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Safety Recommendation Details

Safety Recommendation A-16-035
Details
Synopsis: On November 10, 2015, about 1453 eastern standard time, Execuflight flight 1526, a British Aerospace HS 125-700A (Hawker 700A), N237WR, departed controlled flight while on a nonprecision localizer approach to runway 25 at Akron Fulton International Airport (AKR) and impacted a four-unit apartment building in Akron, Ohio. The captain, first officer, and seven passengers died; no one on the ground was injured. The airplane was destroyed by impact forces and postcrash fire. The airplane was registered to Rais Group International NC LLC and operated by Execuflight under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as an on-demand charter flight. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The flight departed from Dayton-Wright Brothers Airport, Dayton, Ohio, about 1413 and was destined for AKR.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: After the action in Safety Recommendation A-16-34 is completed, require all 14 Code of Federal Regulations Part 135 operators to establish a structured flight data monitoring program that reviews all available data sources to identify deviations from established norms and procedures and other potential safety issues.
Original recommendation transmittal letter: PDF
Overall Status: Open Acceptable Alternate Response
Mode: Aviation
Location: Akron, OH, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: CEN16MA036
Accident Reports: Crash During Nonprecision Instrument Approach to Landing Execuflight Flight 1526 British Aerospace HS 125-700A, N237WR
Report #: AAR-16-03
Accident Date: 11/10/2015
Issue Date: 11/3/2016
Date Closed:
Addressee(s) and Addressee Status: FAA (Open Acceptable Alternate Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 3/28/2019
Response: From the Aircraft Accident Report: “Departure from Controlled Flight Trans-Pacific Air Charter, LLC, Learjet 35A, N452DA, Teterboro, New Jersey, May 15, 2017.” Report Number AAR-19-02, Notation 58039, adopted March 12, 2019 and published March 28, 2019, PB2019-100271: Section 2.4 Flight Data Monitoring As discussed in sections 2.2 and 2.3, the flight crew repeatedly deviated from company policy and procedures. If the flight had not ended in an accident, Trans-Pacific would not have a way to identify this crew’s deviations from policy and SOPs, and the company had no way to determine whether this (or any) crew’s previous operations were conducted in accordance with company policy and SOPs. As discussed in the NTSB’s report on a 2014 accident involving a Gulfstream G-IV at BED, procedural drift and normalization of procedural deviance can pose a significant threat to the safety of flight operations, particularly for small operators (including Trans-Pacific) with limited operational oversight and consistent crew pairings (NTSB 2015). Flight data monitoring (FDM) can be a very useful tool for combating these problems.52 As a result of an increase in fatal helicopter air ambulance (HAA) accidents in 2008, the NTSB recommended that the FAA “require helicopter emergency medical services operators to install flight data recording devices and establish a structured flight data monitoring program that reviews all available data sources to identify deviations from established norms and procedures and other potential safety issues” (Safety Recommendation A-09-90). On February 21, 2014, the FAA issued a comprehensive final rule, “Helicopter Air Ambulance, Commercial Helicopter, and Part 91 Helicopter Operations” (79 Federal Register 9932), addressing many aspects of these operations. The final rule included 14 CFR 135.607, “Flight Data Monitoring System,” which required that helicopters used for Part 135 HAA operations be equipped with an approved FDM system capable of recording flight performance data (FAA 2014). However, the final rule did not require that all HAA operators establish an FDM program. In a November 1, 2017, response to Safety Recommendation A-09-90, the FAA said that it endorsed using voluntary flight operational quality assurance programs to continuously monitor and evaluate operational practices and procedures. However, because the protections provided in Part 193, “Protection of Voluntarily Submitted Information,” pertain only if data are collected by operators as part of a voluntary FAA-approved program, the FAA did not intend to initiate rulemaking to mandate that HAA operators establish FDM programs. In a January 25, 2018, response, the NTSB pointed out that the intent of Safety Recommendation A-09-90 was for HAA operators to establish an internal program that analyzes recorded FDM system data and monitors trends in their operations. Because the data collected would not need to be shared with the FAA, there would be no need to protect the data. Because the FAA did not intend to take any additional actions regarding this recommendation, the NTSB classified Safety Recommendation A-09-90 “Closed—Unacceptable Action.” During our investigation of the November 10, 2015, accident involving an Execuflight Hawker 700A that departed controlled flight while on an instrument approach to Akron Fulton International Airport, Akron, Ohio, the NTSB found that operational FDM programs could provide Part 135 operators with objective information regarding the manner in which their pilots conduct flights (NTSB 2016). Our investigation also found that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from company SOPs (NTSB 2016). Therefore, the NTSB recommended that the FAA “require all 14 Code of Federal Regulations Part 135 operators to install flight data recording devices capable of supporting a flight data monitoring program” (Safety Recommendation A-16-34). We also recommended that the FAA, “after the action in Safety Recommendation A-16-34 is completed, require all 14 Code of Federal Regulations Part 135 operators to establish a structured flight data monitoring program that reviews all available data sources to identify deviations from established norms and procedures and other potential safety issues” (Safety Recommendation A-16-35). In a January 9, 2017, response addressing Safety Recommendation A-16-34, the FAA stated that it would evaluate the costs and benefits of requiring all Part 135 operators to install flight data recording devices. The FAA also stated that, in advance of the 2014 rule change to 14 CFR 135.607, it conducted a similar study of the costs and benefits to require data recording devices for HAA operators. The FAA determined, through a financial analysis, that the proposed rule change “did not meet the cost-benefit requirements for safety” but noted that the proposed change, as mandated, applied only to Part 135 operators providing air ambulance services. In an April 6, 2017, response to the FAA, the NTSB expressed surprise that the FAA’s published regulatory evaluation of the rule change to 14 CFR 135.607 showed costs of about $20.4 million over a 10-year period but that the benefits determination amounted to $0. The NTSB’s response provided the results of our review of major aviation accident investigations from 2000 to 2015 involving Part 135 on-demand operators to identify accidents with findings related to pilot performance. The review identified seven such accidents in which a total of 53 people died and 4 people were seriously injured. Our response restated that an effective FDM program could help an operator identify issues with pilot performance (such as noncompliance with SOPs) and, through an SMS, could lead to mitigations that would prevent future accidents. The NTSB asked that the FAA, in its review of Safety Recommendation A-16-34, consider likely benefits from such a mandate instead of determining that there would be no quantifiable benefit. Pending completion of the FAA’s review and actions, the NTSB classified Safety Recommendation A-16-34 “Open—Acceptable Response.” In its January 9, 2017, response concerning Safety Recommendation A-16-35, the FAA stated that it planned to review Part 135 operators’ level of participation in voluntary programs and evaluate additional actions needed to increase the level of participation; however, the FAA also stated that “maintaining a voluntary nature is paramount to the success of [FDM] programs.” In our April 6, 2017, response, the NTSB stated that, based on our review of major aviation accident investigations involving Part 135 on-demand operators (as discussed above), FDM programs are not common among Part 135 operators; as a result, we disagreed that the implementation of voluntary programs was successful. The NTSB further stated that the FAA’s planned review might be a basis for an acceptable alternate action to satisfy Safety Recommendation A-16-35 if the review identified additional actions to encourage and periodically evaluate the level of Part 135 operators’ voluntary compliance. However, the NTSB cautioned that any acceptable response must measure the level of voluntary participation in FDM programs and must find widespread participation among Part 135 operators. Pending completion of the FAA’s review of its voluntary FDM programs and the identification and implementation of additional activities to encourage and measure Part 135 operators’ level of voluntary participation in FDM programs, the NTSB classified Safety Recommendation A-16-35 “Open—Acceptable Alternate Response.” Another recent accident investigation that demonstrated the benefits of FDM programs for Part 135 operators involved a Cessna 208B operated by Hageland Aviation Services, which collided with terrain in low-visibility conditions near Togiak, Alaska, on October 2, 2016 (NTSB 2018). The NTSB found that the company had safety programs in place—including an aviation safety action program (ASAP), an online internal reporting system, and an anonymous safety hotline—and that safety program deficiencies did not play a role in the accident.53 However, the investigation also identified two instances of the flight crew’s noncompliance with SOPs on the day of the accident that were not related to the accident and found that the company did not have a process to ensure compliance with SOPs and regulations. The NTSB concluded that operational FDM programs could provide Part 135 operators with objective information on how their pilots conduct flights and that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from company SOPs. As a result, the NTSB reiterated Safety Recommendations A-16-34 and -35 to the FAA. As with the operators involved in the accidents in BED, Akron, and Togiak, the NTSB’s investigation of the TEB accident found a Part 135 operator that had no means to monitor flights to identify and mitigate operational deficiencies (such as noncompliance with established SOPs) before the accident occurred. An FDM program would have enabled Trans-Pacific to identify issues, such as airspeed deviations and unstable approach profiles, and address them. Such a program could have led to corrective actions before the accident. Thus, the NTSB concludes that an FDM program could help Part 135 operators identify and mitigate procedural noncompliance, including the operational deficiencies identified in this accident investigation. Therefore, the NTSB reiterates Safety Recommendations A-16-34 and A-16-35. In addition, the NTSB notes that, on February 4, 2019, we announced our 2019-2020 Most Wanted List of Transportation Safety Improvements, and Safety Recommendations A-16-34 and -35 were associated with one of the issue areas on the Most Wanted List, “Improve the Safety of Part 135 Aircraft Flight Operations.”

From: NTSB
To: FAA
Date: 4/26/2018
Response: The following is from the NTSB Aviation Accident Report “Collision with Terrain Hageland Aviation Services, Inc. dba Ravn Connect Flight 3153 Cessna 208B, N208SD, Togiak, Alaska October 2, 2016.” Report number AAR-18-02. Adopted on April 17, 2018 and published on April 26, 2018. As a result of the Akron investigation (as well as others cited in that accident report), on November 7, 2016, the NTSB issued Safety Recommendation A-16-34 to recommend that the FAA require all Part 135 operators to install flight data recording devices capable of supporting an FDM program (NTSB 2016). The NTSB also issued Safety Recommendation A-16-35, which recommended that the FAA, after the action in Safety Recommendation A-16-34 was completed, require all Part 135 operators to establish a structured FDM program that reviews all available data sources to identify deviations from established norms and procedures and other potential safety issues (NTSB 2016). On January 9, 2017, the FAA said that it would conduct a review to determine the feasibility of requiring all Part 135 certificate holders to install FDM recording devices on their aircraft. The FAA noted that, in 2014, a similar review was conducted as part of the cost-benefit analysis (CBA) in the regulatory review associated with proposed rule changes to 14 CFR 135.607, “Flight Data Monitoring System,” associated with a final rule to improve the safety of HAA operations. In that review, the FAA determined that the proposed rule change did not meet the cost-benefit requirements of the Office of Management and Budget (OMB) for federal safety regulations. However, because the proposed change was mandated by Congress in Section 306(a) of the FAA Modernization and Reform Act of 2013, which specifically restricted the revised regulations to only Part 135 certificate holders providing air ambulance services, on February 21, 2014, the FAA published the “[HAA], Commercial Helicopter, and Part 91 Helicopter Operations” final rule, which contained 14 CFR 135.607 requiring FDM equipment for Part 135 HAAs to be equipped with an FDM system. In its January 9, 2017, letter, the FAA said that a key focus of its review for Safety Recommendation A-16-34 would be to determine the feasibility of achieving a favorable cost/benefit ratio if FDM recording devices were mandated for all Part 135 operators. On April 6, 2017, the NTSB responded that it had reviewed the FAA’s CBA in its regulatory evaluation associated with changes to 14 CFR 135.607. That review showed costs of about $20.4 million over a 10-year period; however, the NTSB was surprised to see that the benefits determination amounted to $0. The NTSB stated that it believed that an FDM program offers a great opportunity for operators to improve the safety of their operations and avoid accidents. A review of major NTSB investigations of accidents involving Part 135 on-demand operators between 2000 through 2015 (discussed above regarding Safety Recommendation A-16-36) identified seven accidents that killed 53 people and seriously injured 4. The NTSB believes that an effective FDM program can help an operator identify issues with pilot performance, such as noncompliance with SOPs, and, through an SMS, can lead to mitigations that will prevent future accidents. The NTSB does not believe that the FAA’s indication that there were no quantifiable benefits from a mandate for FDM equipment and programs is appropriate. In its response, the NTSB asked the FAA to consider in its planned review the likely benefits from such a mandate. Pending the FAA’s completion of the review and responsive actions, the NTSB classified Safety Recommendation A-16-34 “Open—Acceptable Response.” With regard to Safety Recommendation A-16-35, the FAA said in its January 9, 2017, letter that it planned to review Part 135 operators’ level of participation in voluntary programs and evaluate additional actions needed to increase it. On April 6, 2017, the NTSB replied that, based on the FAA’s review of Part 135 on-demand major accident investigations, the FAA believed that FDM programs were not common among Part 135 operators; the NTSB disagreed that the FAA’s voluntary programs were successful. The NTSB stated that, if the FAA identified additional actions to encourage and periodically evaluate the level of voluntary compliance, this might be the basis for an acceptable alternate action to satisfy this recommendation. The NTSB cautioned that any acceptable response must measure the level of voluntary participation in FDM programs and must find that there is widespread participation among Part 135 operators. Pending completion of the FAA’s review and the identification and implementation of additional activities to encourage and measure Part 135 operators’ level of voluntary participation in FDM programs, the NTSB classified Safety Recommendation A-16-35 “Open—Acceptable Alternate Response.” Hageland stated that it expected that its planned use of FOQA-type flight data recording devices and planned data monitoring department will “further enable [the company] to review compliance with company procedures through data analysis, similar to a Part 121 operation.” The use of flight data recording devices capable of supporting an FDM program, along with active participation in such a program, can enable a company to identify shortcomings and address them through training and additional procedural guidance before an accident occurs. FDM programs can be supported by a variety of flight data recording devices, including, but not limited to, the quick-access recorder and lightweight aircraft recording system, both of which can provide operators access to recorded flight data. These types of flight recording devices, when part of an operator program to review and analyze the data collected, can contribute to improvements in operational safety. The NTSB notes that some flight data recording devices include cockpit imaging and audio recording capabilities, which could help an operator identify hazards and develop risk mitigations associated with operating VFR flights in dynamic and/or deteriorating weather conditions, CRM challenges in the operational environment, and the use of the TAWS inhibit switch. Thus, the NTSB concludes that operational FDM programs can provide Part 135 operators with objective information on how their pilots conduct flights, and a periodic review of such information can assist operators in detecting and correcting unsafe deviations from company SOPs. Therefore, due the relevance of FDM programs (and flight data recording devices capable of supporting them) to the circumstances of this accident, the NTSB reiterates Safety Recommendations A-16-34 and -35.

From: NTSB
To: FAA
Date: 4/6/2017
Response: We note that you considered the recommended action during your rulemaking that resulted in the February 20, 2014, final rule regarding helicopter air ambulances. During this consideration, you determined that your voluntary programs successfully monitor and evaluate operational practices and procedures. We were not previously aware of this determination, and we ask that you provide more information on the analyses that you conducted and the results you found that support your determination. We are aware that, for FDM programs to be nonpunitive, they must be voluntary, and that if you were to require an FDM program under existing laws, operators would be subject to FAA enforcement action based on their FDM program findings. To address Safety Recommendation A-16-35, you plan to review Part 135 operators’ level of participation in voluntary programs and evaluate additional actions needed to increase it. Based on our review of Part 135 on-demand major accident investigations, described above, we believe that FDM programs are not common among Part 135 operators, and we disagree that your voluntary programs are successful. If your review can identify additional actions to encourage and periodically evaluate the level of voluntary compliance, this may be the basis for an acceptable alternate action to satisfy this recommendation. However, we caution that any acceptable response must measure the level of voluntary participation in FDM programs, and must find that there is widespread participation among Part 135 operators. Pending completion of your review, and the identification and implementation of additional activities to encourage and measure Part 135 operators’ level of voluntary participation in FDM programs, Safety Recommendation A 16-35 is classified OPEN—ACCEPTABLE ALTERANTE RESPONSE.

From: FAA
To: NTSB
Date: 1/9/2017
Response: -From Michael P. Huerta, Administrator: The FAA previously considered this issue as a part of the helicopter final rule. During this consideration, it was determined that the FAA's voluntary programs are successful for monitoring and evaluating operational practices and procedures. These programs are important to the FAA. However, we believe maintaining a voluntary nature is paramount to the success of flight data monitoring programs. To address this safety recommendation, we will conduct a review of the level of participation of part 135 certificate holders in voluntary programs and evaluate additional actions that can increase awareness and participation.