What is the problem?
Regardless of the purpose of the flight or the type of aircraft, all
flights should be safe—right now they may not be. That’s because
the Federal Aviation Administration (FAA) doesn’t require air medical service, air taxi, charter, or on-demand flights to meet
the same safety requirements as commercial airlines. Even without
requirements, many such operators could be taking more initiative to
ensure the highest level of safety for their aircraft and passengers.
Most of the organizations that conduct Part 135 operations do
not have—and are not required to have—a safety management
system (SMS), flight data monitoring (FDM), or controlled flight into
terrain (CFIT)-avoidance training program. These programs enable
operators to take a strategic approach to safety management,
requiring that safety-focused policies, practices, and procedures
be implemented to keep aircrews and passengers safe. SMS and
FDM programs also yield data that can be used to improve safety
practices to better prevent accidents. We don’t know how many
operators have SMS or FDM programs because the FAA doesn’t
require operators to implement and report on them.
CFIT-avoidance training programs are required for Part 135 helicopter
operations, but not for Part 135 fixed-wing operations. We have
investigated several fatal CFIT accidents involving flights operated
under visual flight rules at low altitudes where terrain awareness
and warning system (TAWS) alerts were inhibited due to the lack of
effective TAWS protections and nuisance-alert mitigations.
Despite the availability of SMS, FDM, and CFIT-avoidance programs,
preventable crashes involving Part 135 aircraft are occurring all
too frequently, like the November 10, 2015, fatal accident in Akron,
Ohio, involving a British Aerospace HS 125-700A. Our investigation
identified a lack of compliance with standard operating procedures
that could have been mitigated with an SMS.
Our investigation of the October 2, 2016, crash of a turbine-powered
Cessna 208B Grand Caravan airplane into steep, mountainous terrain
northwest of Togiak, Alaska, identified safety issues related to a lack
of SMS, FDM, and adequate CFIT training and technology use. In this
accident, which killed two pilots and the passenger, we discovered
the need for improvements in the operator’s CFIT-avoidance training,
and the need for SMS and FDM programs (and supporting devices)
for Part 135 operators, among other issues.
What can be done?
We know that SMS, FDM, and CFIT programs can improve safety and
prevent crashes. We currently have 21 open safety recommendations
addressing the safety gap in Part 135 operations. Operators must
be proactive about safety; they should not wait for regulations or
an accident to move them to action. Some operators have already
incorporated SMS, FDM, and CFIT programs and are seeing
tremendous safety returns.
To increase use of SMS, FDM, and CFIT
programs in Part 135 aircraft, the following
actions should be taken:
- Install an SMS and FDM, appropriately scaled to the size of your
operation, to detect and correct unsafe deviations from company
procedures before an accident occurs.
- An SMS is an effective way to establish and reinforce a positive
safety culture and identify deviations from standard operating
procedures so that they can be corrected.
- Collect data through an FDM over the entirety of the operation;
this is the only means an operator has to consistently and
proactively monitor its line operations. FDM should be a
- Use analysis tools provided by associations and the FAA’s
InfoShare to identify safety trends.
- Incorporate a CFIT-avoidance training program that addresses
current TAWS technologies relevant to your operational environment.
- Require all Part 135 operators to install flight data recording
devices capable of supporting an FDM program and to establish
- Work with Part 135 operators to improve voluntarily implemented
training programs aimed at reducing the risk of CFIT accidents
involving continuing flight under visual flight rules into instrument
meteorological conditions, paying special attention to human
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