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Safety Recommendation Details

Safety Recommendation A-14-110
Details
Synopsis: On March 15, 2012, about 0740 Atlantic standard time, a Convair CV-440-38, N153JR, operated by Fresh Air, Inc., crashed into a lagoon about 1 mile east of the departure end of runway 10 at Luis Muñoz Marín International Airport (SJU), San Juan, Puerto Rico. The two pilots died, and the airplane was destroyed by impact forces. The airplane was operated under the provisions of 14 Code of Federal Regulations (CFR) Part 1251 as a cargo flight. Visual meteorological conditions prevailed at the time of the accident, and a visual flight rules flight plan was filed. The flight had departed from runway 10 at SJU destined for Princess Juliana International Airport, St. Maarten. Shortly after takeoff, the first officer declared an emergency, and then the captain requested a left turn back to SJU and asked the local air traffic controllers if they could see smoke coming from the airplane (the two tower controllers noted in postaccident interviews that they did not see more smoke than usual coming from the airplane). The controllers cleared the flight to land on runway 28, but as the airplane began to align with the runway, it crashed into a nearby lagoon (Laguna La Torrecilla).
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Evaluate the effectiveness of your 14 Code of Federal Regulations (CFR) Part 125 oversight program and ensure that 14 CFR Part 125 operations are conducted at the same level of safety as that of Parts 121 and 135.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Aviation
Location: San Juan, PR, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA12FA051
Accident Reports: Crash Following In-Flight Fire Fresh Air, Inc. Convair CV-440-38, N153JR
Report #: AAR-14-04
Accident Date: 3/15/2012
Issue Date: 12/2/2014
Date Closed:
Addressee(s) and Addressee Status: FAA (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 10/3/2018
Response: -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 (per§ 125.287(a)): 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.

From: NTSB
To: FAA
Date: 4/8/2015
Response: In your letter, you reviewed the relevant findings from our investigation of the Fresh Air accident that support these recommendations. Your plan to review the practices employed by your field offices in their oversight of Part 125 certificate holders, including any needed revisions to FAA Order 1800.560, “National Flight Standards Work Program Guidelines,” will constitute an effective initial step in responding to these recommendations. Pending completion of the review and implementation of all needed revisions that you identify, Safety Recommendations A-14-110 through -112 are classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 1/30/2015
Response: -From Michael P. Huerta, Administrator: The first part of the recommendation calls for the Federal Aviation Administration (FAA) to evaluate the effectiveness of its Title 14, Code of Federal Regulations (14 CFR) Part 125 oversight program. This is based on the Board's concerns resulting from its investigation of this accident. Specifically, the Board found that many of the pilot records were incomplete or missing. These records included: • Copies of any training materials provided to Convair CV -440 pilots by Fresh Air or any contracted training program; • First officer employment records (per General Operations Manual, chapter 3, page 2); • 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); • Evidence of authority from the Principal Operations Inspectors to allow Tiger Contract Cargo pilots to conduct proficiency checks of Fresh Air pilots; • Evidence of a check airman observation for the captain from 2005 through 2011 , on either Fresh Air's Convair CV-440 or Douglas DC-4; • Evidence of oral or written evaluation for 2011 for the captain on the Convair CV -440 (per§ 125.287(a)); • Evidence of pi lot in command competency check for 201 1 for the captain on the Convair CV-440 (per§ 125.287(b)); and • Evidence of instrument proficiency for 2011 for the captain on the Convair CY -440 (per §125.29 1). In addition, the Board found missing or incomplete records related to Fresh Air's operations and airworthiness practices. These records included: • Status of aircraft (total flight hours and flight cycles at the time of the accident) and Fresh Air master log (flight and maintenance log); • Status of all airworthiness directives and service bulletins incorporated in the accident airplane; • All engine and propeller maintenance records, including part and serial numbers, times since overhaul, and when removed/replaced; • Listing of all supplemental type certificates incorporated on the accident airplane and when accomplished; • Status of the continuous airworthiness maintenance program (for example, all times for when an A-, B-, C-, or D-check or an airframe, propeller, or engine overhaul was performed); • List of all major repairs and alterations to the accident airplane; • Status of all time-limited components on the accident airplane; • Service difficulty reports submitted to the FAA, if any; • Minimum equipment lists present during the accident flight, if any; and • All mechanic training records. The FAA shares the Board's concerns regarding this matter. The part 125 oversight program is addressed in FAA Order 1800.560, National Flight Standards Work Program Guidelines. At a minimum, this accident compels the FAA to review this order to determine its adequacy in meeting the oversight needs of the part 125 community. Moreover, the FAA plans to take a critical look at the oversight practices employed by its field offices in the oversight of part 125 certificate holders. The second part of the recommendation calls for the FAA to " ... ensure that 14 CFR Part 125 operations are conducted at the same level of safety as that of parts 121 and 135 ." While the part 125 rule was not written to establish a level of safety equal to that of parts 121 and 135, the FAA recognizes that adherence to internal policies for the oversight of part 125 certificate holders must be done with a comparable sense of urgency. As a result, the FAA will not only review its oversight practices as stated above, but plans to also work with industry operators and advocacy groups alike to identify opportunities to improve our oversight methodology.