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Safety Recommendation Details

Safety Recommendation A-78-029
Details
Synopsis: THE NATIONAL TRANSPORTATION SAFETY BOARD IS CONCERNED ABOUT THE NUMBER OF ACCIDENTS INVOLVING COMPLEX FIXED WING, MULTI-ENGINE AIRCRAFT IN AIR TAXI AND CORPORATE/EXECUTIVE OPERATIONS IN WHICH THE ACCIDENT CIRCUMSTANCES REMAIN UNKNOWN. OF THE 194 FATAL ACCIDENTS IN THESE OPERATIONS FROM 1970 TO 1977, CAUSE HAS NOT BEEN DETERMINED FOR 34 OF THE ACCIDENTS. IN ADDITION TO THE ACCIDENTS REFLECTED IN THE DATA IN ATTACHMENT 1, THE SAFETY BOARD HAS RECENTLY INVESTIGATED OR IS INESTIGATING FIVE OTHER ACCIDENTS IN THE CORPORATE/EXECUTIVE FLEET ALONE IN WHICH THERE APPEARS TO BE LITTLE HOPE OF DETERMINING DEFINITIVE CAUSE. THESE ACCIDENTS, WHICH HAVE OCCURRED WITHIN THE PAST 18 MONTHS, HAVE RESULTED IN 26 FATALITIES.
Recommendation: IN THE INTERIM, AMEND 14 CFR TO REQUIRE THAT NO OPERATION (EXC FOR MAINTENANCE FERRY FLIGHTS) MAY BE CONDUCTED WITH TURBINE-POWEREDAIRCRAFT CERTIFICATED TO CARRY SIX PASSENGERS OR MORE, WHICH REQUIRE TWO PILOTS BY THEIR CERTIFICATE, WITHOUT AN OPERABLE CVR CAPABLE OF RETAINING AT LEAST 10 MINUTES OF INTRACOCKPIT CONVERSATION WHEN POWER IS INTERRUPTED. SUCH REQUIREMENTS CAN BE MET WITH AVAILABLE EQUIPMENT TO FACILITATE RAPID IMPLEMENTATION OF THIS REQUIREMENT.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: Hot Springs, VA, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA76AZ039
Accident Reports: Johnson and Johnson, Inc., Grumman Gulfstream II, N500J
Report #: AAR-78-04
Accident Date: 9/26/1976
Issue Date: 4/13/1978
Date Closed: 8/30/1982
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 8/30/1982
Response: The board does not accept your assumption that cvr benefits accrue where safety improvements arise from accidents in which cause/factordata were obtainable from no source other than the cvr. We have never considered the information obtained from the cvr in isolation, but have used it primarily as a tool in uncovering (sometimes) subtle clues to assist us in determining probable cause and in making recommendations for preventing future accidents. More often than not, the raw cvr data has (1)provided extremely valuable clues to the cause, (2) allowed more rapid dissemination of safety information to operators, (3) established the sequence of events in the cockpit and the timing of critical events, and (4) in conjunction with the fdr, provided the basis for aircraft perform- ance analysis which, in turn, either uncovers or corroborates the probable cause and contributes to safety recommendations to prevent future accidents. . . . . Because of the factors discussed above, the safety board does not accept the faa's cost benefit analysis as demonstrating that its recommendation is not feasible. We are, therefore, classifying recommenda-tion a-78-29 as closed--unacceptable action.

From: FAA
To: NTSB
Date: 6/30/1982
Response: FAA LETTER: CVR BENEFITS ACCRUE WHERE SAFETY IMPROVEMENTS ARISE FROM ACCIDENTS IN WHICH CAUSE/FACTOR DATA WERE OBTAINABLE FROM NO SOURCE OTHER THAN THE CVR. WE FOUND THAT THE CVR EQUIPMENT MARGINALLY PAYS FOR ITSELF ONLY WHEN ASSUMING THAT INFORMATION GLEANED FROM CVR TAPES ALWAYS LEADS TO CORRECTIVE ACTIONS TAKEN. THE MORE PLAUSIBLE ASSERTION, THAT CVR RESULTS IN REMEDIAL ACTION IN SELECT INSTANCES, YIELDS A BENEFIT TO COST RATIO OF 0.4. WE AGREE THAT A CVR REQUIREMENT MAY PROVIDE A SOMEWHAT BETTER UNDERSTANDING OF EVENTS LEADING TO AN ACCIDENT, BUT APPEARS TO LACK SUFFICIENT ECONOMIC JUSTIFICATION.

From: NTSB
To: FAA
Date: 8/19/1981
Response: From the accident report of the Texasgulf Aviation, Inc. Lockheed Jetstar N520S near Westchester County Airport in White Plains, New York on February 11, 1981. The Board adopted this report on 8/19/1981. As a result of this accident and several others involving general aviation aircraft, the National Transportation Safety Board reiterates the following recommendations made to the Federal Aviation Administration on April 13, 1978: A-78-27, A-78-28, and A-78-29.

From: NTSB
To: FAA
Date: 2/24/1981
Response: We reiterated safety recommendations a-78-27 thru -29 because of our concern with the number of accidents involving complex multiengine general aviation aircraft about which the accident circumstances remain unknown. These recommendations dealt with the development and installa- tion of low-cost cockpit voice recorders and flight data recorders for use on complex fixed wings multiengine aircraft. The safety board is pleased to note that the faa is taking action to fulfill these recommendations and will keep us advised of their progress. Safety recommendations a-78-27 thru -29 are now classified in an open--acceptable action status.

From: FAA
To: NTSB
Date: 11/6/1980
Response: FEDERAL AVIATION ADMINISTRATION LTR: WE UPDATED THE STATUS OF THIS RECOMMENDATION IN OUR JULY 29, 1980, LETTER.

From: FAA
To: NTSB
Date: 7/29/1980
Response: FEDERAL AVIATION ADMINISTRATION LTR IN RESPONSE TO NTSB 5/1/80 LTR: IN PARTIAL FULFILLMENT OF THIS RECOMMENDATION, 14 CFR 135 WAS AMENDED, AS PUBLISHED OCTOBER 10, 1978, IN VOL. 43 FR 46742, TO REQUIRE UNDER SECTION 135.151 (COPY WAS FORWARDED) THAT NO PERSON MAY OPERATE A TURBOJET AIRPLANE HAVING A PASSENGER SEATING CONFIGURATION, EXCLUDING ANY PILOT SEAT, OF 10 SEATS OR MORE, UNLESS IT IS EQUIPPED WITH AN APPROVED COCKPIT VOICE RECORDER. IN FURTHER FULFILLMENT OF THIS RECOMMENDATION, THE FAA CURRENTLY IS DRAFTING AN NPRM WHICH WOULD REQUIRE UNDER PART 91, GENERAL OPERATING AND FLIGHT RULES, SEVERAL ADDITIONAL EQUIPMENT ITEMS, INCLUDING A CVR ON ALL MULTIENGINE TURBOJET AIRPLANES. THIS WOULD EXPAND THE COVERAGE UNDER SECTION 135.151 SINCE THERE WOULD BE NO MINIMUM SEATING REQUIREMENT SPECIFIED.

From: NTSB
To: FAA
Date: 7/22/1980
Response: From the special study of commuter airline safety from 1970-1979. The Board published this study on 7/22/1980. Based on the findings of this study, the Safety Board reiterates the following safety recommendations which were previously issued to the Federal Aviation Administration: A-79-80, A-79-81, A-78-27, A-78-28, and A-78-29.

From: NTSB
To: FAA
Date: 5/1/1980
Response:

From: NTSB
To: FAA
Date: 12/13/1979
Response: From the accident report of Inlet Marine, Inc. gates Learjet N77RS Century III, model 25C at Anchorage International Airport in Anchorage, Alaska on December 4, 1978. The Board adopted this report on 12/13/1979. As a result of this accident and several others involving general aviation aircraft, the National Transportation Safety Board reiterates the following recommendations to the Federal Aviation Administration: A-78-27, A-78-28, and A-78-29.

From: NTSB
To: FAA
Date: 10/2/1979
Response: Recommendations a-78-27 and 28 are being held in an open-- unacceptable action status until the faa takes some positive action towardtheir resolution. Recommendation a-78-29 is being held in an open-acceptable action status because we understand that regulatory action has been initiated. Since the safety board considers cvr's and fdr's to be invaluable tools in accident investigation, we would appreciate receiving an updated status report on all three recommendations.

From: NTSB
To: FAA
Date: 9/20/1979
Response: From the accident report of Champion Home Builders Company Gates Learjet 25B, N999HG in Sanford, North Carolina on September 8, 1977. The Board adopted this report on 9/20/1979. As a result of this accident and several others involving corporate jet aircraft, the National Transportation Safety Board reiterates the following recommendations to the Federal Aviation Administration: A-78-027, A-78-028, and A-78-029.

From: FAA
To: NTSB
Date: 6/30/1978
Response: FAA LTR: WE HAVE RECENTLY ESTABLISHED A REGULATORY PROJECT TO UPGRADE FAR 91. THE SUBSTANCE OF THE RECOMMENDATION WILL BE CONSIDERED FOR INCLUSION IN THE NOTICE OF PROPOSED RULEMAKING. WE PLAN TO ISSUE THE NPRM BY DECEMBER 31, 1978. (NTSB FOLLOWUP LETTERS DATED 10/2/79 AND 5/1/80).