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Safety Recommendation Details

Safety Recommendation A-16-041
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: Review the Safety Assurance System and develop and implement procedures needed to identify 14 Code of Federal Regulations Part 135 operators that do not comply with standard operating procedures.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable 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: 11/7/2016
Date Closed:
Addressee(s) and Addressee Status: FAA (Open - Unacceptable 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 2.5 Operational Safety Programs 2.5.2 Procedural Compliance Although section 2.4 discussed the benefits of an FDM program, the NTSB recognizes that some procedural noncompliance, such as the flight crew’s apparent omission of programming the FMS with all of the approach waypoints, could be difficult to detect using FDR data. FAA Order 8900.1 states that en route inspections are another method for detecting deviations from SOPs. However, the POI responsible for Trans-Pacific’s oversight during the 6 years before the accident stated that his primary method of conducting oversight was by reviewing company records. The POI said that he had little first-hand knowledge of Trans-Pacific’s operations. He also stated that funding and logistical issues associated with scheduling en route inspections prevented him from conducting them and that he had never done an en route inspection of Trans-Pacific or any other Part 135 operator. Trans-Pacific did not have any Learjet-qualified check airmen on staff, so the POI conducted line checks for the company’s Learjet pilots (including the PIC’s line check on October 7, 2016). Because of logistical issues, these checks were conducted on short nonrevenue flights, and the POI stated that he did not know if company pilots were complying with SOPs during revenue flights. Thus, the NTSB concludes that, because the FAA was not conducting checks in a manner that allowed observation of routine flight operations, the FAA could not evaluate Trans-Pacific pilots’ compliance with SOPs during these operations. The impediments to conducting en route inspections and line checks mentioned by Trans-Pacific’s POI are neither unique nor new. As a result of our investigation of the July 31, 2008, East Coast Jets accident in Owatonna, Minnesota, the NTSB determined that Part 135 line checks were not adequate because they were not conducted on flights that represented typical revenue operations (NTSB 2011). The NTSB recommended the following to the FAA: Require that 14 Code of Federal Regulations Part 135 pilot-in-command line checks be conducted independently from other required checks and be conducted on flights that truly represent typical revenue operations, including a portion of cruise flight, to ensure that thorough and complete line checks, during which pilots demonstrate their ability to manage weather information, checklist execution, sterile cockpit adherence, and other variables that might affect revenue flights, are conducted. (Safety Recommendation A-11-30) On August 8 2013, the FAA responded that the action in Safety Recommendation A-11-30 would be logistically problematic and would increase the FAA’s workload without a corresponding improvement in safety. The FAA also asserted that current guidance to POIs concerning line checks was appropriate and stated that it planned no further action. Given this response, the NTSB classified Safety Recommendation A-11-30 “Closed—Unacceptable Action” on November 7, 2013. Lack of verification of procedural compliance remained a problem after the Owatonna accident. During the Akron accident investigation, the NTSB found multiple flight crew failures to comply with SOPs and noted that the FAA had never conducted an en route inspection of the operator. The accident report stated that, although the FAA’s new oversight system for Part 135 operators (SAS) had not been fully implemented at the time of the accident, SAS was “an opportunity to develop and use oversight procedures to identify and correct problems with failures of…Part 135 operators to use SOPs.”58 As a result, the NTSB recommended that the FAA “review the Safety Assurance System and develop and implement procedures needed to identify 14 Code of Federal Regulations Part 135 operators that do not comply with standard operating procedures” (Safety Recommendation A-16-41). In its January 9, 2017, response to the NTSB, the FAA indicated that it would conduct a review and make necessary corrective actions to the SAS to develop and implement a methodology to identify Part 135 certificate holders that either had or had not established procedures to ensure pilot compliance with SOPs. On April 6, 2017, pending the results of the FAA’s review and the development of effective procedures to ensure pilot compliance with Part 135 carriers’ SOPs, the NTSB classified Safety Recommendation A-16-41 “Open—Acceptable Response.” Although the NTSB notes that the FAA assesses pilot compliance with SOPs during line checks, the intent of Safety Recommendation A-16-41 was to ensure that the FAA used the SAS to develop a strategy to identify those Part 135 operators that do not have procedures promoting pilot adherence to SOPs. As of February 2019, the FAA had not provided the results of its SAS review to the NTSB and had not released any revisions to SAS to address pilot noncompliance with SOPs during Part 135 operations. The NTSB concludes that effective oversight procedures within the SAS would help the FAA identify operators that do not ensure flight crew compliance with SOPs. Therefore, the NTSB reiterates Safety Recommendation A-16-41. In addition, because of the FAA’s lack of action in this area since January 2017, the NTSB reclassifies Safety Recommendation A-16-41 OPEN—UNACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 4/6/2017
Response: We issued this recommendation because in the Akron accident, the FAA inspector assigned to Execuflight stated that he did not know what pilots did in normal operations because he only observed them during the line checks required by section 135.299. Had the inspector conducted en-route inspections of Execuflight flights, the failure to follow SOPs and other required flight deck procedures may have been discovered and corrected before the accident occurred. At the time of the accident, SAS had not yet been fully implemented for Part 135 operators. We concluded that implementing SAS was a way to develop and use oversight procedures to identify and correct Part 135 operators’ failure to use SOPs. We note that you agree with this recommendation and have initiated an SAS review. After this review is completed, you plan to revise the SAS to identify Part 135 certificate holders that have not established adequate SOPs and to ensure pilot compliance with the certificate holders’ SOPs. We point out that, to satisfy this recommendation, you must review oversight of pilot compliance with SOPs, as well as the existence and adequacy of a carrier’s SOPs. Pending the results of your review and the development of effective procedures to assure pilot compliance with Part 135 carriers’ SOPs, Safety Recommendation A-16-41 is classified OPEN--ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 1/9/2017
Response: -From Michael P. Huerta, Administrator: The FAA agrees with the intent of this safety recommendation and initiated a review of the Safety Assurance System (SAS). Upon completion of the review, the FAA will make the necessary corrective actions in the SAS to develop and implement a methodology to identify part 135 certificate holders that have or have not established procedures and to ensure pilot compliance with the certificate holder's SOPs.