Safety Recommendation a-10-096
Details
Synopsis: On December 14, 2008, about 1700 eastern standard time (EST),1 a Bombardier CRJ CL-600-2B19, N407AW, operated as Air Wisconsin Airlines Corporation (AWAC) flight 3919, landed with the left main landing gear (MLG) in the retracted position at Philadelphia International Airport (PHL), Philadelphia, Pennsylvania.2 The two flight crewmembers and one flight attendant aboard the airplane were uninjured, and the airplane sustained damage to the left wing, aileron, and flap. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 as a nonscheduled positioning flight from Norfolk International Airport (ORF), Norfolk, Virginia, to PHL. An instrument flight rules (IFR) flight plan was filed.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require that mechanics performing required inspection item and other critical tasks receive on-the-job training or supervision when completing the maintenance task until the mechanic demonstrates proficiency in the task.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode:
Location: Philadelphia, PA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA09IA017
Accident Reports:
Report #: None
Accident Date: 12/14/2008
Issue Date: 5/28/2010
Date Closed: 2/10/2017
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s): Maintenance,Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 2/10/2017
Response: We issued these recommendations because ACMT programs are accepted by the FAA rather than approved by the FAA. Before a program is approved, an FAA inspector has considerable authority to influence the carrier to make needed changes to their ACMT program. In contrast, when a program is accepted, the FAA inspector has considerably less authority to require changes to the carrier’s ACMT program. A major change planned for the ACMT rulemaking was to require that ACMT training programs be approved rather than just accepted. Implementing that change would have satisfied these recommendations. However, as a result of a 2014 reevaluation, you cancelled the ACMT programs rulemaking project in 2015. When you performed your original regulatory analysis in 2011, you believed the planned rule would have mitigated 35 past accidents. In 2014, you reevaluated the accidents used in the original regulatory evaluation and found that only two would have been mitigated. In addition, these two accidents did not occur within the segment of the industry that would have been the subject of the rule (that is, Part 121 carriers). In your letter, you said that you believe that your recently implemented Safety Assurance System (SAS) is an alternative approach that satisfies our recommendations. ACMT training programs are part of an air carrier’s continuous airworthiness maintenance program, which is required for a carrier to be acceptable to the FAA. The acceptability of the ACMT program is evaluated using information collected with SAS data collection tools ED 4.1.3 and EP 4.1.3, and by using the procedures in FAA Order 8900.1, “Flight Standards Information Management System,” volume 3, chapter 24, section 1, “Safety Assurance System: Training Program Evaluation.” The procedures in Order 8900.1 require FAA aviation safety inspectors (ASIs) to evaluate the design and performance of Part 121 ACMT programs. In issuing these recommendations, we were emphasizing that a carrier’s ACMT program needs a more thorough review than that likely to occur with a program that an ASI could not require to be revised. With the implementation of SAS, procedures are now in place to collect and evaluate specific information about the ACMT programs that are accepted. That is the level of review that we anticipated would result from requiring that the training program be approved; although, because the programs continue to be accepted rather than approved, ASIs will still not be able to compel carriers to revise their ACMT programs. We believe that if your SAS review of a carrier’s ACMT program reveals problems, the ASI is likely to discuss the issues identified with the carrier, and the carrier is likely to revise the program to address the issues of concern. Therefore, we agree with you that implementing the SAS procedures described in your letter is an alternative approach that satisfies these recommendations. As a result, Safety Recommendations A-04-15 and A-10-96 and 97 are classified CLOSED—ACCEPTABLE ALTERNATE ACTION.

From: FAA
To: NTSB
Date: 10/18/2016
Response: -From Michael P. Huerta, Administrator: Overall FAA Comment. In our May 9, 2014, response, the Federal Aviation Administration (FAA) indicated that we had initiated the Air Carrier Maintenance Training Programs rulemaking project and would be issuing a notice of proposed rulemaking to set clear training standards, including on-the-job training and comprehensive human factors training. This rulemaking effort was cancelled in August 2015 due to a lack of accident data to support rulemaking activities. Current part 121 and 135 regulations require that any person performing required inspection items to be appropriately certificated, properly trained, qualified, and authorized per the air carriers' program. FAA guidance contained in FAA Order 8900.1, Volume 3, Chapter 24, Section 1, Safety Assurance System: Training Program Evaluation, lists the use of OJT as a mechanism to train all personnel performing required inspections. The required inspection item training program is accepted and monitored by the FAA through SAS Data Collection Tools ED 4.1 .3 and EP 4.1 .3, which requires inspectors to evaluate the design and performance of the part 121 air carrier required inspection item training program. The SAS provides standardized protocols to evaluate required inspection item training programs through the implementation of system safety principles. The FAA uses this risk-based, data-supported system to conduct oversight that validates the certificate holder's ability to manage risk and achieve safety objectives. The FAA has determined that the current regulations and guidance are sufficient alternatives to rulemaking and satisfy the intent of these recommendations. Therefore, we consider our actions complete and request closure.

From: NTSB
To: FAA
Date: 7/11/2014
Response: You have been developing Air Carrier Maintenance Training Programs (ACMTP) rulemaking since the project received internal FAA approval, in May 2010. As recently as November 2012, you indicated that the notice of proposed rulemaking (NPRM) for the ACMTP was in senior management coordination and was expected to be published in 2013. On the basis of descriptions in your letters of the revisions planned for inclusion in the NPRM, we have stated that it would address these recommendations, but we have expressed concern for the slow pace of progress in developing and issuing the regulation. We note that the NPRM was not published in 2013 and has subsequently been placed on hold because of limited rulemaking resources within the FAA and changes in priorities to address other unrelated rulemakings mandated by the Congress in the Airline Safety and Federal Aviation Administration Extension Act of 2010 and the FAA Modernization and Reform Act of 2012. Although we acknowledge that these Congressional mandates have resulted in the latest delays to the ACMTP rulemaking, we point out that the recommendations issued as a result of our investigation of the January 8, 2003, accident in Charlotte, North Carolina, are over 10 years old, and there has been little to no progress thus far in responding to them. We remain hopeful that the NPRM will propose the recommended actions, but the continuing delays are not acceptable. Accordingly, pending timely issuance of the ACMTP NPRM and of a final rule that fully satisfies these recommendations, Safety Recommendations A-04-11 and -15 remain classified “Open—Unacceptable Response” and Safety Recommendations A-10-96 and -97 are classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/9/2014
Response: -From Michael P. Huerta, Administrator: As mentioned in our previous letter, the Federal Aviation Administration (FAA) initiated the Air Carrier Maintenance Training Programs (ACMTP) rulemaking project, which was approved in May 20 10 by the FAA Rulemaking Council (FRC). The ACMTP Notice of Proposed Rulemaking (NPRM) sets clear training standards to ensure uniform compliance with ACMTPs, including on-the-job training and comprehensive human factors training. A requirement for the FAA to approve (rather than accept) maintenance training programs was added to the NPRM. This NPRM was placed on hold due to limited rulemaking resources and changes in priorities to address the remaining rulemakings mandated by provisions called out in the Airline Safety and Federal Aviation Administration Extension Act of 2010 and the FAA Modernization and Reform Act of2012. The ACMTP NPRM will likely be removed from this hold in 2014. The FAA issued the Air Carrier Contract Maintenance Requirements (ACCMR) NPRM on November 13, 2012 (77 FR 67584). The ACCMR NPRM proposes to require operators to develop policies, procedures, methods, and instructions for performing contract maintenance that are acceptable to the FAA and to include them in their maintenance manuals. The NPRM also proposes to require operators to provide the FAA a list of all persons with whom they contract their maintenance. The ACCMR Final Rule will likely be published in 2015. I will keep the Board informed of the FAA's progress on these recommendations and provide an update by April 30, 2015.

From: NTSB
To: FAA
Date: 2/4/2013
Response: In our previous letter to the FAA about these recommendations, we stated that a notice of proposed rulemaking (NPRM) that the FAA was developing concerning air carrier maintenance training programs was likely to include a requirement for the FAA to approve maintenance training programs, rather than simply accept them. We believed that implementing such a requirement would address the issue raised in these recommendations. In its current letter, the FAA provided an update on the status of this rulemaking project and stated that it expected to issue the NPRM in 2013. Accordingly, pending the timely issuance of an NPRM and a final rule that satisfy these recommendations as discussed above, Safety Recommendations A 10 96 and 97 remain classified OPEN—ACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 11/30/2012
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) notice of proposed rulemaking (NPRM), titled “Airworthiness Directives; Bombardier, Inc. Airplanes,” which was published at 77 Federal Register 63281 on October 16, 2012. The NPRM proposes to adopt a new airworthiness directive (AD) for certain Bombardier Model CL-600-2B19 airplanes. This proposed AD was prompted by reports of two in-service incidents where the left main landing gear (MLG) failed to extend. The investigations revealed that in both cases, the MLG uplock assembly had been replaced before the incidents, and the upper bolt of the MLG uplock assembly was incorrectly installed. This proposed AD would require installing stopper plates on the aft uplock frames in the MLG bay adjacent to the right and left MLG uplock assemblies. The FAA is proposing this AD to prevent the incorrect installation of the upper bolt in the MLG uplock assembly, which could prevent the MLG from extending and adversely affect the safe landing of the airplane. On December 14, 2008, Air Wisconsin Airlines Corporation flight 3919, a Bombardier CL-600-2B19, N407AW, landed at Philadelphia International Airport, Philadelphia, Pennsylvania, with the left MLG in the retracted position. Maintenance had been performed on both the left and right MLG systems before the incident flight. Although unrelated to this NPRM, on May 28, 2010, the NTSB issued Safety Recommendations A-10-96 and -97 to the FAA related to training for mechanics and inspectors associated with required inspection item maintenance tasks. These recommendations are currently classified “Open—Acceptable Response” pending the issuance of a final rule regarding maintenance training programs.However, when the incident mechanic replaced the left MLG uplock assembly, the upper attachment bolt, nut, and cotter pin assembly used to mount the left MLG uplock assembly to the airplane structure were installed but did not engage the uplock assembly, which allowed the uplock assembly to pivot about the lower bolt. The incorrect installation of the upper bolt prevented the left MLG from extending. Following the incident, Bombardier revised Maintenance Manual 32-32-05 on May 10, 2009, to give mechanics clearer and more specific instructions when installing the MLG uplock assembly. On September 1, 2011, Delta Connection flight 5058, a Bombardier CL-600-2B19, N875AS, landed at the Baton Rouge Metropolitan Airport, Baton Rouge, Louisiana, with the left MLG in the retracted position. Postincident inspection of the airplane revealed that the upper attachment bolt for the left MLG uplock assembly was not installed correctly. The NTSB believes that the proposed design change will help ensure the proper installation of the MLG uplock assembly. The NTSB fully supports the proposed AD and appreciates the opportunity to comment on this NPRM.

From: FAA
To: NTSB
Date: 11/9/2012
Response: -From Michael P. Huerta, Acting Administrator: The Federal Aviation Administration (FAA) initiated the Air Carrier Maintenance Training Programs (ACMTP) rulemaking project which was approved in May 2010 by the FAA Rulemaking Council. The notice of proposed rulemaking (NPRM) sets clear training standards to ensure uniform compliance with ACMTPs, including on-the-job training and comprehensive human factors training. A requirement for the FAA to approve (rather than accept) maintenance training programs has also been added to the proposed rulemaking language. This NPRM is currently in senior management coordination and is expected to be published in 2013. I will keep the Board informed of the FAA's progress on these safety recommendations and provide an update by September 30, 2013.

From: NTSB
To: FAA
Date: 9/22/2011
Response: In its letter, the FAA stated that, after reviewing current regulations and recent revisions to FAA Order 8900.1, it planned no further actions regarding these recommendations and it considered its actions complete. Safety Recommendations A-04-11, -15, and -16, which we issued to the FAA as a result of our investigation of the January 8, 2003, crash of Air Midwest flight 5481, a Raytheon Beechcraft 1900D, shortly after takeoff from Charlotte-Douglass International Airport, Charlotte, North Carolina, were reiterated at the same time as Safety Recommendations A-10-96 and -97 were issued. On February 15, 2011, the FAA wrote to us about Safety Recommendations A-04-11, -15 and -16, indicating that it planned to issue a notice of proposed rulemaking (NPRM) and associated guidance material concerning air carrier maintenance training programs. The FAA stated that the NPRM would propose requiring FAA approval of these programs, as well as set clear training standards to ensure compliance with the training programs, including OJT and comprehensive human factors training. On June 29, 2011, staff from the FAA and the NTSB met to discuss Safety Recommendations A-10-96 and -97 to better understand why existing regulations and guidance had not prevented the Air Wisconsin flight 3919 event. During this meeting, our staff indicated that the section included in FAA Order 8900.1 (discussed in the FAA’s May 6, 2011, letter) that states “Personnel authorized to accomplish RII inspections receive proper training and qualification for each RII task that they receive the authorization to perform” was responsive to Safety Recommendation A-10-97. However, we were concerned that this might be loosely interpreted and that an operator might indicate that it provides general training in RII tasks because the airline expects inspectors, who possess airframe and powerplant licenses issued by the FAA, to be qualified to perform required inspections. At the meeting, the FAA indicated that, among the revisions in the NPRM, will be a requirement for the FAA to approve maintenance training programs rather than just accept them. Although the FAA believes that its actions in response to Safety Recommendations A-10-96 and -97 are complete and plans no further action, the NTSB believes that the NPRM that will be issued shortly concerning air carrier maintenance training programs is relevant to these recommendations. Accordingly, Safety Recommendations A-10-96 and -97 are classified OPEN—ACCEPTABLE RESPONSE, pending the issuance of a final rule, based on that NPRM, addressing the issues in these recommendations.

From: FAA
To: NTSB
Date: 5/6/2011
Response: CC#201100195: - From J. Randolph Babbitt, Administrator: Currently, multiple regulations exist that pertain to the accomplishment and inspection of required inspection items. Section 121.363, Responsibility for Airworthiness, states, "[e]ach certificate holder is primarily responsible for: (1) the airworthiness of its aircraft, including airframes, aircraft engines, propellers, appliances, and parts thereof; and (2) the perfonnance ofthe maintenance, preventive maintenance, and alteration of its aircraft, including airframes, aircraft engines, propellers, appliances, emergency equipment, and parts thereof., in accordance with its manual and the regulations of this chapter." Additionally, the sections below address required inspection items: • 121.365, Maintenance, Preventive Maintenance, and Alteration Organization; • 121.367, Maintenance, Preventive Maintenance, and Alteration Programs; • 121.369, Manual Requirements; and • 121.371, Required Inspection Personnel all address required inspection items. The Federal Aviation Administration has recently revised several chapters of FAA Order 8900.1, Flight Standards Information Management System (FSIMS), to provide additional guidance to FAA Airworthiness Inspectors and Operators. FAA Order 8900.1, Volume 3, Chapter 43, Evaluate a Continuous Airworthiness Maintenance Program, and Chapter 44, Assess Continuing Analysis and Surveillance System for Parts 121 and 135, provide expectations for what should be included in an operator's maintenance program, which includes training programs. FAA Order 8900.1, Chapter 43, in particular, addresses personnel training requirements, which include initial training, recurrent training, specialized training, maintenance provider training, and competency training. Order 8900.1 is available online at http://fsims.faa.gov/. After reviewing current regulations and revisions to FAA Order 8900.1, the FAA plans no further actions in regards to these recommendations. I believe that the FAA has effectively addressed these safety recommendations, and I consider our actions complete.

From: NTSB
To: FAA
Date: 2/28/2011
Response: The FAA stated that current regulations require personnel to be appropriately certificated and properly trained, qualified, and authorized to conduct required inspections. However, the NTSB reiterates that the Air Wisconsin Airlines Corporation incident mechanic was not properly trained or supervised when he replaced the uplock assembly on the incident airplane for the first time, which led to the error in installation, and his error was not detected by the inspector. The NTSB’s May 28, 2010, letter transmitting these safety recommendations highlights other instances in which untrained or unsupervised mechanics performing maintenance tasks for the first time were found at Part 121 carriers. Pending our receipt and review of the FAA’s plan for addressing these safety recommendations, Safety Recommendations A-10-96 and -97 remain classified OPEN -- AWAIT RESPONSE.

From: FAA
To: NTSB
Date: 8/23/2010
Response: CC# 201000344: - From J. Randolph Babbitt, Administrator: The Federal Aviation Administration currently has regulations in place, such as § 121.371, that require personnel to be appropriately certificated and properly trained, qualified, and authorized to conduct required inspections. The FAA will review the current regulations regarding these recommendations and determine the best feasible course of action. I will keep the Board informed of the progress of these recommendations and provide an updated response by December 2010.