Transportation Safety Board and other agencies have extracted during the investigations of icing accidents and incidents.

From: NTSB
To: FAA
Date: 12/16/2011
Response: We note that an aviation rulemaking committee (ARC) was chartered to address stick pusher and adverse weather event training. We also note that on July 21, 2011, the FAA received the ARC's final report, which included recommendations to revise Part 121 and other associated regulations regarding minimum flight simulator fidelity requirements and icing training. Pending our review of a plan to address these recommendations, Safety Recommendations A-II-46 and -47 are classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/22/2011
Response: CC# 201100334: - From J. Randolph Babbitt, Administrator: As a result of Public Law 111-216, an ARC was chartered in September 2010, to address stick pusher and adverse weather event training, as defined in section 208(b) of Public Law 111-216. The objectives of this ARC include "identifying best goals, procedures, and training practices that will enable air carrier pilots to accurately and consistently respond to unexpected icing conditions." The scope of the ARC specifically includes recommendations to part 121 and other associated regulations as may be required to comply with the intent of section 208(b) of Public Law 111-216. Flight simulation is an integral component of pilot training and associated training for in-flight icing conditions. The ARC presented its final report and recommendations to the FAA on July 11, 2011. The report includes recommendations on minimum flight simulator fidelity requirements, as defined in 14 CFR part 60. It also incorporated recommendations for icing training. The FAA is reviewing the report and its recommendations to determine its next step. I will keep the Board informed of the FAA's progress and provide an updated response to these recommendations by October 2012.

From: NTSB
To: FAA
Date: 7/15/2011
Response: Notation 8106A: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration's (FAA) supplemental notice of proposed rulemaking (SNPRM) titled "Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers," published at 76 Federal Register 29336-29526 on May 20, 2011. The notice proposes to amend the regulations for flight and cabin crewmember and aircraft dispatcher training programs in domestic, flag, and supplemental operations. The proposed regulations are intended to contribute significantly to reducing aviation accidents by requiring the use of flight simulation training devices (FSTD) for flight crewmembers and including additional training and evaluation requirements for all crewmembers and aircraft dispatchers in areas that are critical to safety. The proposal also reorganizes and revises the qualification, training, and evaluation requirements. The SNPRM is based on the FAA's review of comments submitted in response to the January 12, 2009, notice of proposed rulemaking (NPRM) on these issues and its determination that the NPRM did not adequately address or clarify some topics; it is also based on provisions of the Airline Safety and Federal Aviation Administration Extension Act of 2010. The NTSB believes that developments in simulators in response to Safety Recommendation A-11-46 will be necessary before the actions in Safety Recommendation A-11-47 can be taken. However, the NTSB also believes that once simulators with improved ability to provide training for icing encounters are available, the requirements proposed in the SNPRM will provide the FAA needed authority to require that these improved simulators be used for pilot training.