-From Daniel K. Elwell, Acting Administrator: An effective oversight program must achieve two goals. First, it must address and mitigate, to an appropriate extent, the known risks associated with a specific type of operation. Second, it must ensure regulatory compliance and conformity with internal safety policies. The Federal Aviation Administration's (FAA) consistency in conducting its oversight program is a critical element in achieving both of these goals, and was the focus of the FAA' s efforts in responding to recommendation A-14-110.
In response to this recommendation, we conducted an overview of the FAA's internal guidance materials for the part 125 oversight program, found in the Flight Standards Information Management System and FAA Order 1800.56P, National Flight Standards Work Program Guidelines. Specifically, we sought to identify any areas where our oversight philosophy for part 125 certificate holders differed significantly from part 121 or 135 certificate holders.
We determined that our oversight of part 125 certificate holders includes elements consistent with our oversight of part 121 and 135 certificate holders, such as:
• A robust certification process that includes pre-application, formal application, document compliance, demonstration and inspection, and certification phases;
• The approval and monitoring of the operator's airplane inspection and engine maintenance programs;
• The review of airplane inspection and maintenance records;
• The review and acceptance of policies and procedures, and approval of maintenance inspection program manuals;
• The inspection of the operator's home base and other corporate facilities;
• The inspection of crewmember records;
• The conduct of periodic pilot proficiency checks;
• The conduct of enroute inspections;
• The evaluation of management personnel;
• The provision of proscriptive and risk-based inspection intervals;
• The evaluation and issuance of operating specifications; and
• The evaluation and approval of maintenance training programs, and pilot training associated with part 142 training centers.
Based on this evaluation, we conclude that the FAA has structural (policy) elements in place that ensure part 125 certificate holders conform to an appropriate regulatory framework similar to part 121 and part 135 operators.
In our review, we also focused equal attention on the qualification of the inspector workforce charged with the oversight of part 125 certificate holders. Our review concluded that inspectors whose duties include the oversight of part 125, 121 , or 135 certificate holders must meet the same qualification standards commensurate with their duties and responsibilities.
For example, all aviation safety inspectors must hold advanced pilot ratings and certificates and must pass an initial flight check before being hired by the FAA. All inspectors must then successfully complete a string of indoctrination courses before being assigned to a Flight Standards District Office (FSDO).
Once there, all inspectors undergo a period of apprenticeship under the guidance of more experienced inspectors and supervisory staff. During this time, inspectors are made familiar with their regulatory and oversight duties, including the oversight of air certificate holders (parts 125, 121 , 135, etc.) as appropriate. Inspectors must also be currently qualified in the aircraft used by the operators they oversee, including holders of part 125, 121, and 135 certificates. The FAA expends considerable resources each year to ensure its safety inspectors are able to meet these standards.
Based on this review, we determined that current policies and qualifications standards of the FAA's inspector workforce are sufficiently effective to oversee part 125 operations and ensure a level of risk-based oversight consistent among all certificate holders.
Regarding the specific accident addressed by this recommendation, the Board identified a number of concerns that called into question the efficacy of the F AA's oversight of Fresh Air's operations. We reviewed the records identified by the Board as missing or incomplete and addressed each record as follows:
• Copies of any training materials provided to Convair CV-440 pilots by Fresh Air or any contracted training program:
We note that part 125 does not require training materials to be provided to pilots, and that the only contracted training programs approved for part 125 pilot training is contracted through part 142 Training Centers. These centers provide pilot training materials and records on behalf of the company. Jn our letter dated January 30, 2015, we noted that the part 125 rule was not written to achieve a level of safety equal to that of parts 121 and 135. Instead, as with all regulations, part 125 was intended to establish a level of safety commensurate with the operational realities of the regulated community, as well as the expectations of the public at large. That is not to say that the FAA takes a more casual approach to its oversight of part 125 certificate holders. We assert that the mitigation of known risks, consistent with the public's expectations, can only be achieved through an effective oversight regimen. In that regard, our philosophy is consistent among all certificate holders;
• First officer employment records (per General Operations Manual (GOM), chapter 3, page 2):
We note that part 125 also does not require a GOM, only a policy and procedures manual, which is reviewed and accepted;
• Copy of the captain's FAA check airman letter of authority to conduct check rides for Fresh Air (per FAA Order 8900.1 , Chg 45, volume 3, section 3-1456):
We note that the section cited applies to the approval of part 142 Training Center personnel, and is not applicable to company check airmen;
• Evidence of authority from the Principal Operations Inspector (POI) to allow Tiger Contract Cargo pilots to conduct proficiency checks of Fresh Air pilots:
We note that Tiger Contract Cargo pilots must be authorized and designated as check airmen for the company that employs the pilot. There is no authority for another company check airman to conduct checks unless the POI has designated the check airman the authority to conduct checks for the company, in this case for Fresh Air;
• Evidence of a check airman observation for the captain from 2005 through 2011 , on either Fresh Air's Convair CV-440 or DC-4:
Although this is a yearly requirement under the FAA's policy, the captain was not conducting check airman duties on the day of the accident, and our review found no evidence that the captain was conducting check pilot activities; • Evidence of oral or written evaluation for 2011 for the captain on the Convair CV-440
We note that the Certificate Management Team (CMT) stated the captain's§ 125.287(a)
check was current and complete and verified via the proper documentation.
• Evidence of pilot in command competency check for 201 l for the captain on the Convair CV-440 (per§ 125.287(b)):
We note that the CMT stated the captain's§ 125.287(b) check was current and complete and verified by the proper documentation.
• Evidence of instrument proficiency for 2011 for the captain on the Convair CY-440 (per § 125.29 1):
We note that the flight was conducted in visual meteorological conditions (VMC) and on a visual flight rules (VFR) Flight Plan. The requirement for completion of the § l 25.29 l instrument proficiency check is for conducting flight operations under instrument flight rules.
Since the flight was conducted under VMC conditions and on a VFR flight plan on the day of the accident, the rule does not require a current § l 25.291 instrument proficiency check. In response to the missing or incomplete records related to Fresh Air's operations and airworthiness practices (as identified by the Board), the FAA more closely examined our oversight of the operator.
Our review included a look at inspection data, and found that the FAA conducted 2753 operations and maintenance inspections of part 125 operators from 2011-2014. The breakdown on the timing of these inspections is as follows:
• 2011 - 713;
• 2012 - 684;
• 2013 - 596; and
• 2014 - 760 .
With regard to the maintenance findings, the CMT noted that aircraft records met the minimum standards, and were avai lable at the operator's primary business address. The operator was unable to produce the records for the Supplemental Type Certificate conversion, but the actual conversion was verified by the CMT. We note that aircraft records that were kept at Fresh Air's principal base, the deceased captain's home, were difficult to access. We also note that the operator's other aircraft, a Douglas DC-4, had a nose gear collapse which caused the operator to cease operations approximately I 0 days after the accident prompting this recommendation.
However, the Orlando FSDO increased surveillance of the operator to ensure both operations and maintenance records were complete and in compliance. The operator ceased operations as a part l 25 operator in March 2012, and the FAA revoked the company's part l 25 certificate in 2015.