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Safety Recommendation Details

Safety Recommendation A-93-163
Details
Synopsis: ON OCTOBER 26, 1993, ABOUT 1552, N82 A BEECH SUPER KING AIR 300/F, OWNED BY THE FEDERAL AVIATION ADMINISTRATION (FAA) AND OPERATED BY THE FLIGHT INSPECTION AREA OFFICE (FIAO) AT ATLANTIC CITY, NEW JERSEY, WAS DESTROYED DUE TO AN IN-FLIGHT COLLISION WITH TERRAIN NEAR FRONT ROYAL, VIRGINIA. ALL THREE CREWMEMBERS RECEIVED FATAL INJURIES. THE AIRPLANE HAD DEPARTED THE NEARBY WINCHESTER REGIONAL AIRPORT IN VISUAL METEOROLOGICAL CONDITIONS (VMC). HOWEVER, WITNESSES INDICATED THAT INSTRUMENT METEOROLOGICAL CONDITIONS (IMC) PREVAILED AT THE ACCIDENT SITE, WHICH WAS ABOUT 15 MILES FROM THE DEPARTURE AIRFIELD. AN INSTRUMENT FLIGHT RULES (IFR) FLIGHT PLAN TO NEWPORT NEWS, VIRGINIA, WAS ON FILE IN THE AIR TRAFFIC CONTROL (ATC) SYSTEM, BUT THE FLIGHT PLAN HAD NOT YET BEEN ACTIVATED. THE FLIGHT WAS OPERATING UNDER PROVISIONS OF TITLE 14 CODE OF FEDERAL REGULATIONS (CFR) PART 91.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: INSTITUTE COCKPIT RESOURCE MANAGEMENT TRAINING, AS OUTLINED IN FAA ADVISORY CIRCULAR 120-51 AT EACH OFFICE OF AVIATION SYSTEM STANDARDS FLIGHT OPERATIONS UNIT.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: FRONT ROYAL, VA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA94GA010
Accident Reports: Controlled Flight into Terain Federal Aviation Administration Beech Super King Air 300/F, N82
Report #: AAR-94-03
Accident Date: 10/26/1993
Issue Date: 11/24/1993
Date Closed: 12/30/1996
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Crew Resource Management, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 12/30/1996
Response: A-93-163 ASKED THE FAA TO INSTITUTE [CREW] RESOURCE MANAGEMENT (CRM) TRAINING, AS OUTLINED IN ADVISORY CIRCULAR 120-51 AT EACH OFFICE OF AVIATION SYSTEM STANDARDS FLIGHT OPERATIONS UNIT. THE FAA HAS STATED THAT AS OF JULY 1995, 148 FLIGHT INSPECTION CREWMEMBERS COMPLETED CRM TRAINING, & ALL NEWLY HIRED CREWMEMBERS COMPLETED CRM TRAINING BY OCTOBER 1995. ADDITIONALLY, RECURRENT CRM TRAINING IS AN ONGOING ACTIVITY THAT IS NOW INCLUDED AS AN ELEMENT OF THE ANNUAL 14 CFR PART 135 FLIGHT INSPECTION CURRENCY TRAINING. BECAUSE CRM IS A PART OF THE OFFICE OF AVIATION SYSTEM STANDARDS FLYING OPERATIONS, THE BOARD CLASSIFIES A-95-163 "CLOSED--ACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 9/16/1996
Response: AS OF JULY 1995, THE FAA COMPLETED CREW MANAGEMENT (CRM) TRAINING TO ALL 148 FLIGHT INSPECTION CREWMEMBERS. CRM TRAINING FOR ALL NEWLY HIRED CREWMEMBERS WAS COMPLETED IN OCTOBER 1995. RECURRENT CRM TRAINING IS AN ONGOING ACTIVITY THAT IS NOW INCLUDED AS AN ELEMENT OF THE ANNUAL 14 CFR PART 135 FLIGHT INSPECTION CURRENCY TRAINING. I CONSIDER THE FAA'S ACTION TO BE COMPLETED ON THIS RECOMMENDATION.

From: NTSB
To: FAA
Date: 1/23/1996
Response: THE BOARD NOTES THAT BETWEEN OCTOBER 1994 & JULY 1995, THE FAA CONDUCTED SEVEN INITIAL CRM TRAINING CLASSES. ALL 148 FLIGHT INSPECTION CREWMEMBERS HAVE COMPLETED THE INITIAL CRM CLASS WITH THE EXCEPTION OF RECENT NEW HIRES. THE NEW HIRES HAVE BEEN SCHEDULED FOR AN ADDITIONAL CLASS. ALSO, THE FAA IS CONTINUING ITS DEVELOPMENT OF A RECURRENT TRAINING CLASS FOR ALL FLIGHT INSPECTION CREWMEMBERS. PENDING COMPLETION OF THE INITIAL TRAINING BY ALL FLIGHT INSPECTION CREWMEMBERS & DEVLOPMENT OF RECURRENT TRAINING, THE BOARD CLASSIFIES A-93-163 "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 10/10/1995
Response: BETWEEN OCTOBER 1994 & JULY 1995, THE FAA CONDUCTED SEVEN INITIAL CREW RESOURCE MANAGEMENT TRAINING CLASSES FORMERLY ENTITLED COCKPIT RESOURCE MANGEMENT). ALL 148 FLIGHT INSPECTION CREWMEMBERS HAVE COMPLETED THE INITIAL CRM CLASS WITH THE EXCEPTION OF RECENT NEW HIRES. THE NEW HIRES ARE SCHEDULED FOR A CLASS BEGINNING IN OCTOBER 1995. THE FAA IS CONTINUING ITS DEVELOPMENT OF A RECURRENT TRAINING CLASS FOR ALL FLIGHT INSPECTION CREWMEMBERS. I BELIEVE THAT THE FAA HAS ADDRESSED THE INTENT OF THIS RECOMMENDATION, & I CONSIDER THE FAA'S ACTION TO BE COMPLETED.

From: NTSB
To: FAA
Date: 9/19/1995
Response: THE BOARD NOTES THAT THE FAA HAS MADE PROGRESS TO INITIATE CRM TRAINING WITHIN ALL FLYING UNITS. THEREFORE, THE BOARD CLASSIFIES A-93-163 "OPEN--ACCEPTABLE RESPONSE," PENDING FURTHER CORRESPONDENCE ON THIS ISSUE.

From: FAA
To: NTSB
Date: 3/15/1995
Response: THE INITIAL COCKPIT RESOURCE MANAGEMENT TRAINING COURSE WAS CONDUCTED AT THE ATLANTIC CITY FIAO IN OCTOBER 1994 FOR ATLANTIC CITY FIAO CREWMEMBERS & SEVEN FIAO REPRESENTATIVE WHO WERE SELECTED AS TRAINERS. AN ADDITIONAL CRM COURSE WAS CONDUCTED IN FEBRUARY 1995 FOR THE SACRAMENTO, OKLAHOMA CITY, & BATTLE CREEK FIAO'S. ALL CRM INITIAL TRAINING COURSES WILL BE COMPLETED BY 7/30/95. I WILL KEEP THE BOARD APPRISED OF THE FAA'S PROGRESS ON THIS RECOMMENDATION.

From: FAA
To: NTSB
Date: 1/31/1994
Response: The FAA agrees with these safety recommendations. Training for cockpit resource management (CRM) and aeronautical decisionmaking (ADM) techniques, as presented in the referenced advisory circulars, is being developed by the FAA in concert with the Civil Aeromedical Institute (CAMI) and industry. A prototype course will be conducted in February 1994 with final implementation in March 1994. The results of this program will be implemented at each AVN flight operations unit and in the AVN aircrew training program. The CRM and ADM programs will be professionally facilitated with CAMI participation and will be conducted for all crewmembers. The training will include interpersonal relations, conflict resolution, and emphasis on processes to be used to alert managers and supervisors of problem situations. A quality action team has been established to take a broad look at the implication of safety, standardization, and training in the FAA aircraft program. Efforts of this team will result in a plan to be developed by January 31, 1994. In the interim, managers of FAA flight programs met with all flight crewmembers regarding CRM's responsibilities during the standdown completed the week of November 15, 1993. The role of CRM in AVN flight operations, ADM techniques, and the facts of the N82 accident were topics at the November standdown and are regular discussion topics at safety briefings for all flightcrews. I will keep the Board apprised of the FAA's progress on these safety recommendations.