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On January 9, 1997, an Empresa Brasileira de Aeronautica, S/A (Embraer) EMB-120RT, operated by COMAIR Airlines, Inc., crashed during a rapid descent after an uncommanded roll excursion near Monroe, Michigan. The flight was a scheduled, domestic passenger flight from the Cincinnati/Northern Kentucky International Airport, Covington, Kentucky, to Detroit Metropolitan/Wayne County Airport, Detroit, Michigan. The flight departed Covington with 2 flightcrew, 1 flight attendant, and 26 passengers on board. There were no survivors. The airplane was destroyed by ground impact forces and a postaccident fire. IMC prevailed at the time of the accident, and the flight was operating on an IFR flight plan.The probable cause of this accident was the FAA's failure to establish adequate aircraft certification standardds for flight in icing conditions.
TO THE FEDERAL AVIATION ADMINISTRATION: Require principal operation inspectors (POIs) to discuss the information contained in airplane flight manual revisions and/or manufacturers' operational bulletins with affected air carrier operators and, if the POI determines that the information contained in those publications is important information for flight operations, to encourage the affected air carrier operators to share that information with the pilots who are operating those airplanes.
Original recommendation transmittal letter:
Closed - Acceptable Action
MONROE, MI, United States
In-Flight Icing Encounter and Uncontrolled Collision with Terrain, Comair Flight 3272, Embraer EMB-120RT, N265CA
Addressee(s) and Addressee Status:
FAA (Closed - Acceptable Action)
Safety Recommendation History
On May 28, 1999, the FAA issued a joint flight standards handbook bulletin for air transportation, airworthiness, and general aviation, titled “Flight Standards Policy–Company Operating Manuals and Company Training Program Revisions for Compliance,” which it believed would fully satisfy these recommendations. The handbook bulletin directed that POIs encourage their operators to (1) have a reliable delivery system in place for flight manual revisions to ensure that operators receive revisions within 30 calendar days of approval and (2) develop an action plan to notify, in writing, respective POIs of new flight manual revisions within 15 days after receipt. On July 7, 2000, the FAA informed the NTSB that it had initiated a notice of proposed rulemaking (NPRM), proposing to revise 14 Code of Federal Regulations (CFR) Part 121, subparts N and O, to include the policy contained in the bulletins, and that the FAA anticipated that the NPRM would be published in the Federal Register for comment by February 2001. It was not published until January 12, 2009, when the FAA published an NPRM titled “Qualification, Service and Use of Crewmembers and Aircraft Dispatchers,” which was followed on May 20, 2011, with the publication of a supplemental notice of proposed rulemaking (SNPRM) with a similar title. Both that NPRM and the SNPRM proposed revisions to Part 121, subparts N and O, and both contained proposed revisions that addressed Safety Recommendations A-98-89 and -102. As recently as March 14, 2013, then?Secretary of Transportation Ray LaHood stated in the second annual report to the Congress on the Department of Transportation responses to the NTSB’s air carrier safety recommendations that Safety Recommendations A-98-89 and -102 had “been incorporated into the proposed rule change to part 121, subparts N and O. The Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers NPRM was published for public comment on January 12, 2009. Due to the extensive comments received, the FAA drafted an SNPRM, which was published for public comment on May 20, 2011. The SNPRM proposes to include §121.134, Preparation of Manuals, and §121.540, Manual Procedures Requirements.” The November 12, 2013, final rule was based on the NPRM and SNPRM but did not contain the proposed revisions to Sections 121.134 and 121.540. We reconsidered whether the bulletins issued on May 28, 1999, fully addressed these recommendations without the revisions contained in the SNPRM. The FAA no longer uses flight standards handbook bulletins; however, the relevant information in the May 1999 bulletins is now contained in FAA Order 8900.1, “Flight Standards Information Management System,” Volume 3, Chapter 32, “Manuals, Procedures, and Checklists for 14 CFR Parts 91 K, 121, 125, and 135.” In addition, we learned that the FAA’s air transportation oversight system contains procedures in element performance inspection 2.1.1 and safety attribute inspection 2.1.1 on manual management that require POIs to perform recurrent checks of the items specified in the recommendations. Consequently, Safety Recommendations A-98-89 and -102 are classified CLOSED—ACCEPTABLE ACTION.
In a SWAT meeting, the FAA indicated that it shares the Board’s concern about POIs having access to the latest information and changes to airplane flight manuals and manufacturer’s operational bulletins. The FAA believes that some sort of regulation to require manufacturers to provide this information to the FAA for use by POIs may be needed. The FAA will consider how this might be achieved and provide an update to the Board on planned actions.
The Safety Board believes that it is not the operator's duty to provide POIs with the appropriate documents for AFM revisions, rather the POIs should be up-to-date on their assigned carriers' aircraft, which includes having the most current updates of applicable manuals and instructions. Relying on operators to provide POIs with such documentation interferes with the official performance of their duties as regulatory officials. Although the Safety Board agrees that it is a POI's duty to evaluate operators' compliance with FAA regulations, the board also believes that POIs should have a system of evaluation standards that does not rely on operators' initiative. The Safety Board is encouraged by the creation of a user-friendly database and its use by POIs in their surveillance activities and other flight standards personnel in the performance of their duties. It is the Safety Board's understanding of HBAT 99-16A, HBAW 99-14A, and HBGA 99-20A that FAA personnel will independently be responsible for updating this database and will not rely on carriers to submit this information. The bulletin describes the use of the database and the measures that the FAA plans to develop to assist in monitoring implementation of AFM revisions and manufacturer's operational bulletins. However, several items of concern remain; therefore, we request that the FAA clarify the following matters: (1) will the database include manufacturers' operational bulletins as well as AFMs? Retention of operational bulletins in the database is included under the heading "purpose and records" in the database sections of HBAT 99-16A, HBAW 99-14A, and HBGA 99-20A. However, in section 4b, "database use during surveillance," inspectors are instructed to use the database for surveillance and compare the database to "operator's AFM(s), manual(s), and training program(s)." Manufacturers' operational bulletins are not included in this list. (2) HBAT 99-16A, HBAW 99-14A, and HBGA 99-20A, as written, describe the inclusion of information and its use during surveillance. However, there is no system to make flight standards personnel, including POIs, aware of new revisions to the AFMs or manufacturers' operational bulletins. Waiting until the next surveillance round to make flight standards personnel aware of such changes may create an excessive period of time before the POI ensures the operator's compliance with these revisions. (3) the database will contain only the number, date, and name of the document corresponding to each AFM revision and each operational bulletin listed. The database will not include full text information reflecting the content. Therefore, when the POI or other flight standards personnel use the database, they will be required to obtain copies of these documents. A-98-103 specifically mentions "including the background and justification for the revision." Existing computer technology should allow for at least an abstract, including the background and justification of the document, to be placed in the database. Pending clarification from the FAA that manufacturers' operational bulletins in the database will be included in oversight activities by the POI, the development of a system within the FAA to alert POIs and other flight standards personnel when new information is posted to the database, and revision of the database to include an abstract including background and justification of the revisions to the AFMs and Operational Bulletins, A-98-89 and A-98-103 are classified as OPEN – ACCEPTABLE RESPONSE.
Letter Mail Controlled 9/22/99 9:22:50 AM MC# 991064 - From Jane F. Garvey, Administrator: The FAA agrees with the intent of this recommendation and on 5/28/99, issued joint flight standards handbook bulletin for air transportation (HBAT), airworthiness (HBAW), and general aviation (HBGA). The bulletin directs principal operations inspectors to encourage their operators to have a reliable delivery system in place for airplane flight manual (AFM) and rotorcraft flight manual (RFM) revisions. The delivery system should ensure that the operator receives flight manual revisions within 30 calendar days of FAA approval. Each operator will be encouraged to develop an action plan and notify its respective POI in writing within 15 calendar days of receipt when a new AFM/RFM revision has been received. I have enclosed a copy of the bulletin for the Board's information. To address issues concerning manuals and currency of airplane operating information, working group V was established at the FAA's in-flight operations in icing conditions conference in February 1999. The participants on the work group consisted of representatives from the FAA, Safety Board, manufacturers, operators, and industry groups. Regarding the issue of operators reviewing aircraft manufacturers' operations bulletins with the possibility of incorporating that information into various company manuals and training programs, the working group participants reached consensus on the following points: (1) operators need a sole source of information from which to implement operating procedures recommended by aircraft manufacturers. The participants agreed that the current AFM revision process would be the sole source of changes in company flight manuals and training programs. (2) operational procedures recommended in an aircraft manufacturer's operations bulletin, although deemed desirable, may conflict with operational procedures contained in an approved AFM or company flight manual currently in use by the operator. Based on the above, the FAA established safety policy in the joint flight standards handbook bulletin for air transportation (HBAT), airworthiness (HBAW), and general aviation (HBGA), flight standards policy - company operating manuals and company training program revisions for compliance with current airplane or rotorcraft flight manual revisions. The bulletin, dated 5/28/99, establishes the following safety policy: (1) aircraft operating procedures contained in aircraft manufacturers' operations bulletins are for information only. (2) operators shall not change existing approved aircraft manufacturers' recommended operating procedures in the company flight manuals based solely on information contained in the aircraft manufacturers' operations bulletins, unless the change is coordinated through the POI. POIs will coordinate approval of any proposed changes through the aircraft evaluation group and aircraft certification office. This coordinated process, which involves collective expertise of the operator, the POI, and the subject matter experts in the aircraft in the aircraft evaluation group and the aircraft certification office, ensures a uniform implementation within the industry of new operational procedures recommended in an aircraft manufacturer's operations bulletin. The FAA policy with respect to aircraft manufacturer operations bulletins makes it clear to manufacturers that recommended operating procedures in operations bulletins must be incorporated into the appropriate AFM/RFM through the revision process. In addition to the above actions, the joint flight standards handbook bulletin for air transportation (HBAT), airworthiness (HBAW), and general aviation (HBGA), flight standards policy - company operating manuals and company training program revisions for compliance establishes the following FAA policy: (1) information contained in approved sections of the AFM/RFM pertaining to operating limitations, operating procedures, performance information, loading information, and other information necessary for safe operations must be incorporated in the operator's company flight manual and in its training program. (2) each operator shall ensure that its AFM/RFM, company flight manual, and training program are kept current. The actions that have been outlined, address the full intent of this safety recommendation. It is the operator's responsibility to ensure receipt of AFM and RFM revisions, evaluate and incorporate the information into company manuals and training programs, disseminate information to flightcrews, and furnish current copies of AFM and RFM revisions to the POI upon request. The poi's responsibility is to assess if the procedures considered by the operator are in compliance with information required in the AFM operating limitations, operating procedures, performance information, and loading information sections. If the procedures are in compliance, the poi will either approve or accept them as applicable. If they are not in compliance, the poi will not approve the procedures. I have enclosed a copy of the bulletin for the board's information, and I consider the FAA's action to be completed on this safety recommendation.
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