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Safety Recommendation Details

Safety Recommendation A-93-013
Details
Synopsis: ON APRIL 22, 1992, ABOUT 1553 HAWAIIAN STANDARD TIME, SCENIC AIR TOURS (SAT) FLIGHT 22, A BEECH MODEL E18S (BE-18), N342E, COLLIDED WITH MOUNTAINOUS TERRAIN ON THE ISLAND OF MAUI, HAWAII, WHILE ON AN AIR TOUR FLIGHT FROM HILO, HAWAII, TO HONOLULU, HAWAII. THE FLIGHT WAS CONDUCTED AS AN ON-DEMAND AIR TAXI OPERATION UNDER THE PROVISIONS OF TITLE 14 CODE OF FEDERAL REGULATIONS (CFR) PART 135 AND UNDER VISUAL FLIGHT RULES (VFR). AS A RESULT OF THE ACCIDENT, THE PILOT AND EIGHT PASSENGERS ON BOARD SUSTAINED FATAL INJURIES. THE AIRPLANE WAS DESTROYED BY IMPACT FORCES AND A POSTCRASH FIRE.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: ISSUE AN AIR CARRIER OPERATIONS BULLETIN INSTRUCTING ALL PRINCIPAL OPERATIONS INSPECTORS TO AGGRESSIVELY ENCOURAGE ALL COMMERICAL OPERATORS TO INCORPORATE COMPREHENSIVE AERONAUTICAL DECISION MAKING (ADM) TRAINING IN THEIR PILOT TRAINING PROGRAMS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: MOUNT HALEAKALA, HI, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: LAX92MA184
Accident Reports: Tomy International, Inc. d/b/a Scenic Air Tours Flight 22, Beech Model E18S, N342E In-Flight Collision with Terrain
Report #: AAR-93-01
Accident Date: 4/22/1992
Issue Date: 2/19/1993
Date Closed: 2/22/1994
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Flightcrew, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 2/22/1994
Response: THE BOARD NOTES THAT THE FAA PUBLISHED ADVISORY CIRCULAR (AC) 120-51, "COCKPIT RESOURCE MANAGEMENT TRAINING," ON DECEMBER 1, 1989, AND THE FAA PUBLISHED AC 60-22, "AERONAUTICAL DECISION MAKING" ON DECEMBER 13, 1991. ADDITIONALLY, THE FAA WILL PUBLISH AN INFORMATION BULLETIN IN ORDER 8400.10 TO EMPHASIZE TO FIELD OFFICE INSPECTORS THE IMPORTANCE OF ENCOURAGING OPERATORS TO INCORPORATE DECISIONMAKING IN THEIR COMPANY TRAINING PROGRAMS. BASED ON THIS INFORMATION, THE BOARD CLASSIFIES RECOMMENDATION A-93-13 "CLOSED--ACCEPTABLE ACTION," AND REQUESTS THAT THE FAA SEND THE BOARD A COPY OF THE INFORMATION BULLETIN WHEN IT IS PUBLISHED.

From: FAA
To: NTSB
Date: 4/29/1993
Response: THE FAA AGREES WITH THIS RECOMMENDATION. ON DECEMBER 1, 1989, THE FAA PUBLISHED ADVISORY CIRCULAR (AC) 120-51, COCKPIT RESOURCE MANAGEMENT TRAINING, AND ON DECEMBER 12, 1991, THE FAA PUBLISHED AC 60-22, AERONAUTICAL DECISION MAKING. BOTH OF THESE AC'S ADDRESS THE IMPORTANCE OF INCLUDING DECISIONMAKING IN PILOT TRAINING PROGRAM. THE FAA WILL PUBLISH AN INFORMATION BULLETIN IN ORDER 8400-10 TO EMPHASIZE TO FIELD OFFICE INSPECTORS THE IMPORTANCE OF ENCOURAGING OPERATORS TO INCORPORATE DECISIONMAKING IN THEIR COMPANY TRAINING PROGRAMS.