Safety Recommendation A-88-041
Details
Synopsis: ON NOVEMBER 23, 1987, AT 6:25 P.M., ALASKAN STANDARD TIME, RYAN AIR SERVICE, INC., (RYAN AIR) FLIGHT 103, A BEECHCRAFT 1900C, N401RA, WITH 2 FLIGHT CREWMEMBERS AND 19 PASSENGERS ON BOARD, CRASHED SHORT OF RUNWAY 3 AT HOMER AIRPORT, HOMER, ALASKA. FLIGHT 103 WAS A REGULARLY SCHEDULED 14 CFR PART 135 FLIGHT OPERATING BETWEEN KODIAK AND ANCHORAGE, ALASKA, WITH INTERMEDIATE STOPS AT HOMER AND KENAI, ALASKA. SIXTEEN PASSENGERS AND THE TWO FLIGHT CREWMEMBERS WERE FATALLY INJURED. THREE PASSENGERS RECEIVED SERIOUS INJURIES.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: AMEND 14 CFR PART 135 TO REQUIRE THAT COMMUTER AIR CARRIER CERTIFICATE HOLDERS MAINTAIN, FOR AT LEAST 90 DAYS, COPIES OF THE COMPLETED LOAD MANIFEST AND THE WEIGHT AND BALANCE DOCUMENTATION THAT SUPPORT THE CALCULATED TOTAL WEIGHT OF THE AIRCRAFT AND ITS CENTER OF GRAVITY LOCATION.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: HOMER, AK, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA88MA005
Accident Reports:
Report #: AAR-88-11
Accident Date: 11/23/1987
Issue Date: 3/14/1988
Date Closed: 4/11/1990
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 4/11/1990
Response: Thank you for the FAA's December 8, 1989, response to Safety Recommendation A-88-41, which proposes a requirement for Title 14 Code of Federal Regulations (CFR) Part 135 operators to maintain copies of load manifest and weight and balance documentation for 90 days. The Safety Board has previously agreed with the FAA position that problem areas in Part 135 operations include incorrect data, omissions, failure to compute maximum allowable takeoff weight, and operations manuals that either lack or do not have adequate weight and balance procedures. The FAA states in the current response that weight and balance is a subject being discussed within the current series of Principal Operations Seminars. The letter closes by stating that "the real safety issue is the manner in which the operator manages its weight and balance program and the effectiveness of the FAA surveillance programs." In the last 2 years, the Safety Board has investigated a number of accidents involving operations conducted under 14 CFR Part 135. We have reviewed accident rates for aircraft where Part 135 weight and balance procedures were an issue. These investigations and reviews lead to two conclusions. First, operators should improve their weight and balance programs. Enclosed is a list of nine accidents involving aircraft under Part 135 operations from the two most recent years of complete data, 1987 and 1988. There were 53 people involved in these accidents, and of that total, 23 sustained fatal injuries and 16 sustained other than fatal injuries. It is significant that in at least seven of the nine accidents in these 2 years, the pilots either definitely knew or possibly knew of their operations being outside weight and balance limits. The second conclusion is that the FAA should improve its operational surveillance programs, which cover far more than just weight and balance. Problems with FAA surveillance have been discussed in the Safety Board's reports of the Air New Orleans (Continental Express flight 962) accident on May 26, 1987, the Ryan Air Service flight 103 accident on November 23, 1987, and the Avair flight 3378 accident on February 19, 1988. The enclosed list of accidents is restricted to only those Part 135 accidents investigated by the Safety Board that resulted in formal aircraft accident reports. In at least two cases (N401RA and N76Q), the FAA knew beforehand of improper activities by the aircraft operators. Each of the other seven accidents involved an operator conducting business under FAA surveillance. The Safety Board concludes that the operator and FAA surveillance programs regarding weight and balance are not adequate and that the FAA's actions have not satisfied the intent of the recommendation. As the FAA considers this action to be completed, Safety Recommendation A-88-41 has been classified as "Closed--Unacceptable Action."

From: FAA
To: NTSB
Date: 12/8/1989
Response: The FAA has reviewed the Safety Board's weight and balance incident and accident data and the National Aviation Safety Inspection Program's (NASIP) weight and balance findings cited by the Safety Board. The FAA agrees that the weight and balance issue is an important operational and safety element, and that accurate, well documented procedures are mandatory for all 14 CFR Part 135 flights. As a result of the NASIP findings and the FAA's analysis of 14 CFR Part 135 weight and balance procedures, the FAA conducted a Part 135 Principal Operations Seminar in December 1988. The purpose of the seminar was to discuss the problem areas identified during the inspection program. At the conclusion of the seminar, the principal operations inspectors were directed to visit their respective operators for the purpose of sharing the information contained in the inspection report and to initiate corrective action programs as necessary. The FAA has conducted nine seminars in various locations around the United States to reinforce FAA inspector surveillance requirements for 14 CFR Part 135 operators. The FAA will continue to direct a specific effort to improve the weight and balance programs of all commuter air carrier certificate holders through similar seminars, by stressing the subject during routine surveillance and through management emphasis within the flight standards organization. The FAA believes that these positive, constructive efforts will produce accurate and complete manual guidance, training programs, and proper execution of weight and balance procedures. I believe that the recognition of weight and balance issues is an important safety concern and the very specific measures taken by the FAA will satisfy the intent of this safety recommendation and will improve the overall quality of commuter air carriers. The FAA requires 14 CFR Part 135 operators to maintain weight and balance records for 30 days in order to ensure that an adequate sample of records are available for surveillance purposes. The FAA has found that a 30-day sample provides a sufficient basis to determine the strengths and shortcomings of an operator's weight and balance program and to make a judgment of the quality of the operator's effort in this area. I do not believe that a regulatory action which would require operators to maintain weight and balance records for 90 days would improve the safety or efficiency of the airline. The real safety issue is the manner in which the operator manages its weight and balance program and the effectiveness of the FAA surveillance programs. I am confident that the accomplishments of the FAA on this subject is resulting in improved weight and balance programs within the 14 CFR Part 135 industry. I believe that FAA's ongoing actions satisfy the intent of this safety recommendation, and I request that it be closed as "acceptable" action.

From: NTSB
To: FAA
Date: 7/19/1989
Response: Thank you for the FAA's May 1, 1989, response to Safety Recommendation A-88-41, which concerns a requirement for Title 14 Code of Federal Regulations (CFR) Part 135 operators to maintain copies of load manifests and weight and balance documentation for 90 days. The National Transportation Safety Board notes that even though the FAA survey found problem areas in Part 135 operations, including incorrect data, omissions, failure to compute maximum allowable takeoff weight, and operations manuals with inadequate or lack of weight and balance procedures and that the FAA inspection program indicates that there would be no benefit derived from keeping records for 90 days, the Safety Board still believes that if operators knew that records would be open for inspection, there would be incentive for greater accuracy. This is further justified by the results of the National Aviation Safety Inspection Program (NASIP), which found weight and balance considerations to be the third greatest source of operational findings and fifth greatest source of airworthiness findings. As a result of a May 12, 1989, meeting with FAA staff, the Safety Board staff agreed to provide data on weight and balance accidents and incidents in Part 135 operations. A computer search of the years 1967 through 1988 revealed that Part 135 operators average 9.5 accidents and incidents per year where weight and balance is causal or a factor, resulting in an annual average of 16.73 fatalities and 14.27 other injuries. The Safety Board believes that the information on the enclosed Table A will add justification to Safety Recommendation A-88-41. The FAA staff also questioned the Safety Board staff at the May 12 meeting, as to whether the incidents and accidents indicated that the problem was systemic to Alaska and/or single-engine aircraft. The data indicate that Alaska was over represented, with about one quarter of the weight and balance accidents, especially in light of hours flown. Single-engine aircraft represented 35.4 percent of the total data and are involved in two-thirds of the Alaska cases (which is notably opposite of the conterminous U.S. cases). The qualitative comparison value of this information is unknown without data regarding normal single- versus multi-engine usage (See enclosed Table B). The Safety Board believes that Part 135 operators should have the same responsibility to record and retain complete center of gravity calculations as required of Part 121 operators. The present Part 135 load manifest requirements do not require pilots to record complete weight and balance calculations. Requiring retention of these calculations would necessitate that pilots perform them, and assist in assuring compliance with existing regulations. This requirement should alleviate some of the problems revealed in the NASIP findings. Additionally, the Safety Board believes that the load manifests required by 14 CFR Part 135 should be retained for 90 days, the same requirement as for Part 121 operators. The NASIP and Safety Board information found weight and balance problems to be greater than anticipated. Due to the new information, the Safety Board requests that the FAA review its position with respect to Safety Recommendation A-88-41. Pending further information, Recommendation A-88-41 has been classified as "Open-- Unacceptable Action."

From: FAA
To: NTSB
Date: 5/1/1989
Response: THE FAA COMPLETED ITS SPECIAL INSPECTION PROGRAM OF COMMUTER AIR CARRIERS CERTIFICATED UNDER 14 CFR PART 135. I HAVE ENCLOSED A COPY OF THE REPORT FOR THE BOARD'S INFORMATION. THE RESULTS OF THE INSPECTION PROGRAM INDICATE THAT THERE IS NO SIGNIFICANT BENEFIT IN REQUIRING OPERATORS TO MAINTAIN WEIGHT AND BALANCE RECORDS FOR 90 DAYS AS REQUESTED BY THIS SAFETY RECOMMENDATION. THE PROBLEM AREAS IDENTIFIED DURING THE REVIEW CENTERED AROUND OMISSIONS, INCORRECT DATA, FAILURE TO COMPLETE MAXIMUM ALLOWABLE TAKEOFF WEIGHT IN LOAD MANIFESTS, AND INADEQUATE OR LACK OF WEIGHT AND BALANCE PROCEDURES IN OPERATIONS MANUALS. THE FAA BELIEVES THAT THESE PROBLEMS ARE DIRECTLY RELATED TO THE NEED TO USE ACCURATE AND COMPLETE MANUAL GUIDANCE, TRAINING, AND AUDIT AS THE PRINCIPAL MEANS TO ENSURE WEIGHT AND BALANCE PROCEDURES ARE CARRIED OUT PROPERLY AND SAFELY. THE FAA CONDUCTED A PART 135 PRINCIPAL OPERATIONS SEMINAR IN DECEMBER 1988, TO DISCUSS THE PROBLEM AREAS IDENTIFIED DURING THE INSPECTION PROGRAM. AT THE CONCLUSION OF THE SEMINAR, THE PRINCIPAL OPERATIONS INSPECTORS WERE DIRECTED TO VISIT THEIR RESPECTIVE OPERATORS FOR THE PURPOSE OF SHARING THE INFORMATION CONTAINED IN THE INSPECTION REPORT AND INITIATE CORRECTIVE ACTION PROGRAMS AS NECESSARY. THE FAA IS SCHEDULED TO CONDUCT AN ADDITIONAL SEVEN SEMINARS IN VARIOUS LOCATIONS AROUND THE UNITED STATES TO REINFORCE FAA INSPECTOR SURVEILLANCE REQUIREMENTS FOR 14 CFR PART 135 OPERATORS. I CONSIDER THE FAA'S ACTION TO BE COMPLETED, AND I PLAN NO FURTHER ACTION ON THIS SAFETY RECOMMENDATION.

From: NTSB
To: FAA
Date: 6/20/1988
Response: The Safety Board will hold this item in abeyance and consider it as an "Open-- Acceptable Action" until January 9, 1989. We would appreciate being kept aware of the progress of the FAA inspections.

From: FAA
To: NTSB
Date: 5/20/1988
Response: THE FAA IS IN THE PROCESS OF CONDUCTING INDEPTH INSPECTIONS OF APPROXIMATELY 30 COMMUTER AIR CARRIER CERTIFICATE HOLDERS SELECTED FROM APPROXIMATELY 173 OPERATORS. AS SOON AS THE INSPECTIONS ARE COMPLETED, THE FAA WILL REVIEW THE DATA AND MAKE A DETERMINATION AS TO A REGULATORY CHANGE. IT IS ANTICIPATED THAT THE FINAL REPORT WILL BE COMPLETED BY 1/1/89. I (MCARTOR) WILL KEEP THE BOARD APPRISED OF THE FAA'S PROGRESS ON THIS RECOMMENDATION.