Safety Recommendation A-13-013
Details
Synopsis: On August 26, 2011, about 1841 central daylight time, a Eurocopter AS350 B2 helicopter, N352LN, crashed following a loss of engine power as a result of fuel exhaustion near the Midwest National Air Center (GPH), Mosby, Missouri. The pilot, flight nurse, flight paramedic, and patient were killed, and the helicopter was substantially damaged by impact forces. The emergency medical services (EMS) helicopter was registered to Key Equipment Finance, Inc., and operated by Air Methods Corporation, doing business as LifeNet in the Heartland, as a 14 Code of Federal Regulations Part 135 medical flight. Day visual meteorological conditions prevailed at the time of the accident, and a company visual flight rules flight plan was filed. The helicopter was not equipped, and was not required to be equipped, with any onboard recording devices. The flight originated from Harrison County Community Hospital, Bethany, Missouri, about 1811 and was en route to GPH to refuel. After refueling, the pilot planned to proceed to Liberty Hospital, Liberty, Missouri, which was located about 7 nautical miles (nm) from GPH. The helicopter impacted the ground in about a 40° nose-down attitude at a high rate of descent with a low rotor rpm. Wreckage examination determined that the engine lost power due to fuel exhaustion and that the fuel system was operating properly. The investigation revealed that the pilot did not comply with several company standard operating procedures that, if followed, would have led him to detect the helicopter’s low fuel state before beginning the first leg of the mission (from the helicopter’s base in St. Joseph, Missouri, to Harrison County Community Hospital). After reaching the hospital, the pilot reported to the company’s EMS communication center that he did not have enough fuel to fly to Liberty Hospital and requested help locating a nearby fuel option. During their conversation, the pilot did not report and the communication specialist did not ask how much fuel was on board the helicopter, and neither of them considered canceling the mission and having fuel brought to the helicopter. After determining that GPH was the only airport with Jet-A fuel along the route of flight to Liberty Hospital, the pilot decided to proceed to GPH, although the estimated flight time to GPH was only 2 minutes shorter than that to Liberty Hospital. The engine lost power about 1 nm short of the airport, and the pilot did not make the flight control inputs necessary to enter an autorotation, which resulted in a rapid decay in rotor rpm.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require all existing turbine-powered, nonexperimental, nonrestricted-category aircraft that are not equipped with a flight data recorder or cockpit voice recorder and are operating under 14 Code of Federal RegulationsParts 91, 121, or 135 to be retrofitted with a crash-resistant flight recorder system. The crash-resistant flight recorder system should record cockpit audio and images with a view of the cockpit environment to include as much of the outside view as possible, and parametric data per aircraft and system installation, all as specified in TechnicalStandard Order C197, “Information Collection and MonitoringSystems.”
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Aviation
Location: Mosby, MO, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: CEN11FA599
Accident Reports:
Report #: AAR-13-02
Accident Date: 8/26/2011
Issue Date: 5/6/2013
Date Closed:
Addressee(s) and Addressee Status: FAA (Open - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: FAA
To: NTSB
Date: 3/2/2022
Response: -From Steve Dickson, Administrator: In our previous response, we noted that the Federal Aviation Administration (FAA) submitted a rulemaking project for Fiscal Year (FY) 2020 to determine the feasibility of requiring parts 91, 121, and 135 aircraft to be fitted with a crash-resistant flight recorder system. However, due to other rulemaking priorities and associated resource constraints, we now expect approval of this rulemaking project in FY 2022. We will provide further information on this rulemaking project when an update is available. The FAA is conducting a review of information from the National Transportation Safety Board aviation accident database to assist our efforts to address these recommendations. Our focus is on possible benefits from fitting newly manufactured aircraft and retrofitted aircraft with a crash resistant flight recorder system that records cockpit audio and images. This would include a view of the cockpit environment with as much of the outside view as possible and parametric data per aircraft and system installation, as specified in Technical Standard Order (TSO) C197, Information Collection and Monitoring Systems. If the rulemaking is approved, this data will also be used to determine the feasibility of requiring parts 91, 121, and 135 aircraft to be fitted or retrofitted, with a crash-resistant flight recorder that meets requirements in TSO-C197 and the Board’s safety recommendations. I will keep the Board informed of the FAA’s progress on these recommendations and anticipate providing an update by March 31, 2023.

From: NTSB
To: FAA
Date: 4/20/2021
Response: We note that, in 2019, you submitted a rulemaking project for fiscal year 2020 to review the feasibility of requiring Title 14 CFR Parts 91, 121, and 135 aircraft to be fitted with crash resistant flight recorder systems. We also note that you postponed directing your aviation safety inspectors who oversee turbine-powered aircraft operators to determine how many subject aircraft have voluntarily installed FDM systems. We believe the rulemaking you are considering is positive; however, we are concerned that, since your last update in 2017, you appear to have made no progress in implementing these recommendations. We are surprised to learn that the notice, which you had planned to issue in 2018, has still not been issued, especially because we believe it would be useful for developing the cost-benefit analyses necessary to justify rulemaking, given it would provide you with valuable information about the number of operators who have voluntarily installed FDM systems and how many of those systems are TSO C197 compliant. Since 2017, Safety Recommendations A-13-12 and -13 have been reiterated four and five times, respectively. Safety Recommendation A-13-13 was most recently reiterated on February 9, 2021, in our accident report, Rapid Descent Into Terrain, Island Express Helicopters, Inc., Sikorsky S-76B, N72EX, Calabasas, California, January 26, 2020, where it was classified “Open—Unacceptable Response.” We recognize that you have many competing priorities, and the required cost-benefit analysis will be challenging; however, we encourage you to make this safety issue a priority and act now. Pending your taking the recommended actions, Safety Recommendation A-13-12 is classified “Open—Unacceptable Response,” and Safety Recommendation A-13-13 remains classified OPEN-- UNACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 2/25/2021
Response: Reiterated and reclassified in NTSB Aviation Accident Report AAR-21-01 “Rapid Descent Into Terrain Island Express Helicopters Inc. Sikorsky S-76B, N72EX Calabasas, California January 26, 2020.” Published on February 25, 2021. 2.7 Crash-Resistant Flight Recorder Systems Certain circumstances of this accident could not be conclusively determined, including the visual cues associated with the adverse weather and the pilot’s focus of attention in the cockpit following the flight’s penetration of clouds and entry into IMC. A crash-resistant flight recorder system capable of capturing audio and images could have provided this valuable information, possibly enabling the identification of additional safety issues and the development of safety recommendations to prevent similar accidents in the future. The NTSB has previously issued recommendations to require recorders on helicopters, such as on the Sikorsky S-76B helicopter involved in this accident. The first of these helicopter-specific recommendations resulted from our participation in the 2005 foreign-led investigation of a fatal accident involving a Sikorsky S-76C+ helicopter, registered in Finland, that experienced an upset and crashed into the Baltic Sea due to an airworthiness problem.71 This was the first time that we participated in an accident investigation involving a helicopter that was equipped with a flight data recorder (FDR), which was required equipment per Finland’s regulations. Importantly, without the FDR data, the investigation would not have been able to identify and address the airworthiness issue that caused the accident. 71 The accident, which killed both pilots and all 12 passengers, occurred on August 10, 2005, and involved a Sikorsky S-76C+ helicopter that departed Tallinn, Estonia, en route to Helsinki, Finland. 72 The types of CVRs and FDRs that are required by regulation to be installed on certain aircraft are designed to stringent crash-survivability standards. Crash-resistant flight recorders, which are designed to a less stringent survivability standard, are generally less expensive, lighter weight, and able to record much of the same information as CVRs and FDRs, as well as cockpit images. As a result, we not only issued three urgent NTSB safety recommendations to address the airworthiness issue, but we also issued Safety Recommendations A-06-17 and -18 to the FAA to address recorders for helicopters in the United States. These recommendations asked the FAA to require all rotorcraft operating under Parts 91 and 135 with a transport-category certification (such as the Sikorsky S-76-series helicopter) to be equipped with a cockpit voice recorder (CVR) and an FDR, and to not permit exemptions or exceptions to the flight recorder regulations that allow such rotorcraft to operate without recorders (NTSB 2006). As a result of the FAA’s decision not to take these actions, we classified both A-06-17 and -18 “Closed—Unacceptable Action” on September 11, 2014. On May 6, 2013, the NTSB issued Safety Recommendation A-13-13 to recommend that the FAA require a crash-resistant flight recorder system compliant with Technical Standard Order (TSO) C197, “Information Collection and Monitoring Systems,” as a retrofit on existing turbine-powered, nonexperimental, nonrestricted-category aircraft that are not equipped with an FDR or CVR and are operating under Parts 91, 121, or 135.72 The crash-resistant flight recorder system should record cockpit audio and images with a view of the cockpit environment to include as much of the outside view as possible, and parametric data per aircraft and system installation(NTSB 2013).73 In the 7 years since we issued Safety Recommendation A-13-13, we have reiterated it five times based on our findings from investigations of other fatal accidents (NTSB 2014, 2017a, 2017b, 2018, and 2020a).We have been issuing similar recommendations since 2000 (NTSB2000).74 During this 20-year period, the FAA has replied that it does not disagree with these recommendations but that it is unable to create a cost-benefit analysis for such a mandate that would satisfy the requirements of the Office of Management and Budget for new federal regulations. The FAA has not been able to identify quantifiable benefits associated with a mandate for recorders. During 2017, staff from the FAA and the NTSB met to discuss what information from the NTSB would help the FAA develop the needed cost-benefit analysis to justify the recommended mandate. On July 19, 2017, NTSB staff provided the FAA a list of all accidents in our database from 2005 through 2017 that involved turbine powered, nonexperimental, nonrestricted-category aircraft and in which flight crew were killed. There were 185 such accidents. For159 of these, the accident aircraft had no form of recording equipment and involved advanced aircraft with complex systems that are more difficult to investigate due to the lack of information. Of the 159 accidents, the probable cause for 18contained “unknown” (for example, if the aircraft crashed after take off for unknown reasons). On October 2, 2017, we noted that, although doing the cost-benefit analysis needed to issue the recommended mandate would be challenging, the FAA now appeared to be examining how to accomplish it. Pending the FAA taking the recommended action, Safety Recommendation A-13-13 was classified “Open—Acceptable Response.” In addition, on June 2, 2020, the NTSB issued Safety Recommendation A-20-29 to six helicopter manufacturers (including Sikorsky) to recommend that they provide, on existing turbine-powered helicopters that are not equipped with an FDR or CVR, a means to install a crash-resistant flight recorder system that records cockpit audio and images with a view of the cockpit environment to include as much of the outside view as possible and parametric data per aircraft and system installation, all as specified in TSOC197. The recorder system installation should be considered essential equipment that remains installed for the life of the helicopter and have provisions to ensure it remains operational during each flight (NTSB 2020b).75 Thus, the NTSB concludes that a crash-resistant flight recorder system that records parametric data and cockpit audio and images with a view of the cockpit environment to include 73We also issued Safety Recommendation A-13-12, which applied to newly manufactured helicopters; see appendix C for more information. The accident helicopter, as operated by Island Express (per its OpsSpecs) for VFR flights, was not required to be equipped with a CVR because only one pilot was required. (Per 14 CFR135.151[a], a CVR was required for multiengine, turbine-powered airplanes and rotorcraft having a seating configuration of six or more and for which two pilots were required by certification or operating rules.) 74See appendix C for more information. 75Safety Recommendation A-20-29 is classified “Open—Acceptable Response” overall (with the recipient classification for Sikorsky “Open—Await Response”); see appendix C for more information. On October 5,2020, the General Aviation Manufacturers Association sent us a letter stating that, although it (on behalf of the rotorcraft community) supported the objective of our safety recommendation, it found it to be prohibitively prescriptive. as much of the outside view as possible could have provided valuable information about the visual cues associated with the adverse weather and the pilot’s focus of attention in the cockpit following the flight’s entry into IMC. Therefore, the NTSB reiterates Safety Recommendations A-13-13 and A-20-29. Also, on September 29, 2020, the FAA provided us with an update stating that it submitted a rulemaking project for fiscal year 2020 to review various standards and methodologies to determine the feasibility of requiring aircraft operated under Parts 91, 121, and 135 to be equipped with a crash-resistant flight recorder system. However, w

From: NTSB
To: FAA
Date: 2/25/2021
Response: Reiterated and reclassified in NTSB Aviation Accident Report AAR-21-01 “Rapid Descent Into Terrain Island Express Helicopters Inc. Sikorsky S-76B, N72EX Calabasas, California January 26, 2020.” Published on February 25, 2021. This report classified Safety Recommendation A-13-13 OPEN--UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/29/2020
Response: -From Steve Dickson, Administrator: In September 2019, the Federal Aviation Administration (FAA) submitted a rulemaking project for Fiscal Year 2020 to review various standards and methodologies to include determining the feasibility of requiring part 91, 121, and 135 aircraft to be fitted with a crash-resistant flight recorder system. We will provide further information on this rulemaking project when an update is available. In our letter dated July 20, 2017, we reported that we intended to publish a notice to our aviation safety inspectors that oversee operators of turbine-powered aircraft not required to be equipped with a flight data recorder or cockpit voice recorder under parts 91 and 135 to determine how many have voluntarily installed flight data monitoring systems. At this time, we have paused these efforts until next steps with the rulemaking project are determined. I will keep the Board informed of the FAA’s progress on these recommendations and provide an update by September 30, 2021.

From: NTSB
To: FAA
Date: 6/8/2020
Response: Reiterated in Aviation Accident Report AAR-20-01, PB2020-101001, Notation 64859, Adopted on May 19, 2020 and published on June 8, 2020 “Helicopter Air Ambulance Collision with Terrain Survival Flight Inc. Bell 407 Helicopter N191SF near Zaleski, Ohio January 29, 2019 From the report: 2.5 Lack of Flight Recorder Because the helicopter was not equipped with a video recorder, flight data recorder, or cockpit voice recorder, the accident pilot’s control inputs during the final 30 seconds are unknown. Additionally, because of the lack of a video recorder, the investigation could not conclusively determine the specific weather conditions encountered. Although FDM data were available to determine the altitude, groundspeed, and flightpath of the helicopter, the data dropped for 2 minutes during the flight and ended about 30 seconds before impact. During the periods when no FDM data were available, the NTSB could only estimate the helicopter’s altitude, airspeed, and flightpath based on satellite data. Therefore, the NTSB concludes that if a recorder system that captured cockpit audio, images, and parametric data had been installed, it would have enabled NTSB investigators to reconstruct the final moments of the accident flight and determine why the accident pilot did not maintain the helicopter’s altitude and successfully exit the encounter with inadvertent instrument meteorological conditions. The NTSB notes that the helicopter was not required to have a crash-resistant recorder installed. Previous NTSB recommendations have addressed the need for recording information on aircraft such as the helicopter involved in this accident. For example, as a result of the NTSB’s investigation of the August 26, 2011, fatal accident involving a Eurocopter AS350 B2 helicopter, on May 6, 2013, the NTSB issued Safety Recommendations A-13-12 and A-13-13 to the FAA.99 These recommendations proposed the required installation of crash-resistant flight recorder systems in both newly manufactured and existing turbine-powered, nonexperimental, nonrestricted-category aircraft that are not equipped with a flight data recorder and a cockpit voice recorder. Specifically, these recommendations proposed that the flight recorder system should record cockpit audio and images with a view of the cockpit environment to include as much of the outside view as possible and parametric data per aircraft and system installation, all as specified in FAA Technical Standard Order C197, “Information Collection and Monitoring Systems.”100 On August 1, 2013, the FAA responded to the recommendations stating it did not intend to mandate the equipage of crash-resistant flight recording systems on all turbine-powered, non-experimental, non-restricted-category aircraft in part because: (1) the cost estimate to the industry could be as high as $180 million (or $20,000 or more per aircraft); (2) the FAA could not determine a quantitative benefit for mandating these recorders because it had no way of estimating the number of lives that could be saved or the number of accidents that could be prevented; and (3) crash-resistant flight recording systems were primarily used for accident investigation activities and, as early as 2005, the FAA adopted a position of promoting voluntary equipage and use of voluntary and non-punitive FDM programs. On December 10, 2013, the NTSB classified Safety Recommendations A-13-12 and A-13-13 as “Open-Unacceptable Response” because the FAA stated that it had not found any compelling evidence to require the installation of cockpit image recording systems and planned no further action. The NTSB stated it would be premature to close the recommendations as the lack of image recording systems on aircraft remained an important safety issue. Despite the FAA’s position, the NTSB continues to investigate accidents in which the benefit of flight recording devices, specifically cockpit image recording systems, has been demonstrated. For example, in the March 30, 2013, accident investigation involving a Eurocopter AS350 B3 helicopter, the NTSB gained valuable information from the helicopter’s onboard Appareo Systems Vision 1000 unit.101 The helicopter was involved in a search-and-rescue mission when the pilot encountered deteriorating weather conditions, which resulted in the pilot’s spatial disorientation and loss of control. The images that were captured by the Appareo unit provided information that helped investigators determine precisely how the cockpit navigational displays were configured and that the pilot caged the attitude indicator in flight. This information, along with the wreckage examination, enabled investigators to conclusively determine that icing was not a factor in the accident and that there were no mechanical anomalies with the helicopter. While the NTSB acknowledges that many operators have voluntarily installed recorder systems, such as FDM systems and Appareo units, they are not required to comply with the crash-resistant requirements outlined in Technical Standard Order C197. Consequently, the NTSB has investigated accidents in which these units were badly damaged during the accident and we were unable to recover data. For example, in the NTSB’s investigation into the July 3, 2015, accident involving an Airbus AS350 B3e helicopter, the NTSB was unable to recover data from the Appareo device due to the impact and fire damage sustained during the accident. The helicopter experienced a hydraulic failure after takeoff, resulting in a loss of control and impact with the ground. Because the data from the Appareo unit was unable to be recovered, the NTSB could not determine the possible reasons that the pilot did not complete the hydraulic check or perform a hover check. Additionally, the NTSB could not determine the application or duration of flight control inputs and any annunciations on the caution and warning panel. The NTSB acknowledges that investigators sometimes have multiple sources of data when investigating an accident; however, a crash-resistant flight recorder system would provide a more conclusive dataset for the discovery of hazards that may otherwise remain undetected in the aviation system. Therefore, the NTSB reiterates Safety Recommendations A-13-12 and A-13-13.

From: NTSB
To: FAA
Date: 4/26/2018
Response: The following is from the NTSB Aviation Accident Report “Collision with Terrain Hageland Aviation Services, Inc. dba Ravn Connect Flight 3153 Cessna 208B, N208SD, Togiak, Alaska October 2, 2016.” Report number AAR-18-02. Adopted on April 17, 2018 and published on April 26, 2018. Since 1999, the NTSB has issued a series of recommendations regarding the need for crash-resistant flight recorder systems on new and existing aircraft that are not already required to have such recorders. The NTSB’s most recent recommendations resulted from its investigation of the 2011 fatal accident involving a Eurocopter AS350 B2 helicopter that crashed after a loss of engine power in Mosby, Missouri. On May 6, 2013, the NTSB issued Safety Recommendations A-13-12 and -13 to the FAA, respectively, as follows: Since these recommendations were issued, the FAA has maintained that it is unable to develop the recommended requirement for recorders because the FAA is required to obtain approval for all new regulations from the OMB, which rigorously reviews the CBA associated with any regulatory revisions to ensure that the safety benefits resulting from new regulations justify the societal costs of the proposed regulation. The FAA has been unable to develop a CBA to justify a recorder mandate because the benefits of recorders are difficult to identify and quantify because the absence of a recorder will never cause an accident. On July 20, 2017, the FAA stated it was working to develop a preliminary CBA associated with these safety recommendations to determine if pursuing rulemaking is cost beneficial. In an October 2, 2017, reply, the NTSB said that these recommendations were issued because the information recorders provide helps investigators identify important aviation safety issues, and recorder data are necessary to effectively mitigate these safety risks; therefore, any CBA the FAA developed to justify a recorder mandate must be based on said safety risks. An adequate evaluation of these recommendations should include reviewing safety improvements that would not have been identified without recorder data. The evaluation should also acknowledge the number of investigated accidents in which the probable cause included “for unknown reasons.” In its October 2, 2017, letter, the NTSB supplied to the FAA an analysis listing accidents in the NTSB database from 2005 through 2017 that involved turbine-powered, nonexperimental, nonrestricted-category aircraft and in which flight crew were killed. Of the 185 accident aircraft, 159 had no form of recording equipment, and all 159 aircraft without recorders were advanced with complex systems that are typically much more difficult to investigate when there is a lack of information. Of the 159 accidents involving aircraft without recorders, 18 had probable cause determinations that contained “unknown.” Pending responsive action from the FAA, the NTSB classified Safety Recommendations A-13-12 and -13 “Open—Acceptable Response” on October 2, 2017. During the Hageland accident investigation, a crash-resistant flight recorder system would have provided a more appropriate dataset for the discovery of hazards that may otherwise remain undetected in the aviation system. Because of the relevance of crash-resistant flight recorder systems to this accident and their importance for all turbine-powered, nonexperimental, nonrestricted-category aircraft not presently equipped with an FDR or a CVR, the NTSB reiterates Safety Recommendations A-13-12 and -13.

From: NTSB
To: FAA
Date: 10/2/2017
Response: In our August 11, 2016, letter to you about these recommendations, we acknowledged that you need to analyze any new regulation to show a positive cost–benefit, and that it was difficult to identify the benefits of recorders because the absence of a recorder will never cause an accident. However, we issued these recommendations because the information recorders provide help investigators identify important aviation safety issues, and recorder data is necessary to effectively mitigate these safety risks; therefore, we believe that any cost–benefit analysis you developed to justify a recorder mandate must be based on said safety risks. We are aware that you frequently use our aviation accident investigation findings when analyzing the benefits of new requirements. We believe that an adequate evaluation of these recommendations should include reviewing your safety improvements that would not have been identified without recorder data. We also believe your evaluation should acknowledge the number of investigated accidents in which the probable cause included “for unknown reasons.” We believe this information is important for developing the cost–benefit analyses necessary to justify a recorder mandate. On January 11, 2017, we met with your staff to discuss these safety recommendations and determine what data you needed from us for you to prepare a cost–benefit analysis. At this meeting, and in your letter, you indicated that your staff resources for a new rule are obligated through fiscal year 2018, and you are not currently considering rulemaking for these safety recommendations. After our meeting, your staff asked us to answer four questions, which are included and answered below. On July 19, 2017, we e-mailed you our answers, along with a spreadsheet (Affected Airplane Accidents.xlsx) containing all of the accidents in our database from 2005 through 2017 that involved turbine powered, nonexperimental, nonrestricted-category aircraft, in which flight crew were killed. 1. In the last 10 years, how many accidents involved a turbine-powered, nonexperimental, nonrestricted-category aircraft operated under Title14 CFR Parts 91 or 135? Our answer: The spreadsheet file, Affected Airplane Accidents.xlsx, which we sent by e-mail on July 19, 2017, shows all of the accidents from 2005 through 2017 in our database involving turbine powered, nonexperimental, nonrestricted-category aircraft in which flight crew were killed. There were 185 of these accidents. 2. How many accident investigations identified in question 1 revealed an accident aircraft with no form of recording equipment (recording equipment would include flight data monitoring (FDM) systems, cockpit voice recorder (CVR), and flight data recorder (FDR))? Our answer: There were 159 accident aircraft with no form of recording equipment. 3. How many accident investigations identified in question 2 were either significantly hindered or unresolved due to lack of recording equipment installed? Our answer: All of the accidents without recorders (159) involved advanced aircraft with complex systems that are much more difficult to investigate due to the lack of information. The information recorders provide enables us to identify vital aviation safety issues and remedies to effectively mitigate the associated safety risks. As we explained in our July 19, 2017 e-mail, the spreadsheet indicates if the probable cause contained “unknown” (for example, if the plane crashed after takeoff for unknown reasons). There were 18 such accidents. 4. For those accident investigations identified in question 3, what was the total quantified burden in time and costs to the Board? Our answer: The total quantified burden cannot be determined by available data. We note that, in early 2018, you plan to issue a notice to your aviation safety inspectors that oversee operators of turbine-powered aircraft not required to be equipped with an FDR or a CVR under 14 CFR Parts 91 or 135. This notice will ask them to determine how many subject aircraft have had FDM systems voluntarily installed. We believe the findings from this activity will provide you with valuable information to use when determining how effective your voluntary program is in satisfying these recommendations. Please note that Safety Recommendations A-13-12 and -13 specify that you require recorders that are compliant with TSO C197. We have investigated a number of accidents involving aircraft equipped with FDM systems that were not TSO C197 compliant; in many of those cases, we were unable to recover data due to impact and postcrash fire damage, and we believe that a TSO-C197–compliant recorder would have provided the needed information. We reiterated these recommendations in our report about the July 3, 2015, accident in Frisco, Colorado, because the helicopter in that accident was equipped with an FDM system that was not TSO C197 compliant. We were not able to retrieve data from that recorder because of damage from the postcrash fire, but we believe that if it had been TSO C197 compliant, we likely would have retrieved the data needed to fully understand the safety issues in the accident. We ask that when you do your survey, you obtain information about how many of the FDM systems installed are TSO C197 compliant. We also request a copy of the survey results once it is completed. We are pleased that, although doing the required cost–benefit analysis needed to issue the recommended mandate will be challenging, you now appear to be examining how to accomplish it. Pending your taking the recommended actions, Safety Recommendations A-13-12 and -13 are classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 7/20/2017
Response: -Michael P. Huerta, Administrator: On January 11. 2017. staff fron1 the Federal Aviation Administration's (FAA) Flight Standards Service, Office of Rulemaking, and Office of Accident Investigation and Prevention met with Board staff to discuss these safety recommendations. The FAA outlined challenges related to the current rulemaking environment. New rulemaking projects are prioritized according to predefined criteria whereby the proposed rulemaking project must demonstrate how the rule's safety improvements will justify the cost to the industry. Currently, staff resources for a new rule are obligated through Fiscal Year 2018. and we are not considering rulemaking for these safety recommendations. The Board and FAA staff are working together to develop a preliminary cost benefit analysis associated with these safety recommendations to determine if pursuing rulemaking is cost beneficial. One of the action items from the meeting was for the FAA to send the following questions to the Board. On January 12, 2017, the following questions were sent, and we are awaiting responses. While we are not considering rulemaking at this time for these recommendations, this information will help the FAA quantify and qualify the potential safety impact (from the Board’s investigative perspective) when evaluating our rulemaking options. 1. In the last 10 years, how many accidents involved a turbine-powered. Nonexperimental, non-restricted-category aircraft operated under 14 CFR parts 91 or 135? 2. How many accident investigations identified in question 1 revealed an accident aircraft with no form of recording equipment (recording equipment would include flight data monitoring (FDM) systems. cockpit voice recorder (CVR), and flight data recorder (FDR))? 3. How many accident investigations identified in question 2 were either significantly hindered or unresolved due to lack of recording equipment installed? 4. For those accident investigations identified in question 3. what was the total quantified burden in time and costs to the Board? The FAA also took the action to examine possible ways of polling operators through our aviation safety inspectors (/\Sis) to identify voluntary FDM system equipage rates. In early 2018. The FAA plans to issue a Notice to our AS Is that oversee operators of turbine-powered aircraft not required to be equipped with an FDR or CVR under 14 CFR parts 91 and 135. to determine how many subject aircraft have voluntarily installed FDM systems." This data will help quantity the fleet’s equipage level lo offset the total industry burden. I will keep the Board informed of the FAA"s progress on these recommendations and provide an update by May 31, 2018.

From: NTSB
To: FAA
Date: 5/9/2017
Response: From the NTSB Accident Report “Collision with Terrain, Promech Air, Inc., de Havilland DHC-3, N270PA, Ketchikan, Alaska, June 25, 2015” AAR-17-01, PB2017-102178, Notation 56539, adopted on April 25, 2017: 2.6 Crash-Resistant Flight Recorder Systems The airplane was not equipped, and was not required to be equipped, with any crash-resistant flight recorder system. However, data were retrieved from other devices recovered from the wreckage, including the Chelton EFIS and passenger PEDs and cameras. These devices were not designed for crash-resistance; however, investigators were able to extract data from them. Collectively, data recovered from these items (as well as recorded ADS-B data) provided information about the airplane’s position, attitude, airspeed, altitude, and cockpit switch positions, as well as photographic and video evidence of weather conditions. Had these devices been destroyed by the accident sequence or ADS-B not been installed, none of the noted information would have been available to the investigation. Without this information, the accident airplane’s flightpath and altitude, the localized weather conditions, and the pilot’s actions at the end of the flight would have been in doubt. Although the recovered data were invaluable to this investigation, the nonregulated nature of the devices challenged the investigation because their data lacked the types of critical details provided by devices that record the parameters specified in TSO-C197. For example, the Chelton data contained only indicated altitude (not pressure altitude) and a one-time snapshot of the altimeter setting; passenger photographs and videos did not include a view of the cockpit, pilot, or direct imagery out the front of the aircraft. Further, the recorded data did not include any cockpit conversations or radio communications. Because the accident airplane was not equipped with a flight recorder system that captured cockpit images, investigators lacked detailed information about the visual scene the pilot faced as the events leading up to the accident progressed. Having more information about dynamic aspects of the weather the pilot faced when he turned toward high terrain and how the visual scene evolved thereafter would have allowed investigators to highlight specific characteristics of the weather situation faced by the pilot. This could have provided invaluable information about the types of scenarios that Ketchikan air tour pilots should be trained to recognize and avoid, which could be used to enhance operator training programs aimed at preventing VFR into IMC accidents. Thus, the NTSB concludes that a flight recorder system that captured images of the pilot’s forward view would have benefitted this accident investigation and provided potentially valuable information for air tour operator training programs. As discussed in section 1.9.2.3, the FAA has indicated repeatedly and as recently as May 23, 2016, that it does not intend to mandate the equipage of additional recorder systems on all turbine-powered, nonexperimental, nonrestricted-category aircraft. On March 28, 2017, when the NTSB met to determine the probable cause of a July 3, 2015, fatal accident involving an Airbus Helicopters AS350 B3e that crashed following a loss of control at takeoff in Frisco, Colorado, the Board voted to reiterate Safety Recommendations A-13-12 and -13, which remain classified “Open—Unacceptable Response.” Although investigators had some sources of data when investigating this accident, a crash-resistant flight recorder system would provide a more appropriate dataset for the discovery of hazards that may otherwise remain undetected in the aviation system. Because of the relevance of crash-resistant flight recorder systems to this accident and their importance for all turbine-powered, nonexperimental, nonrestricted-category aircraft not presently equipped with a flight data recorder or cockpit voice recorder, the NTSB reiterates Safety Recommendations A-13-12 and A-13-13.

From: NTSB
To: FAA
Date: 4/13/2017
Response: From the Aviation Accident Report AAR-17-01, PB2017-101425, Adopted March 28, 2017, "Loss of Control at Takeoff Air Methods Corporation Airbus Helicopters AS350 B3e, N390LG, Frisco, Colorado, July 3, 2015": 1.8.2 Analysis The NTSB has investigated some accidents in which aircraft had been voluntarily equipped with crash-resistant flight recorder systems, and the data retrieved from those recorders significantly aided the investigations. However, the NTSB has also investigated some accidents in which aircraft were voluntarily equipped with flight recorders that did not comply with TSO-C197, as requested in Safety Recommendations A-13-12 and -13. In many of the cases involving flight recorders that did not comply with TSO-C197, including the Frisco accident, the NTSB was unable to recover data due to impact and postcrash fire damage. The inability to recover such data precluded the identification of potential safety issues that might not be detectable through other means. For example, as a result of the inability to recover data from the Appareo device that was installed on the helicopter involved in the Frisco accident, the NTSB could not determine possible reasons that the pilot did not complete the last step of the yaw servo hydraulic check or perform a hover check. Also, the NTSB could not determine the duration of the pilot’s full right pedal input before ground impact, his cyclic input, and any annunciations on the caution and warning panel. Most aircraft involved in the NTSB’s investigations do not have a crash-resistant flight recorder, which can affect the agency’s ability to fully investigate the circumstances leading to an event. For example, the lack of available data significantly hindered the NTSB’s investigation of the November 10, 2013, accident involving a Mitsubishi MU-2B-25 that impacted wooded terrain while maneuvering near Owasso, Oklahoma. The NTSB found that, if a crash-resistant flight recorder system had been required and installed on the airplane, recorded video images could have shown where the pilot’s attention was directed during the problems (including a left engine shutdown) that he reported to air traffic control, his interaction with the airplane controls and systems, and the status of cockpit switches and instruments. A crash-resistant flight recorder system could also have provided information about the engine’s operating parameters and the airplane’s motions, which would have allowed the NTSB to determine the reasons for the left engine shutdown and evaluate the pilot’s recognition of and response to an engine problem.102 Although many of the events leading to the Frisco accident could be determined from surveillance videos, such videos are not available for most NTSB investigations, and surveillance videos do not contain the audio, image, and parametric data provided by a crash-resistant flight recorder system. Also, this accident demonstrated that important data might not be recoverable from a flight recorder system that does not comply with the crash-resistance requirements of TSO-C197 if the system was damaged by impact forces and/or fire. The NTSB concludes that data to better understand the safety issues involved in this accident could likely have been recovered from a flight recorder system that complied with the provisions of FAA TSO-C197. As a result, the NTSB reiterates Safety Recommendations A-13-12 and -13.

From: NTSB
To: FAA
Date: 8/11/2016
Response: We understand that you still do not intend to mandate that all turbine-powered, nonexperimental, nonrestricted-category aircraft be equipped with crash-resistant flight recording systems because you have no way of estimating the positive cost benefit of such a mandate to society, as required by the Office of Management and Budget. Although you have never disputed that the recommended action would significantly benefit accident investigations and result in better understanding of underlying aviation safety problems, your inability to quantify a positive cost benefit renders you unable to create a new regulation. In our previous letter, we noted that you have also long indicated that, because you were unable to issue a mandate, you have adopted a “position of promoting and incentivizing the voluntary equipage of crash-resistant flight recording systems,” and that you believed that “industry is already realizing the proliferation and benefits of crash-resistant flight recording systems without a forced mandate.” We were not aware of these programs and asked that you provide us with more information. In particular, we asked that you describe the incentives in these programs and provide any documentation that you collected indicating that industry was already equipping its fleets. We wrote that such programs might constitute the basis for an acceptable alternate response to Safety Recommendations A-13-12 and -13. According to your most recent letter, your program for promoting and incentivizing voluntary equipage consists of the following: • Your November 15, 2010, publication of TSO C197, which standardizes design and production certification requirements for equipment manufacturers so they can streamline aircraft installation and integration. We regard the issuance of the TSO as a positive action, but it does not satisfy our recommendations. We also point out that our original recommendations reference TSO C197. • Your February 18, 2014, final rule, titled “Helicopter Air Ambulance, Commercial Helicopter, and Part 91 Helicopter Operations,” which, in Section 135.607, requires that helicopters conducting air ambulance operations be equipped with flight data monitoring systems. Although we acknowledge that this final rule addresses some of the aircraft covered by these recommendations, it does not address all turbine-powered, nonexperimental, nonrestricted-category aircraft that are not equipped with flight data recorders or cockpit voice recorders. Also, we do not consider a requirement to be a program for promoting, encouraging, or incentivizing. • Your September 1, 2011, publication of “Helicopter Flight Data Monitoring—Industry Best Practices," which you believe covers the incentives of these voluntary flight data monitoring programs. We have reviewed this document and, although it provides good guidance on establishing and operating a flight data monitoring program, we were unable to find anything that could be considered an “incentive” for establishing such a program. We also believe that it is unlikely that anyone not involved in operating helicopters would know about and refer to this document. We note that you do not have documentation indicating the number of aircraft voluntarily equipped with recorders, nor do you have the means to gather such data; therefore, you cannot evaluate whether your voluntary recorder equipage promotion and incentive programs are effective. We have begun to investigate a small number of accidents in which aircraft addressed by these recommendations were voluntarily equipped with crash-resistant flight recorders; however, there was no recorder on the aircraft in the overwhelming majority of our investigations. We have also investigated a number of accidents of aircraft equipped with recorders that were not TSO C197 compliant. In many of these cases, we were unable to recover data due to impact and postcrash fire damage, and we believe that a TSO-C197–compliant recorder would have survived these accidents and provided the needed information. We acknowledge that you need to analyze any new regulation to demonstrate a positive cost benefit, and we understand it is difficult to identify the benefits of recorders because the absence of one will never cause an accident. However, the information recorders provide enables the identification of important aviation safety issues that have caused accidents, and recorder data is necessary to effectively mitigate these safety risks; therefore, we believe that any cost-benefit analysis used to justify a recorder mandate must be based on said safety risks. We are aware that you frequently use our aviation accident investigations when analyzing the benefits of new requirements. We believe that an adequate evaluation of this recommendation should include a review of your safety improvements that address safety risks that would not have been identified, or that would not have been sufficiently understood to develop a mitigation, without the recorder data. We believe the evaluation should also acknowledge the number of accidents investigated where the resulting probable cause included “for unknown reasons.” We believe this information is important for developing the needed cost-benefit analyses necessary to justify a recorder mandate. We welcome the opportunity to meet with your staff to discuss the details of such analyses. Although you plan no further action in response to these recommendations, it would be premature to close them until after such a review is concluded and you have had the opportunity to evaluate the results. Accordingly, pending your taking action to satisfy Safety Recommendations A-13-12 and -13, they remain classified OPEN--UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/23/2016
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) does not intend to mandate the equipage of additional recording systems on all turbine-powered, nonexperimental, non-restricted-category aircraft because of significant costs and limited ability to assess benefits. The FAA’s position, as stated in our response to Safety Recommendations A-09-09 through -11 dated February 15. 2011 , which the Board closed and Safety Recommendations A-13-12 and -13 dated August 1, 2013, has not changed. The Board cited and we agree, that crash-resistant flight recorder systems provide additional data including a visual account of crew actions and parametric data, to use for accident investigation. However, in today's rulemaking environment, we have no way of estimating the number of lives that could be saved or the number of future accidents that could be prevented with the use of this additional data. Therefore, we cannot determine a quantitative benefit for mandating this equipage. Since rulemaking to mandate the equipage of these recorders on these aircraft is not a viable option, the FAA adopted a position of promoting and incentivizing the voluntary equipage of image recorders through the following framework: • On November 15, 20 I 0, the FAA published Technical Standard Order (TSO) C 197, Information Collection and Monitoring Systems. This TSO provides the minimum operational performance standards for recording systems, including audio and image, and invokes certain requirements of European Organization for Civil Aviation Equipment document ED-ISS. This standardizes the design and production certification requirements for equipment manufacturers in an effort to streamline aircraft installation and integration. The current rulemaking environment requires that new regulations have a positive economic cost/benefit to society. The estimated cost for industry to comply with these recommendations is $20,000 or more per aircraft totaling $ 180 million. • While these recommendations apply to all turbine-powered, nonexperimental. non-restricted category aircraft, they were issued as a result of a helicopter air ambulance operation. On February 18, 2014, we issued the Helicopter Air Ambulance, Commercial Helicopter, and Part 91 Helicopter Operations Final Rule. This rule, influenced by these recommendations, requires that helicopters conducting air ambulance operations be equipped with flight data monitoring (FDM) systems by April 23, 2018 (79 FR 9975, § 135.607). • In its November 17, 2014, letter, the Board asked that the FAA describe the programs for incentivizing the voluntary equipage of FDM systems and provide documentation indicating that industry is equipping its fleets. In response, please sec "Heli copter Flight Data Monitoring - Industry Best Practices," dated September 1, 2011 (enclosed), for additional information on FDM programs, which covers the incentives of these voluntary programs. This document is an excellent resource for the rotorcraft community and can be applied generally to airplane operations. Additionally, the FAA does not have documentation indicating FDM fleet equipage data nor a means to gather that data. Because FDM systems are non-required, non-essential systems, except for helicopter air ambulances, the FAA does not have oversight of an operator's voluntary use of such systems. I believe the FAA has effectively addressed these recommendations and consider our actions complete.

From: NTSB
To: FAA
Date: 11/17/2014
Response: Mr. Fazio repeated your previous statements regarding this and similar, older recommendations: You do not intend to mandate the equipage of crash resistant flight recording systems on all turbine-powered, nonexperimental, nonrestricted category aircraft because new regulations must have a positive cost-benefit to society. You estimate that the total cost to industry to take the recommended action would be approximately $180 million, but, without a way of estimating the number of lives that could be saved or the number of future accidents that would be avoided because of a mandate, no quantitative societal benefit can be determined. Although you have never disputed that the recommended action would result in significant benefits to accident investigations and to better understanding underlying aviation safety problems, the inability to quantify the positive cost-benefit for the Office of Management and Budget renders you unable to proceed. We have refrained from closing these recommendations because we believe that, although you are unable to take the recommended action, positive benefits have resulted because the recommendations were open. For example, some aircraft manufacturers, such as Airbus Helicopters (formerly Eurocopter), have started placing recording equipment on their newly manufactured units. We also note that the final rule that you published on February 21, 2014, titled “Helicopter Air Ambulance, Commercial Helicopter, and Part 91 Helicopter Operations,” contains a requirement in Section 135.607 for equipping helicopter air ambulances with recorder systems. Although neither of these actions fully satisfies Safety Recommendations A 13 12 and 13, both show that, with the recommendations remaining open, progress is being made. We have begun to receive data from accidents involving helicopters using these systems that have improved our accident investigations and enabled better understanding of the associated safety issues. Mr. Fazio stated that the FAA has adopted a “position of promoting and incentivizing the voluntary equipage of crash-resistant flight recording systems” and that “industry is already realizing the proliferation and benefits of crash-resistant flight recording systems without a forced mandate.” We are not aware of these programs, and we ask that you provide more information about them. In particular, we ask that you describe the incentives in these programs and provide us any documentation that you have collected indicating that industry is already equipping its fleets. Such programs may constitute the basis for an acceptable alternate response to Safety Recommendations A-13-12 and -13. Although we have begun to investigate accidents in which aircraft in the subject category were equipped with the recommended recorders, the overwhelming majority of investigations we have conducted concerning such aircraft involved aircraft without recorders. We continue to believe that keeping these recommendations open reflects the best interests of aviation safety, despite your position that you do not intend to mandate the equipage of crash resistant flight recording systems on all turbine-powered, nonexperimental, nonrestricted category aircraft. We invite you to provide information describing alternate actions you have taken in place of the recommended mandate but, pending your taking the recommended actions or providing us information about an acceptable alternative that you have taken or plan to take, Safety Recommendations A 13 12 and 13 remain classified OPEN—UNACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 10/23/2014
Response: On October 23, 2014, the NTSB reiterated A-13-013 with the issuance of A-14-096 through -099, which address operational training and checklist usage for Mitsubishi MU-2B series airplanes. A-14-096 through -099 are derived from the NTSB’s investigation of a November 10, 2013 MitsubishiMU-2B-25 airplane accident in Owasso, Oklahoma.

From: FAA
To: NTSB
Date: 8/14/2014
Response: -From Tony Fazio, Director, Accident Investigation and Prevention: As previously stated, the Federal Aviation Administration's(FAA) position has not changed. The FAA does not intend to mandate the equipage of crash resistant flight recording systems on all turbine-powered, nonexperimental, nonrestricted category aircraft for the following reasons: 1) The current rulemaking environment requires that new regulations have a positive economic cost-benefit to society. We believe the cost estimates for system installations on these aircraft could be as high as $20,000 or more per aircraft, with a total cost to the industry of $180 million. 2) The FAA has no way of estimating the number of lives that could be saved or the number of future accidents that could be prevented with the use of this additional data. Therefore, we cannot place a quantitative benefit for mandating crash-resistant flight recording system equipage. 3) The FAA has adopted a position of promoting and incentivizing the voluntary equipage of crash-resistant flight recording systems. The industry is already realizing the proliferation and benefits of crash-resistant flight recording systems without a forced mandate. The Board cites, and we agree, that crash-resistant flight recorder systems provide additional data, including a visual account of crew actions and parametric data, to use for accident investigation. However, in today's rulemaking environment, the FAA's position is to continue to promote voluntary equipage and participation in flight data monitoring programs. We carefully reconsidered our actions, and we continue to find that our response to this safety recommendation reflects the best interests of aviation safety. Accordingly, we will take no further action in direct response to this safety recommendation.

From: NTSB
To: FAA
Date: 12/10/2013
Response: We point out that, if a recorder system that captured cockpit audio, images, and parametric data had been installed on the accident helicopter, it would have enabled NTSB investigators to reconstruct the final moments of the accident flight and determine why the pilot had not successfully entered an autorotation. Although we continue to investigate accidents in which image recorders would have provided vital, detailed information regarding the facts, conditions, and circumstances surrounding the accidents, the FAA stated it had not found any compelling evidence to require installation of cockpit image recording systems. Accordingly, the FAA reiterated that it planned no further action to mandate flight deck image recording systems and considered its actions complete. Despite the FAA’s position, the lack of image recording systems on aircraft remains an important safety issue, and we therefore believe that it would be premature for us to close these recommendations. Accordingly, pending the FAA’s requiring the installation of a crash-resistant flight recorder system in aircraft operated under 14 CFR Parts 91, 121, or 135, Safety Recommendations A-13-12 and -13 are classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/1/2013
Response: -From Michael P. Huerta, Administrator: The FAA has responded to similar recommendations, including A-09-9,-10, and -11. The FAA's position as stated in our last two letters to the Board (February 15, 2011 and January 27, 2012) has not changed. The FAA does not intend to mandate the equipage of crash-resistant flight recording systems on all turbine-powered, non-experimental, non-restricted-category aircraft for the following reasons: 1) The current rulemaking environment requires that new regulations have a positive economic cost-benefit to society. We believe the cost estimates for system installations on these aircraft could be as high as $20,000 or more per aircraft with a total cost to the industry of $180 million. 2) The FAA has no way of estimating the number of lives that could be saved or the number of future accidents that could be prevented with the use of this additional data. Therefore, we cannot place a quantitative benefit for mandating crash-resistant flight recording system equipage. 3) Crash-resistant flight recording systems are primarily used for accident prevention activities including, identification of risks, evidence-based decision making, enhanced training scenarios, risk mitigation, and remedial action effectiveness. As early as 2005, the FAA has adopted a position of promoting and incentivizing the voluntary equipage of crash-resistant flight recording systems for use in flight data monitoring (FDM) programs. FDM programs, like flight operational quality assurance programs, are successfully being implemented because they a:-e voluntary and non-punitive. The Board cites, and we agree, that crash-resistar1t flight recorder systems provide additional data, including a visual account of crew actions and parametric data, to use for accident investigation. However, with regard to rulemaking, the FAA's position is to continue to encourage voluntary equipage and encourage participation in flight data monitoring programs. The FAA does not intend to mandate such requirements, therefore, I consider our actions complete.