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Safety Recommendation Details

Safety Recommendation A-94-115
Details
Synopsis: ON DECEMBER 1, 1993, EXPRESS II FLIGHT 5719, A JETSTREAM BA-3100, REGISTRATION N334PX, WAS OPERATING AS A REGULARLY SCHEDULED FLIGHT UNDER 14 CODE OF FEDERAL REGULATIONS (CFR), PART 135, FROM MINNEAPOLIS/ST. PAUL INTERNATIONAL AIRPORT, ST. PAUL, MINNESOTA, TO INTERNATIONAL FALLS, MINNESOTA, WITH EN ROUTE STOP AT HIBBING, MINNESOTA (HIB). THE FLIGHT WAS OPERATED BY EXPRESS AIRLINES II, INC., UNDER THE TERMS OF A MARKETING AGREEMENT WITH NORTHWEST AIRLINES, INC., AS NORTHWEST AIRLINK. ABOUT 1950 CENTRAL STANDARD TIME, THE AIRPLANE COLLIDED WITH TERRAIN WHILE ON THE LOCALIZER BACK COURSE APPROACH TO RUNWAY 13 AT HIB. THE 2 FLIGHTCREW MEMBERS AND ALL 16 PASSENGERS WERE FATALLY INJURED IN THE ACCIDENT. THE AIRPLANE WAS DESTROYED.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: BASED ON THE CIRCUMSTANCES AND FINDINGS OF THE INVESTIGATION OF THE EXPRESS II AIRLINES ACCIDENT AT HIBBING, MINNESOTA, ON DECEMBER 1, 1993, DEVELOP A CLEAR AND SPECIFIC DIRECTIVE TO FLIGHT STANDARDS INSPECTORS AND MANAGERS THAT EMPHASIZES THE NEED FOR COMPLIANCE WITH EXISTING FAA ORDERS, DIRECTIVES, AND OTHER GUIDANCE MATERIAL DURING THE CERTIFICATION AND SURVEILLANCE OF COMMUTER AIR CARRIERS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Aviation
Location: HIBBING, MN, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA94MA022
Accident Reports: Controlled Collision with Terrain Express II Airlines, Inc./ Northwest Airlink Flight 5719 Jetstream BA-3100, N334PX
Report #: AAR-94-05
Accident Date: 12/1/1993
Issue Date: 6/13/1994
Date Closed: 10/4/1995
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 10/4/1995
Response: THE BOARD NOTES THAT ON 8/29/94, THE FAA ISSUED A JOINT HANDBOOK BULLETIN FOR AIRWORTHINESS 94-02, AIR TRANSPORTATION 94-08, & GENERAL AVIATION 94-04, WHICH ESTABLISHED CERTAIN PROCEDURES FOR FLIGHT STANDARDS FIELD OFFICES BUT DID NOT FULLY MEET THE INTENT OF A-94-115. HOWEVER, THE FAA ALSO ISSUED NOTICE 8430. 410, "VERIFICATION OF ACTIONS: AIR CARRIER OPERATIONS BULLETINS," WHICH DIRECTS ALL FLIGHT STANDARDS FIELD OFFICE MANAGERS TO VERIFY THAT ACTIONS IN ALL AIR CARRIER OPERATIONS BULLETINS ISSUED BETWEEN 1/1/92, & 12/31/93, HAVE BEEN ACCOMPLISHED. THE BOARD ACKNOWLEDGES THAT, ALTHOUGH THIS NOTICE WAS ISSUED IN RESPONSE TO A-94-71 & 72, IT IS ALSO RELEVANT & PARTIALLY RESPONSIVE TO A-94-115. COLLECTIVELY, THESE ACTIONS MEET THE INTENT OF A-94-115 WHICH IS NOW CLASSIFIED "CLOSED--ACCEPTABLE ALTERNATE ACTION."

From: FAA
To: NTSB
Date: 7/3/1995
Response: ON 8/29/94, THE FAA RESPONDED TO THIS RECOMMENDATION WITH THE ISSUANCE OF A JOINT HANDBOOK BULLETIN FOR AIRWORTHINESS 94-02, AIR TRANSPORTATION 94-08, & GENERAL AVIATION 94-04. THIS BULLETIN ESTABLISHED PROCEDURES BY WHICH ALL FLIGHT STANDARDS FIELD OFFICES ACCOMPLISH & DOCUMENT SURVEILLANCE, INSPECTION, OR CERTIFICATE MANAGEMENT ACTIONS REQUIRED BY AIR CARRIER OPERATIONS BULLETINS, FLIGHT STANDARDS HANDBOOK BULLETINS, & FLIGHT STANDARDS INFO BULLETINS.

From: NTSB
To: FAA
Date: 3/6/1995
Response: THE BOARD NOTES THAT THE FAA ISSUED A JOINT HANDBOOK BULLETIN ENTITLED "PROGRAM TRACKING & REPORTING SUBSYSTEM (PTRS) DOCUMENTATION OF ACTION REQUIRED BY FLIGHT STANDARD BULLETINS" ON 5/12/94. THIS BULLETIN ESTABLISHES PROCEDURES BY WHICH ALL FLIGHT STANDARDS FIELD OFFICES MUST ACCOMPLISH & DOCUMENT SURVEILLANCE, INSPECTION, OR CERTIFICATE MANAGEMENT ACTIONS REQUIRED BY ACOBS, FLIGHT STANDARDS HANDBOOK BULLETINS (HBBS), & FSIBS. IT ALSO REQUIRES THAT EACH FIELD OFFICE MANAGER MAINTAIN A MASTER COPY OF ALL ACOBS FSIBS, & HBBS, SIGN THE BULLETINS ON RECEIPT; & DELIVER SUFFICIENT QUANTITIES OF THE BULLETINS TO THE APPROPRIATE INSPECTORS. ONE OF THE REVELATIONS FROM HIBBING INVESTIGATION WAS THAT BOTH THE FIELD & REGIONAL FAA REPRESENTATIVES FAILED TO FOLLOW GUIDANCE IN THEIR HANDBOOKS. FOR THIS REASON, THE RECOMMENDATION ASKS THAT THE FAA EMPHASIZE THE NEED FOR COMPLIANCE WITH EXISTING FAA ORDERS, DIRECTIVES & OTHER GUIDANCE MATERIAL. ALTHOUGH THE HANDBOOK BULLETIN REFERENCED ABOVE IS A NEEDED EFFORT, THERE IS NO SPECIFIC REFERENCE TO COMPLIANCE WITH EXISTING FAA ORDERS & DIRECTIVES. BECAUSE THE FAA RESPONSE DOES NOT ADDRESS THE INTENT OF THE RECOMMENDATION, THE BOARD CLASSIFIES A-94-115 "OPEN--UNACCEPTABLE ACTIONS."

From: FAA
To: NTSB
Date: 8/29/1994
Response: ON 5/12/94, THE FAA ISSUED A JOINT HANDBOOK BULLETIN FOR AIRWORTHINESS 94-02, AIR TRANSPORTATION 94-08, & GENERAL AVIATION 94-04 ENTITLED PROGRAM TRACKING & REPORTING SUBSYSTEM (PTRS) DOCUMENTATION OF ACTION REQUIRED BY FLIGHT STANDARDS BULLETINS. THIS BULLETIN ESTABLISHES PROCEDURES BY WHICH ALL FLIGHT STANDARDS FIELD OFFICES MUST ACCOMPLISH & DOCUMENT SURVEILLANCE, INSPECTION, OR CERTIFICATE MANAGEMENT ACTIONS REQUIRED BY AIR CARRIER OPERATIONS BULLETINS, FLIGHT STANDARDS HANDBOOK BULLETINS, & FLIGHT STANDARDS INFO BULLETINS. THIS BULLLETIN REQUIRES THAT EACH FIELD OFFICE MANAGER MAINTAIN A MASTER COPY OF ALL AIR CARRIER OPERATIONS BULLETINS, FLIGHT STANDARD INFO BULLETINS & HANDBOOK BULLETINS; SIGN THE BULLETINS UPON RECEIPT; & DELIVER SUFFICIENT QUANTITIES OF THE BULLETINS TO THE APPROPRIATE INSPECTORS.