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Safety Recommendation Details

Safety Recommendation A-93-035
Details
Synopsis: ON JUNE 8, 1992, GP EXPRESS AIRLINES, INC., FLIGHT 861, A BEECHCRAFT MODEL C99, N118GP, CRASHED WHILE MANEUVERING TO LAND AT THE ANNISTON METROPOLITAN AIRPORT, ANNISTON, ALABAMA. THE FLIGHT WAS SCHEDULED PASSENGER FLIGHT FROM THE WILLIAM B. HARTSFIELD ATLANTA INTERNATIONAL AIRPORT IN ATLANTA, GEORGIA, ON AN INSTRUMENT FLIGHT RULES FLIGHT PLAN TO ANNISTON, ALABAMA. THE CAPTAIN AND TWO PASSENGERS RECEIVED FATAL INJURIES. THE FIRST OFFICE AND TWO PASSENGERS WERE SERIOUSLY INJURED. THE AIRPLANE WAS DESTROYED BY IMPACT AND POSTCRASH FIRE.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REQUIRE THAT ALL PILOTS OPERATING AIRCRAFT UNDER 14 CFR PART 135 HAVE ACCESS TO THEIR OWN SET OF INSTRUMENT APPROACH CHARTS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: ANNISTON, AL, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: ATL92MA118
Accident Reports: Controlled Collision with Terrain GP Express Airlines, Inc., Flight 861 A Beechcraft C99, N118GP
Report #: AAR-93-03
Accident Date: 6/8/1992
Issue Date: 4/2/1993
Date Closed: 2/8/1999
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 2/8/1999
Response: THE FAA CITED THE ISSUANCE OF ITS MARCH 1997 COMMUTER RULE AS AN APPROPRIATE ACTION IN RESPONSE TO THIS SAFETY RECOMMENDATION. EVEN THOUGH THE BOARD APPRECIATES THE FAA'S EFFORTS TO INCLUDE PART 135 OPERATIONS UNDER PART 121 REQUIREMENTS, WE BELIEVE THAT THE PART 121 REQUIREMENT IN THIS AREA IS WORDED SOMEWHAT VAGUELY. WE UNDERSTAND THAT MOST OF THE ESTABLISHED PART 121 OPERATORS PROVIDE THEIR PILOTS WITH THEIR OWN SET OF APPROACH CHARTS, BUT WE ARE CONCERNED THAT PART 135 OPERATORS NOW COVERED BY PART 121 REQUIREMENTS MAY NOT INTERPRET THE WORDING OF THE RULE IN A SIMILAR FASHION. BECAUSE THE FAA DOES NOT PLAN ANY FURTHER RULEMAKING ACTIVITY ON THIS ISSUE, THE BOARD CLASSIFIES A-93-35 "CLOSED--UNACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 9/29/1997
Response: Letter Mail Controlled 2/5/99 9:14:27 AM MC# 971367 THE FAA IMPLEMENTED THE COMMUTER RULE IN MARCH 1997. THIS RULE REQUIRED AIR CARRIERS OPERATING AIRPLANES WITH NINE OR MORE PASSENGER SEATS IN SCHEDULED OPERATIONS TO COMPLY WITH 14 CFR PART 121. AIR CARRIERS OPERATING UNDER 14 CFR PART 121 ARE REQUIRED TO PROVIDE THE FLIGHTCREW WITH APPROPRIATE AERONAUTICAL CHARTS, WHICH CONTAIN INFORMATION CONCERNING NAVIGATIONAL AIDS AND INSTRUMENT APPROACH PROCEDURES.

From: NTSB
To: FAA
Date: 7/31/1997
Response: THE BOARD IS PLEASED THAT THE FAA & TSC SUBSEQUENTLY BROADENED THE SCOPE OF THE STUDY BEYOND TURBOJET AIRCRAFT & STANDARD GROUND PROXIMITY WARNING SYSTEMS (GPWS), AS STATED IN THE RECOMMENDATION, TO INCLUDE TURBINE-POWERED PROPELLER AIRCRAFT & ENHANCED GROUND PROXIMITY WARNING SYSTEMS (EGPWS). THE BOARD HAS REVIEWED THE RESULTS OF THE TSC STUDY, WHICH WERE ISSUED IN TWO MEMORANDUMS. FOR THE AIRCRAFT FLEET OPERATING UNDER TITLE 14 CODE OF FEDEAL REGULATIONS (14 CFR) PART 91, THE STUDY CONCLUDED THAT THE NUMBER OF CFIT ACCIDENTS WOULD BE DRAMATICALLY REDUCED. BASED ON THE POTENTIAL SAVINGS OF HUMAN LIFE & ECONOMIC BENEFITS, THE STUDY URGES THE FAA "TO IMPLEMENT NTSB RECOMMENDATION A-95-35," TO "AMEND THIS RECOMMENDATION TO REQUIRE INSTALLATION OF EGPWS," & THAT "THE NTSB RECOMMENDATION BE BROADENED BY THE FAA TO INSTALLATION OF EGPWS," & THAT "NTSB RECOMMENDATION BE BROADENED BY THE FAA TO ENCOMPASS ALL "TURBINE POWERED' (I.E., NOT JUST TURBOJET) AIRCRAFT." THE TSC STUDY OF THE AIRCRAFT FLEETS OPERATING UNDER PARTS 121 & 135 CONCLUDED THAT "EGPWS REPRESENTS A MAJOR IMPROVEMENT IN POTENTIAL CFIT ACCIDENT REDUCTION," & THAT THE FAA SHOULD AMEND 14 CFR PARTS 121 & 135 WITH NEW RULEMAKING THAT WOULD REQUIRE MANDATORY INSTALLATION OF MULTICOLOR TERRAIN DISPLAY EUIPMENT SUCH AS THAT FOUND EGPWS. THE TSC STUDY FULLY SUPPORTS ACTION TO REVISE 14 CFR PART 91, 121, & 135 TO MANDATE EGPWS ON ALL TURBINE-POWERED AIRPLANES WITH SIX OR MORE PASSENGER SEATS, & THE BOARD IS PLEASE THAT THE FAA HAS INITIATED RULEMAKING ACTIVITY TO ACCOMPLISH THIS. NEARLY A YEAR PASSED SINCE THE TSC STUDY WAS COMPLETED; THE BOARD HOPES THAT THIS IMPORTANT RULEMAKING ACTION IS NOT DELAYED FURTHER. WE LOOK FORWARD TO RECEIVING THE NOTICE OF PROPOSED RULEMAKING ON THIS SUBJECT IN THE NEAR FUTURE. PENDING REVIEW OF THE FINAL RULE, THE BOARD HAS CLASSIFIED A-95-35 "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 4/17/1997
Response: FAA HAS INITIATED RULEMAKING PROPOSING TO MANDATE THE INSTALLATION OF ENHANCED GROUND PROXIMITY WARNING SYSTEMS (EGPWS) ON ALL TURBINE-POWERED AIRPLANE WITH SIX OR MORE PASSENGER SEATS.

From: NTSB
To: FAA
Date: 7/19/1995
Response: THE BOARD NOTES THAT THE FAA HAS ISSUED FLIGHT STANDARDS INFO BULLEITN 94-20, "AVAILABILITY & USE OF INSTRUMENT APPROACH CHARTS." AS AN INTERIM MEASURE, & MAY ISSUE A NOTICE OF PROPOSED RULEMAKING IN AUGUST 1995, PROPOSING TO REQUIRE THAT EACH PILOT CONDUCTING OPERATIONS UNDER 14 CFR PARTS 121 & 135 HAVE A CURRENT INSTRUMENT APPROACH PROCEDURE CHART. THEREFORE, PENDING ISSUANCE OF A FINAL RULE THAT MEETS THE INTENT OF THIS RECOMMENDATION, A-93-35 REMAINS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 3/10/1995
Response: THE FAA IS CONSIDERING THE ISSUANCE OF A NOTICE OF PROPOSED RULEMAKING PROPOSING TO REQUIRE THAT EACH PILOT CONDUCTING OEPRATIONS UNDER 14 CFR PARTS 121 & 135 HAS A CURRENT INSTRUMENT APPROACH PROCEDURES CHART. THE FAA PLANS TO INCLUDE THIS REQUIREMENT IN ITS CURRENT NPRM WHICH ADDRESSES VISUAL DESCENT POINTS & CEILING & VISIBILITY REQUIREMENTS. IT IS ANTICIPATED THAT THE NPRM WILL BE ISSUED IN AUGUST 1995. THE FAA STATES IT WILL PROVIDE THE BOARD WITH A COPY OF ANY REGULATORY DOCUMENT THAT MAY BE ISSUED.

From: NTSB
To: FAA
Date: 8/2/1994
Response: THE BOARD NOTES THAT THE FAA PLANS TO ISSUE AN AIR CARRIER OPERATIONS BULLETIN IN JULY 1994 RECOMMENDING THAT EACH PILOT HAVE AN IAP CHART DURING AN INSTRUMENT APPROACH. ALSO, THE FAA MAY ISSUE A NOTICE OF PROPOSED RULEMAKING TO REQUIRE THAT EACH PILOT CONDUCTING OPERATIONS UNDER 14 CFR PARTS 121 & 135 HAVE A CURRENT IAP CHART. BASED ON THIS INFO, & PENDING ISSUANCE OF THE ACOB & A FINAL RULE ADDRESSING THIS SAFETY ISSUE, THE BOARD CLASSIFIES A-93-35 "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 6/14/1994
Response: THE FAA HAS RECONSIDERED ITS POSITION IN RESPONSE TO THIS RECOMMENDATION & IS CONSIDERING THE ISSUANCE OF A NOTICE OF PROPOSE RULEMAKING PROPOSING TO REQUIRE THAT EACH PILOT CONDUCTING OPERATIONS UNDER 14 CFR PARTS 121 & 135 HAS A CURRENT INSTRUMENT APPROACH PROCEDURE CHART. AS AN INTERIM MEASURE, THE FAA WILL PUBLISH AN AIR CARRIER OPERATIONS BULLETIN RECOMMENDING THAT EACH PILOT HAS AN IAP CHART DURING AN INSTRUMENT APPROACH. IT IS ANTICIPATED THAT THIS ACOB WILL BE ISSUED IN JULY.

From: NTSB
To: FAA
Date: 5/24/1994
Response: From the aircraft accident report controlled collision with terrain Express II airlines, Inc./ Northwest Airlink flight 5719 Jetstream BA-3100, N334PX Hibbing, Minnesota on December 1, 1993. The Board adopted this report on 5/24/1994. Also, as a result of the investigation of this accident, the Safety Board reiterates Safety Recommendation A-93-35.

From: NTSB
To: FAA
Date: 11/19/1993
Response: THE BOARD NOTES THAT THE FAA AGREES THAT BOTH PILOTS SHOULD HAVE ACCESS TO AN APPROACH CHART DURING THE INSTRUMENT APPROACH, BUT THAT THIS CAN BE ACCOMPLISHED EITHER BY BOTH PILOTS HAVING THEIR OWN SET OF APPROACH CHARTS OR BY BOTH PILOTS HAVING IMMEDIATE ACCESS AND USE OF A SHARED APPROACH CHART. THE BOARD BELIEVES THAT THE PRACTICE OF HAVING ONLY ONE APPROACH PLATE AVAILABLE IN AIRCRAFT REQUIRING TWO PILOTS INCREASES PILOT WORKLOAD DURING THE APPROACH AND INCREASES THE POTENTIAL FOR THE MISCOMMUNICATION OF CRITICAL INFORMATION, AS OCCURRED IN THE JUNE 8, 1992, GP EXPRESS ACCIDENT. THE BOARD CONTINUES TO BELIEVE THAT THE PRACTICE OF HAVING ONLY ONE SET OF APPROACH CHARTS AVAILABLE IN THE AIRPLANE IS NOT IN THE BEST INTEREST OF AVIATION SAFETY. THEREFORE, THE BOARD CLASSIFIES RECOMMENDATION A-93-35 "OPEN--UNACCEPTABLE RESPONSES" AND ASKS THE FAA TO RECONSIDER ITS POSITION.

From: FAA
To: NTSB
Date: 6/16/1993
Response: THE FAA AGREES THAT BOTH PILOTS SHOULD HAVE ACCESS TO AN APPROACH CHART DURING THE INSTRUMENT APPROACH. THE FAA BELIEVES THAT THIS CAN BE ACCOMPLISHED BY EITHER BOTH PILOTS HAVING THEIR OWN SET OF APPROACH CHARTS OR BY BOTH PILOTS HAVING IMMEDIATE ACCESS AND USE OF AN APPROACH CHART. CONSEQUENTLY, THE FAA WILL ISSUE AN AIR CARRIER OPERATION BULLETIN (ACOB) TO ALL PRINCIPAL OPERATIONS INSPECTORS REQUESTING THAT THEY ENSURE THAT THEIR RESPECTIVE AIR CARRIERS ESTABLISH COCKPIT PROCEDURES FOR THE PLACEMENT AND USE OF A SINGLE APPROACH CHART DURING THE APPROACH PHASE OF FLIGHT OR FOR EACH PILOT TO HAVE HIS/HER OWN SET OF APPROACH CHARTS. I WILL PROVIDE THE BOARD WITH A COPY OF THE ACOB AS SOON AS IT IS ISSUED.