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Safety Recommendation Details

Safety Recommendation A-90-135
Details
Synopsis: ON OCTOBER 28, 1989, ABOUT 1837 HAWAIIAN STANDARD TIME, ALOHA ISLANDAIR, FLIGHT 1712, A DE HAVILLAND DHC-6-300, TWIN OTTER, N707PV, COLLIDED WITH MOUNTAINOUS TERRAIN WHILE EN ROUTE ON A SCHEDULED PASSENGER FLIGHT FROM THE KAHULUI AIR PORT, MAUI, HAWAII TO KAUNAKAKAI AIRPORT, MOLOKAI, HAWAII. THE FLIGHT WAS CONDUCTED UNDER VISUAL FLIGHT RULES (VFR) AND UNDER THE PROVISIONS OF 14 CFR PART 135.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REQUIRE THAT SCHEDULED 14 CFR PART 135 OPERATORS DEVELOP AND USE COCKPIT RESOURCE MANAGEMENT PROGRAMS IN THEIR TRAINING METHODOLOGY BY A SPECIFIED DATE.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: HALAWA,MOLOKAI, HI, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA90MA005
Accident Reports: Aloha IslandAir, Inc., Flight 1712 DeHavilland Twin Otter, DHC-6-300, N707PV
Report #: AAR-90-05
Accident Date: 10/28/1989
Issue Date: 11/21/1990
Date Closed: 7/15/1996
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Crew Resource Management, Part 135, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/15/1996
Response: THE BOARD HAS BEEN SPECIFICALLY CONCERNED ABOUT THE COMPREHENSIVENESS OF AIR CARRIER CRM PROGRAMS. THE BOARD RECOGNIZES THAT THE FAA'S GUIDANCE ON THE SCOPE OF A COMPREHENSIVE CRM PROGRAM, PROVIDED TO AIR CARRIERS IN AC 120-51, HAS BEEN UPDATED IN RECOGNITIOIN OF ADVANCES IN THE STATE OF KNOWLEDGE ABOUT CRM & IN RESPONSE TO RECOMMENDATIONS FROM THE BOARD TO THE FAA. THE FAA'S TIMELY REVISIONS TO THE CRM AC (MOST RECENTLY, IN AC 120-51B & CHANGE 1 TO AC 120-51B) SHOULD ENSURE THAT AIR CARRIER CRM PROGRAMS ARE COMPREHENSIVE. BECAUSE OF THE FAA'S ADOPTION OF A FINAL RULE ON MANDATORY CRM TRAINING & THE FAA'S ADEQUATE GENERAL DEFINITION OF A COMPREHENSIVE CRM PROGRAM, THE BOARD CLASSIFIES A-94-196, A-94-2, A-92-77, & A-90-135, "CLOSED--ACCEPTABLE ACTION." HOWEVER, BASED ON SAFETY ISSUES PREVIOUSLY IDENTIFIED BY THE BOARD IN ITS ACCIDENT INVESTIGATIONS, THE BOARD ENCOURAGES THE FAA TO PROVIDE ADDITIONAL GUIDANCE TO AIR CARRIERS ABOUT THE IMPORTANCE OF GROUP EXERCISES INVOLVING BOTH COCKPIT-CABIN COORDINATION & COORDINATION AMONG THE INDIVIDUAL MEMBERS OF A FLIGHT ATTENDANT CREW.

From: FAA
To: NTSB
Date: 3/26/1996
Response: ON 12/20/95, THE FAA PUBLISHED ITS COMMUTER RULE TO BRING SCHEDULED PASSENGER OPERATIONS IN AIRPLANES OF 10 OR MORE PASSENGER SEATS & ALL TURBOJETS UNDER THE REQUIREMENTS OF 14 CFR PART 121. ON 12/20/95, THE FAA ALSO PUBLISHED ITS FINAL RULE ENTITLED AIR CARRIER & COMMERICAL OPERATOR TRAINING PROGRAMS TO MANDATE CREW RESOURCE MANAGEMENT TRAINING REQUIREMENTS FOR 14 CFR PART 121 & CERTAIN 14 CFR PART 135 OPERATORS. AFTER THE APPLICABLE DATES [GIVEN IN THE FINAL RULE], A CERTIFICATE HOLDER IS PROHIBITED FROM USING A CREWMEMBER OR DISPATCHER UNLESS THAT PERSON HAS COMPLETED APPROVED CREW OR DISPATCHER RESOURCE MANAGEMENT INITIAL TRAINING.

From: NTSB
To: FAA
Date: 4/4/1995
Response: THE BOARD NOTES THAT ON 12/13/94, THE FAA ISSUED NOTICE OF PROPOSED RULEMAKING 94-35 PROPOSING TO REQUIRE THAT ALL 14 CFR PART 121 & CERTAIN 14 CFR PART 135 OPERATORS THAT CONDUCT SCHEDULED PASSENGER-CARRYING SERVICE WITH AIRPLANES HAVING A PASSENGER SEATING CAPACITY OF 1O OR MORE AND REQUIRING TWO OR MORE PILOTS CONDUCT CREW RESOURCE MANAGEMENT TRAINING. BECAUSE THE NPRM SATISFIES THE INTENT OF THIS RECOMMENDATION, THE BOARD CLASSIFIES A-90-135 "OPEN--ACCEPTABLE RESPONSE," PENDING ISSUANCE OF THE FINAL RULE.

From: NTSB
To: FAA
Date: 3/13/1995
Response: Notation 6532: The National Transportation Safety Board has reviewed your Notice of Proposed Rulemaking (NPRM), "Air Carrier and Commercial Operator Training Programs," which was published in Volume 59, Federal Register 64272 on December 13, 1994. The notice, affecting 14 CFR Parts 121 and 135, proposes to revise the training and qualification requirements for certain air carriers and commercial operators by: (1) Requiring certain certificate holders operating under part 135, and permitting certain others, to comply with part 121 training, checking, and qualification requirements, and (2) mandating Crew Resource Management (CRM) training requirements for part 121 and certain part 135 operators. The Safety Board strongly supports this NPRM. Air carrier accident investigation experience has shown repeatedly that shortcomings in flight crew performance have been cited in the majority of commuter and major air carrier accidents. And, human factors research and operating experience have led to significant advances in knowledge about the significance of human performance factors (e.g. communication, decisionmaking, leadership, management) in safe flight operations. Based on this information, the Safety Board has issued numerous safety recommendations to the Federal Aviation Administration (FAA) advocating the upgrading of air carrier pilot training, checking, and qualification requirements; mandating CRM training requirements; and fostering greater use of aircraft flight simulator devices in training programs. Specifically, the proposed rulemaking is responsive to Safety Recommendations A-94-191, -192, -195, and -196, contained in the recently adopted "Commuter Airline Safety study," as well as several earlier recommendations that advocated upgrading part 135 training, checking and qualification requirements to make them comparable/equivalent to those of part 121. (A-86-101, A-86-108, A-88-126, A-90-128, and A-94-24.) The proposed rule also is responsive to Safety Recommendations A-88-69, A-88-71, A-89-124, A-90-135, A-93-37, and A-94-2 addressed to the FAA, that advocated CRM training for flightcrews of part 121 and part 135 operators. The proposed rule also is responsive to Safety Recommendations A-86-103 and A-93-72 that advocated greater use of aircraft flight simulator devices in the training programs of part 135 operators. Finally, the proposed rule also is responsive to Safety Recommendations A-86-l07, A-88-l37, A-90-l07, and A-90-l08, to the FAA, that advocated upgrading existing pilot operating experience requirements for scheduled part 121 and 135 operations. The Safety Board believes that adoption of this proposed rule would contribute significantly toward improving the level of safety in commuter airline operations, as well as in major air carrier operations. The Safety Board appreciates the opportunity, to comment on this proposed rule.

From: FAA
To: NTSB
Date: 2/9/1995
Response: ON 12/8/94, THE FAA ISSUED NPRM 94-35 PROPOSING TO REVISE THE TRAINING & QUALIFICATION REQUIREMENTS FOR ALL 14 CFR PART 121 & CERTAIN 14 CFR PART 135 OPERATORS. THIS NPRM PROPOSED THAT CERTIFICATE HOLDERS OPERATING UNDER 14 CFR PART 135 IN SCHEDULED OPERATIONS USING AIRPLANES HAVING A PASSENGER SEATING CAPACITY OF 10 OR MORE & REQUIRING TWO PILOTS COMPLY WITH 14 CFR PART 121 TRAINING, CHECKING, & QUALIFICATION REQUIREMENTS. IF ADOPTED, THIS NPRM WILL MANDATE CREW RESOURCE MANAGEMENT TRAINING REQUIREMENTS FOR 14 CFR PART 121 & CERTAIN 14 CFR PART 135 OPERATORS.

From: NTSB
To: FAA
Date: 3/2/1993
Response: From the accident report controlled collision with terrain GP Express Airlines, Inc., flight 861, a Beechcraft C99, N118GP, Anniston, Alabama on June 8, 1992. The Board adopted this report on 3/2/1993. Additionally, the Safety Board reiterates Safety Recommendations A-88-137 and A-90-135.

From: NTSB
To: FAA
Date: 10/22/1991
Response: From the report of the runway collision of USAir flight 1493, Boeing 737 and Sky West flight 5569 Fairchild Metroliner, Los Angeles International Airport in Los Angeles, California on February 1, 1991. The Board adopted this report on 10/22/1991. Also, as a result of this accident, the National Transportation Safety Board reiterates the following recommendations to the Federal Aviation Administration: A-89-124 and A-90-135.

From: NTSB
To: FAA
Date: 5/22/1991
Response: Safety Recommendation A-90-135 urges the FAA to require scheduled 14 CFR Part 135 operators to develop and use Cockpit Resource Management programs in their training methodology by a specified date. The Safety Board notes that the FAA is considering amending the training requirements of 14 CFR Parts 121 and 135 to include cockpit resource management for flight crewmembers that will meet the intent of this safety recommendation. Pending further information, Safety Recommendation A-90-135 is classified as "Open--Acceptable Response."

From: FAA
To: NTSB
Date: 2/8/1991
Response: THE FAA IS CONSIDERING AMENDING THE TRAINING REQUIREMENTS OF 14 CFR PARTS 121 AND 135 AND IF ADOPTED, WOULD REQUIRE ALL CERTIFICATE HOLDERS OPERATING UNDER 14 CFR PART 135 WHO ELECT OR WHO WILL BE REQUIRED TO FOLLOW 14 CFR PART 121 TRAINING AND QUALIFICATION REQUIREMENTS TO INCLUDE COCKPIT RESOURCE MANAGEMENT IN THEIR FLIGHT CREWMEMBERS TRAINING PROGRAMS.