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Safety Recommendation Details

Safety Recommendation A-97-070
Details
Synopsis: On 5/11/96, about 1415 eastern daylight time, a McDonnell Douglas DC-9-32 crashed into the everglades swamp shortly after takeoff from Miami International Airport, Miami Florida, the airplane, N904VJ, was operated by ValuJet Airlines, Inc., as ValuJet flight 592. Both pilots, the three flight attendants, and all 105 passengers were killed. Before the accident, the flightcrew reported to air traffic control that it was experiencing smoke in the cabin and cockpit. Visual meteorological conditions existed in the Miami area at the time of the takeoff. The destination of the flight was Hartsfield International Airport, Atlanta, Georgia. Flight 592 was on an instrument flight rules flight plan.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Include, in its development and approval of air carrier maintenance procedures and programs, explicit consideration of human factors issues, including training, procedure development, redundancy, supervision, and the work environment, to improve the performance of personnel and their adherence to procedures.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Miami, FL, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA96MA054
Accident Reports: In-Flight Fire and Impact With Terrain Valujet Airlines Flight 592 DC-9-32, N904VJ
Report #: AAR-97-06
Accident Date: 5/11/1996
Issue Date: 9/9/1997
Date Closed: 5/1/2009
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Maintenance, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 5/1/2009
Response: On August 8, 2005, the FAA informed the Safety Board that it had added Chapter 8, Human Factors Involved in Inspection and Repair in a Heavy Maintenance Environment, to Order 8300.10, Airworthiness Inspector’s Handbook.On May 17, 2006, the Board replied that the revision to Order 8300.10 was responsive to this recommendation, but the Board was disappointed that this revision referenced only research that had been completed 14 years earlier. The FAA has been a leader in studying and sponsoring research examining aviation maintenance human factors and has produced much human factors guidance that would be useful to inspectors when considering their carriers aviation maintenance programs. Pending further revisions to Chapter 8 of FAA Order 8300.10 to reference more current guidance and information on human factors consideration in aviation maintenance, Safety Recommendation A-97-70 remained classified Open Acceptable Response. In its current letter, the FAA indicates that Order 8300.10 has been cancelled and replaced by Order 8900.1, Flight Standards Information Management System (FSIMS). The information contained in Chapter 8 of FAA Order 8300.10 is now included in Order 8900.1, Volume 3, Chapter 24, Section 2, Evaluate and Accept a Maintenance Human Factors Training Program, released in December 2007. Human factors training guidance and information for FAA inspectors regarding the evaluation, acceptance, and approval of human factors training programs is contained in Order 8900.1, Chapter 3 of the “Operator’s Manual for Human Factors in Aviation Maintenance. The Related Regulatory and Content Guidance paragraph was expanded to reference more current guidance and information on human factors in aviation maintenance. The Safety Board reviewed this material and found that it is a good overview and a comprehensive framework for both inspectors and maintenance providers. The revised sections of Order 8900.1 provide appropriate references to additional source material. Therefore, the FAA has completed the action recommended, and Safety Recommendation A-97-70 is classified CLOSED—ACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 10/16/2008
Response: Letter Mail Controlled 11/3/2008 10:37:17 AM MC# 2080661: Robert A. Sturgell, Acting Administrator, FAA, 10/16/08 In its previous letter to the Federal Aviation Administration, dated May 17, 2006, the Board requested more current guidance on human factors in aviation maintenance be included in FAA Order 8300.10, Airworthiness Inspector's Handbook, chapter 8. The Board specifically referenced the information found in an FAA guide to human factors in aviation maintenance as a good example of the type of current information that would satisfy this recommendation. Since then, FAA Order 8300.10 was cancelled and replaced by FAA Order 8900.1, Flight Standards Information Management System (FSIMS). The information contained in chapter 8 of FAA Order 8300.10 can now be found in FAA Order 8900.1, FSIMS, volume 3, chapter 24, section 2, Evaluate and Accept a Maintenance Human Factors Training Program, released in December 2007 (enclosure 1). FAA Order 8900.1 incorporates the human factors training guidance found in chapter 3 of the Operator's Manual for Human Factors in Aviation Maintenance (enclosure 2) in addition to providing guidance for the evaluation, acceptance, and in certain scenarios, approval of human factors training programs. The Related Regulatory and Content Guidance paragraph has also been expanded to reference more current guidance and information on human factors in aviation maintenance. I believe that the FAA has effectively addressed this safety recommendation, and I consider our actions complete.

From: NTSB
To: FAA
Date: 5/17/2006
Response: The Safety Board notes that in addition to issuing two advisory circulars in 2003, the FAA has updated Order 8300.10, "Airworthiness Inspector's Handbook," by adding Chapter 8, "Human Factors Involved in Inspection and Repair in a Heavy Maintenance Environment." The Safety Board recognizes that the FAA has been a leader in studying and sponsoring research examining aviation maintenance human factors and that the FAA has also produced a variety of human factors guidance that would be very useful to inspectors when considering their carrier's aviation maintenance program if it were referenced in Chapter 8. In a previous letter on this recommendation, the Board requested that the FAA better integrate the results of its research into the guidance it issues on aviation maintenance operations-specifically mentioning the FAA's "Human Factors Guide for Aviation Maintenance," (http://hfskyway.faa.gov), as a good example of the type of current information that the FAA has produced that would satisfy this recommendation. Given the variety of useful and more up-to-date guidance information available and produced by the FAA, the Board is disappointed that the FAA has not used its more recent research results in Chapter 8, allowing it to more fully realize the benefits of its investments in producing this information. The actions taken by the FAA, including the addition of Chapter 8, are responsive to this recommendation; however, the Safety Board notes with disappointment that this revision still doesn't take advantage of the FAA's significant efforts in this area and only references research completed 14 years ago. Pending what the Board believes are simple revisions to Chapter 8 that reference the more current guidance and information on human factors consideration in aviation maintenance that the FAA has produced, Safety Recommendation A-97-70 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/8/2005
Response: Letter Mail Controlled 8/16/2005 10:52:35 AM MC# 2050378: The Federal Aviation Administration revised Advisory Circular (AC) 120-16D, Air Carrier Maintenance Programs, in March 2003. The AC was expanded to include descriptions of the nine elements of a maintenance program, as well as greatly expanded material on identifying maintenance program discrepancies using Continuing Analysis and Surveillance Systems (CASS). Also included are descriptions of the maintenance organization, the manual, training programs, and airworthiness responsibility. The scope and substance of the revisions address human factors through the discrepancy identification function of the CASS. In addition, a new inspector training course is currently being deployed that is based on AC 120-16D, as well as AC 120-79, Developing and Implementing a Continuing Analysis and Surveillance System. AC 120-79, published in April 2003, also addresses human factors in air carrier maintenance programs. The CASS provides a structure and process for human factors to be addressed. I have enclosed copies of the two ACs for the Board's information. As part of its continuous improvement process, the FAA is updating FAA Order 8300.10, Airworthiness Inspector's Handbook, to provide indepth guidance on air carrier maintenance programs and their elements to complement the information in the two ACs. I have enclosed a copy of the appropriate chapter of Order 8300.10 for the Board’s information. Additionally, as stated in AC 120-79, the FAA is heavily involved with academia and research facilities in continuing development of human factors concepts and their application in the workplace. There are no plans to discontinue those associations. I believe that the FAA has satisfactorily responded to this safety recommendation, and I look forward to your response.

From: NTSB
To: FAA
Date: 2/23/2004
Response: On October 2, 2000, the FAA stated that, as a result of its review of "Human Factors in Aviation Maintenance and Inspection, Strategic Program Plan," a report produced based on an FAA research program on maintenance human factors, it was amending AC 120-16C to include information contained in the report. On April 24, 2001, the Safety Board responded that it was difficult to determine whether the revisions to the AC would address the issues in this recommendation. Pending issuance of revisions to the AC that addressed the issues in the recommendation, it was classified "Open-Acceptable Response." Although the revised AC (AC 120-16D) addresses many of the human factors issues related to training, procedures development, redundancy, supervision, and the work environment, the Safety Board believes this document would be significantly strengthened if the FAA added references to some specific human factors information related to aviation maintenance operations. For example, the Board believes that chapter 12, paragraph 1202 of the AC, "Where Can You Find Regulatory and Guidance Material Related to the Information in this AC?" could be expanded to include references to available FAA-published guidance material and resources on maintenance human factors, such as the Human Factors Guide for Aviation Maintenance (http://hfskyway.faa.gov). The Safety Board continues to investigate major accidents in which maintenance problems are a significant safety concern, including the recently issued reports, Loss of Pitch Control on Takeoff, Emery Worldwide Airlines, Inc., McDonnell Douglas DC?8?71F, N8079U, Rancho Cordova, California, February 16, 2000, and Loss of Control and Impact with Pacific Ocean, Alaska Airlines Flight 261, McDonnell Douglas MD-83, N963AS, about 2.7 Miles North of Anacapa Island, California, January 31, 2000. In both accidents, incorrect maintenance led to a loss of control of the aircraft. The Safety Board considers issues related to aviation maintenance, including human factors of maintenance operations, to be an important safety issue. Pending inclusion in the AC of references to available FAA-published guidance material on maintenance human factors, Safety Recommendation A-97-70 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 7/21/2003
Response: Letter Mail Controlled 8/7/2003 10:17:48 AM MC# 2030379 AC 120-16D applies to 14 CFR Parts 119, 121, and 135 air carriers. For 14 CFR Part 135 operations, the AC applies only to operations conducted with aircraft type-certificated for a seating capacity of 10 seats or more (excluding any pilot seat). Chapter 11 of the AC discusses procedures, information, instructions, guidance, and precautions that should be contained in operators' manuals concerning hazardous materials. This includes identifying or recognizing aircraft components or consumable materials that contain hazardous materials; the safe movement, storage, or handling of those aircraft components or consumable materials within the facility or one of the maintenance providers' facilities; determining the proper packaging, marking, labeling, and materials compatibility of aircraft components or consumable materials containing hazardous materials while they are within the facility or maintenance provider's facilities; specific hazards associated with aircraft components or consumable materials containing hazardous materials to be moved, stored, or handled within the facility; and proper disposal of unserviceable aircraft components or consumable materials containing hazardous materials. Additionally, Chapter 10 of the AC includes human factors as part of the initial training program. The FAA believes that the requirements for improved and specific hazardous material training programs, authorizations, and notifications included in the NPRM in response to Safety Recommendation A-97-65 will complete the requirements of these recommendations. I believe that the FAA has satisfactorily responded to these safety recommendations, and I look forward to your response.

From: NTSB
To: FAA
Date: 4/24/2001
Response: The Safety Board notes that it is difficult to determine whether the revisions to the AC will address the issues in this recommendation. Pending issuance of revisions to the AC that address the issues in the recommendation, Safety Recommendation A-97-70 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/2/2000
Response: Letter Mail Controlled 10/04/2000 3:48:25 PM MC# 2001485 The FAA has completed its review of the information contained in the report entitled "Human Factors in Aviation Maintenance and Inspection, Strategic Program Plan" and is amending AC 120-16C, Continuous Airworthiness Maintenance Programs, to include information contained in the report. The revision to the AC will also expand on continuing analysis and surveillance systems. It is anticipated that the AC will be issued by December 2000. I will provide the Board with a copy of the AC as soon as it is issued.

From: NTSB
To: FAA
Date: 2/3/2000
Response: The Safety Board has reviewed the information provided on the FAA web site. Although the board is concerned about the amount of time this effort has taken, it believes the FAA has taken a positive step regarding this safety recommendation. The board understands the complexities of this issue and encourages the FAA to continue its research efforts. The primary intent of this recommendation is to reduce human errors by increasing maintenance personnel's compliance with approved procedures in aviation maintenance programs. The FAA needs to use this research and require through regulatory action, that air carrier maintenance programs include provisions for all aspects of the human factors research already completed. These should include emphasis on training, work environment and procedural development. The board looks forward to reviewing the FAA's strategy for implementing its research efforts. Pending such a review, A-97-70 is classified OPEN--ACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 7/23/1999
Response: Pending evaluation of the FAA’s final action, the safety board classifies A-97-70 OPEN--ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/17/1999
Response: Letter Mail Controlled 6/21/99 3:46:34 PM MC# 990670 The FAA completed its study to define and specify human factors issues in developing and approving air carrier and repair station maintenance procedures and programs. In September 1998, the FAA published a report entitled, "human factors in aviation maintenance and inspection, strategic program plan." the report discusses the research program and the strategic program plan. The research program is an industry, government, and labor partnership that involves numerous airline operators, maintenance facilities, universities, research laboratories, and government agencies worldwide. Through these partnerships, the research program has created, implemented, evaluated, and measured a variety of prototype products to enhance training, job aiding, and information systems for aviation maintenance personnel. The results of all research conducted in this area can be obtained on the FAA web site by accessing the following: (www.faa.gov/avr/afs/300/afs300c.html). The strategic program plan describes the ongoing industry, government, and labor partnerships that characterize the human factors in aviation maintenance and inspection research program. The plan provides scientific explanation and rationalization of the need for applied human factors research and development and includes historical, current, and future research and development goals and milestones. Under continuing association with the worldwide aviation industry, the research program ensures that human performance is a central focal point of the aviation maintenance system. The FAA is currently reviewing the information contained in the report and will be developing a strategy on how to implement the information into approved maintenance procedures and programs. The FAA anticipates completing the review by September 1999.

From: FAA
To: NTSB
Date: 11/17/1997
Response: The FAA agrees with the intent of this safety recommendation and is conducting a study to define and specify human factors issues in developing and approving air carrier and repair station maintenance procedures and programs. This study will develop information on human factors issues that can be used by the FAA and industry to establish and approve maintenance procedures and programs. Once the study is completed, the FAA will implement appropriate policy or regulatory change to address these human factors issues. As part of the FAA's ongoing program to incorporate human factors into aviation maintenance, the FAA developed a "Human Factors Guide for Aviation Maintenance," which contains information and guidance to recognize and take into account human capabilities and limitations in the aircraft maintenance domain. The "Human Factors Guide for Aviation Maintenance" is being revised to update the information contained in the guide and to add an additional chapter on Maintenance Resource Management. I will keep the Board informed of the FAA's progress on this safety recommendation.