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Safety Recommendation Details

Safety Recommendation A-14-111
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: Require all principal operations inspectors of 14 Code of Federal Regulations Part 125 certificate holders to conduct at least one en route inspection annually on each airplane type operated by the certificate holder.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
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: 7/19/2019
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/19/2019
Response: We disagree that your existing policies regarding en-route inspections of Part 125 certificate holders are adequate and ensure compliance and safety. Our investigation found that FAA personnel had not conducted line checks or en-route inspections on any Fresh Air airplane from when the POI began his oversight of Fresh Air in 2007 until the accident in 2012. The POI relied on main base and manual procedures inspections at Fresh Air’s main office in Davie, Florida, to review Fresh Air’s pilot records, maintenance records, and manuals. When asked how he would know if Fresh Air was flying in accordance with its general operations manual, OpsSpecs, and the Convair CV 440 airplane flying manual (AFM), the POI said that he relied on the pilot/owner of the company, who was the only FAA check airman to conduct authorization rides, to provide information about the operation. A former Part 125 POI told us that “there would be no way to know if an operator was operating in accordance with their OpsSpecs and flight manual limitations unless you visited the operation in person and conducted en-route observations.” We believe that en-route inspections provide the FAA an opportunity to verify that an operation complies with operational regulations, the operator’s FAA-approved procedures, and the limitations outlined in the FAA-approved AFM. Operations conducted under Parts 135 and 121 incorporate these annual en-route inspections into their line checks, which also include pilot in command observation to ensure that he or she satisfactorily performs his or her duties and responsibilities under the regulations. It is of little value for the FAA to ensure that an operator complies with proper pilot records and manual requirements if the FAA does not ensure that flight crews are applying those procedures and limitations during actual airplane operation. However, because you indicated that your actions in response to this recommendation are complete, Safety Recommendation A-14-111 is classified CLOSED--UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 10/3/2018
Response: -From Daniel K. Elwell, Acting Administrator: In our previous letter, dated January 30, 2015, we also noted that the current oversight program for part I 25 operations, as codified in FAA Order 1800.56P, National Flight Standards Work Program Guidelines, allows for the conduct of en route inspections at the discretion of the POI. It also prescribes the circumstances under which such an inspection would be advantageous, and that POIs may use the Oversight Prioritization Tool to determine when adjustment to inspection intervals may be needed. Given the resources (in terms of staff availability) necessary to implement this recommendation, we determined it would be cost prohibitive to undertake additional en route inspections beyond those currently mandated by FAA policy. For example, the FAA currently oversees 79 part 125 certificate holders, which is greater than the number of overseen part 12 I operators. We conducted a review of FAA records and determined that these part I 25 operators fly over 30 aircraft types, including a number of variants in many cases. It is therefore likely that increasing the number of inspections would divert critical resources from other safety-related duties, unless they are driven by specific safety concerns. We also determine that the public is better served by allowing its inspectors to determine when it is appropriate to conduct additional en route inspections based on proven criteria and guidance. If a POI determines that specific risk factors may be present when conducting required inspection items outlined in FAA Order 1800.56P, the FAA's current policies and procedures allow the POI to conduct additional surveillance to ensure the operator is in compliance and that observed risk elements are mitigated. This process applies equally to en route inspections. If an inspector determines an operator may require additional en route inspections based on observations of improper procedures or non-compliance, an inspector may conduct as many en route inspections as necessary to ensure proper procedures are used and compliance is maintained. As an Agency, we direct our resources and efforts toward those areas that yield the most significant improvements to aviation safety. Our evaluation of part 125 regulations and surveillance requirements determined that the FAA's current oversight methodology is sufficient to ensure compliance and safety. This includes our policies regarding the conduct of en route inspections of part I 25 certificate holders.

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 current oversight progran1 for part 125 operations, as codified in FAA Order 1800.560, National Flight Standards Work Program Guidelines, allows for the conduct of en route inspections at the discretion of the Principal Operations Inspector (POI). It also prescribes the circumstances under which such an inspection would be advantageous. In its investigation of this accident, the Board highlights a concern that since 2007, FAA personnel did not conduct any line checks or en route inspections on any Fresh Air airplanes. They also noted that: En route inspections are a critical part of the FAA oversight responsibility to ensure that pi lots and the operator properly adhere to the operational limitations and procedures outlined in the certificate holder's FAA-approved GOM and AFM. It is of little value for the FAA to ensure that an operator complies with proper pilot records and manual requirements if the FAA does not ensure that flight crews are applying those procedures and limitations during the actual operation of the airplane." While the order allows a POI to conduct additional surveillance, such as an en route inspection if he or she identifies a problem with an operator, this does not address the Board's underlying concern that absent an en route inspection, operational deficiencies may go unnoticed. The FAA acknowledges the validity of this concern. As with the previous recommendation, the FAA plans to review its oversight methodology (policies and procedures) and work collaboratively with industry to identify methods of improving compliance and safety.