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Safety Recommendation Details

Safety Recommendation A-06-008
Details
Synopsis: On October 19, 2004, about 1937 central daylight time,1 Corporate Airlines (doing business as American Connection) flight 5966, a BAE Systems BAE-J3201, N875JX, struck trees on final approach and crashed short of runway 36 at the Kirksville Regional Airport (IRK), Kirksville, Missouri. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 as a scheduled passenger flight from Lambert-St. Louis International Airport (STL), in St. Louis, Missouri, to IRK. The captain, first officer, and 11 of the 13 passengers were fatally injured, and 2 passengers received serious injuries. The airplane was destroyed by impact and a postimpact fire. Night instrument meteorological conditions (IMC) prevailed for the flight, which operated on an instrument flight rules flight plan.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require all 14 Code of Federal Regulations Part 121 and 135 operators to incorporate the constant-angle-of-descent technique into their nonprecision approach procedures and to emphasize the preference for that technique where practicable. (Superseded by safety recommendation A-14-076)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action/Superseded
Mode: Aviation
Location: Kirksville, MO, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA05MA004
Accident Reports: Collision with Trees and Crash Short of Runway, Corporate Airlines Flight 5966, British Aerospace BAE-J3201, N875JX
Report #: AAR-06-01
Accident Date: 10/19/2004
Issue Date: 2/7/2006
Date Closed: 9/25/2014
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action/Superseded)
Keyword(s):

Safety Recommendation History
From: FAA
To: NTSB
Date: 12/24/2014
Response: THIS LETTER IS FROM UPS, NOT THE ADDRESSEE, FAA -From Captain Houston Mills, UPS Airline Director of Safety: Require all 14 Code of Federal Regulations Part 121 and 135 operators to incorporate the constant-angle-of-descent technique into nonprecision approach procedures and to emphasize the preference for that technique where practicable. UPS has previously incorporated the constant-angle-of-decent technique into nonprecision approach procedures and does not train "Dive and Drive" maneuvers. UPS is in the process of explicitly prohibiting "Dive and Drive" maneuvers in its manuals.

From: NTSB
To: FAA
Date: 9/25/2014
Response: -From the accident report, "Crash During a Nighttime Nonprecision Instrument Approach to Landing, UPS FLight 1354, Birmingham, Alabama, August 14, 2013." Report #AAR-14-02, adopted September 9, 2014, Published September 25, 2014. 2.5.4 Continuous Descent Final Approach Technique As noted previously, a CDFA is a specific technique for flying the final approach segment of a nonprecision instrument approach as a continuous descent, without level-off, from a specific altitude near the FAF to a point about 50 ft above the landing runway threshold or the point where the flare maneuver should begin for the type of aircraft flown. FAA AC 120-108 describes and recommends the use of the technique of a stable continuous descent path in lieu of the traditional “dive and drive” type of nonprecision approach, which can lead to unstabilized approaches because of multiple thrust, pitch, and altitude adjustments inside the FAF. Although the flight crew set up and briefed a CDFA approach using the profile method, when the captain changed the autopilot to vertical speed mode, the approach essentially became a “dive and drive” approach. Per the guidance and training provided at UPS, both approach options were available to flight crews. Although CDFA was one of the techniques taught at UPS, the guidance for CDFA was found in the PTG, which is not an FAA-approved or -accepted manual. As stated in FAA AC 120-108, CDFA requires no specific aircraft equipment other than that specified by the nonprecision approach procedure. It also minimizes the risk of unstabilized approaches and CFIT.109 The NTSB concludes that the CDFA technique provides a safer alternative to “dive and drive” during nonprecision approaches. As noted previously, in response to Safety Recommendation A-06-8, which asked the FAA to incorporate the constant-angle-of-descent technique into their nonprecision approach procedures and to emphasize the preference for that technique where practicable, the FAA stated that it would include a requirement for training on and incorporation of the constant-angle-of-descent technique in its final rule on “Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers.” However, the final rule did not contain such a requirement. While the FAA has indicated that it favors the use of CDFA, the use of the approach is in guidance material only, and operators are not required to incorporate the information into their manuals; the FAA also has no mechanism to ensure that carriers are using the CDFA technique and training flight crews to use it. Further, although UPS included the CDFA technique in its PTG and trained flight crews on the technique, it did not require flight crews to use the CDFA when performing nonprecision approaches. In addition, the FAA did not require that the CDFA be included in UPS’s FAA-approved documents nor did they require the inclusion of a prohibition against the use of “dive and drive” approaches in those documents. Because of the safety benefits associated with CDFA, the NTSB believes that FAA-approved nonprecision instrument landing procedures should comply with guidance in AC 120-108 and the FAA must do more to ensure that operators incorporate the CDFA technique in their training and manuals for all nonprecision approaches. Therefore, the NTSB recommends that the FAA require principal operations inspectors of 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to ensure that FAA-approved nonprecision instrument approach landing procedures prohibit “dive and drive” as defined in AC 120-108. Because the FAA did not incorporate the constant-angle-of-descent technique in their final rule on flight crew training, the NTSB classifies Safety Recommendation A-06-8 CLOSED--UNACCEPTABLE ACTION/ SUPERSEDED. A-06-008 is superseded by A-14-076.

From: NTSB
To: FAA
Date: 11/14/2012
Response: We continue to believe that, if included in a final rule, the proposed requirement for Part 121 operators to incorporate a constant-angle-of-descent technique into their nonprecision approach procedures, as stated in the notice of proposed rulemaking (NPRM) and supplemental notice of proposed rulemaking (SNPRM) titled “Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers,” will satisfy this recommendation as it applies to Part 121 operators. The FAA indicated that it believes Safety Alert for Operators (SAFO) 09011 already satisfies this recommendation as it applies to all Part 135 operators and, therefore, the agency does not plan to propose a similar requirement for these operators. We believe that SAFO 09011 contains helpful guidance and may constitute an acceptable alternate solution for addressing this recommendation as it applies to Part 135 operators if the FAA can ensure that the guidance has been adopted by most operators. Accordingly, pending the issuance of a final rule as described above, and our review of information that indicates SAFO 09011 has been widely adopted by the Part 135 community, Safety Recommendation A 06-8 is classified OPEN—ACCEPTABLE ALTERNATE RESPONSE.

From: FAA
To: NTSB
Date: 8/2/2012
Response: -From Michael P. Huerta, Acting Administrator: To require this technique for operators required to train under Title 14 Code of Federal Regulations (14 CFR) part 121 operations, the FAA published the Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers Notice of Proposed Rulemaking on January 12, 2009, and a supplemental notice of proposed rulemaking on May 20, 2011. In addition to the proposed rule, draft Advisory Circular CAC) 120-FCMT includes guidance on non-precision approach performance expectations. We anticipate publishing both a final rule and a final AC in 2013. We note that this technique is increasingly being adopted voluntarily by air carriers that have airplanes equipped with vertical navigation. While we have proposed this requirement for operators required to train under part 121 as part of the Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers rulemaking, we do not plan on requiring a constant angle of descent technique for all 14 CFR part 135 carriers. All part 13 5 operators have the option of complying with part 121 training standards and some 135 operators elect this option. As mentioned in our April 12, 2010, letter to the Board, we issued Safety Alert for Operators (SAFO) 09011, Part 121 and 135 Operators: Constant Angle of Descents Techniques for Non-precision Approaches, on May 21, 2009. The SAFO recommends the use of a constant angle of descent technique on non-precision approaches. We believe that the SAFO is an appropriate action to this recommendation for all 135 operators. SAFOs alert industry regarding issues of concern that do not rise to the level requiring mandatory corrective action. The responsibility to implement any action recommended in a SAFO rests with the operator. This is the best way to address concerns related to this recommendation, rather than a rulemaking solution. I will keep the Board informed of the FAA's progress on this safety recommendation and will provide an update by November 2013.

From: NTSB
To: FAA
Date: 7/9/2010
Response: The FAA’s plan to include the recommended requirement in the final rule that will result from the notice of proposed rulemaking (NPRM) published on January 12, 2009, titled “Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers,” is an acceptable response to this recommendation. However, the proposals contained in the NPRM will only apply to 14 CFR Part 121 operators. Issuance of Safety Alert for Operators (SAFO) 09011, which recommends the use of constant-angle-of-descent techniques while conducting nonprecision approaches for both Part 121 and 135 operators, constitutes an appropriate interim step until the final rule is issued; however, the NTSB asks how the FAA will address the recommended action for Part 135 operators. Pending issuance of a final rule requiring Part 121 operators to incorporate the constant-angle-of-descent technique into their nonprecision approach procedures, and similar action being taken for Part 135 operators, Safety Recommendation A-06-8 is classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 4/12/2010
Response: Letter Mail Controlled 4/26/2010 10:38:18 AM MC# 2100148 - From J. Randolph Babbitt, Administrator: On May 21, 2009, the Federal Aviation Administration issued Safety Alert for Operators (SAFO) 0901 1 (enclosed), to recommend the use of constant-angle-of-descent techniques while conducting nonprecision approaches for part 12 1 and 13 5 air carriers. The benefits of this technique reinforce the stabilized approach concept as well as reduce pilot workload throughout the final approach segment of complex nonprecision approaches. The FAA notes that this technique is increasingly being adopted voluntarily by air carriers that have airplanes equipped with vertical navigation. Nonprecision vertical guidance approaches will be addressed in the subparts N & O rulemaking project and its accompanying guidance material. While we are evaluating what regulatory changes and guidance materials would be needed to implement this safety recommendation, we issued SAFO 09011 as an interim means of addressing the intent of this safety recommendation.

From: NTSB
To: FAA
Date: 11/9/2006
Response: In its response to this recommendation, the FAA indicates that it has long recommended constant angle-of-descent approaches as part of stabilized approach techniques, and that this technique is explicitly recommended in Advisory Circular (AC) 120-71, "Standard Operating Procedures for Flight Deck Crewmembers." The FAA further indicates that among the revisions in the rulemaking currently in progress for 14 CFR Part 121, Subparts N and O, is a requirement for use of the constant-angle-of-descent technique in training and operations. Finally, the FAA indicates that for Part 135, rulemaking is not so well developed as that in Part 121, but the FAA plans to produce a requirement that stabilized approach be used in pilot training and operations. The Safety Board notes that AC 120-71 was issued over 4 years before the Kirksville accident, yet the AC's recommendation for a constant-angle-of-descent approach did not influence the pilots' behavior. While welcoming the prospect of this technique being required in the Part 121, Subparts N and O, regulatory revisions, the Board emphasizes its concern with the FAA's lack of progress on this rulemaking: Seven other Safety Board recommendations are dependent on it, including one recommendation that is 13 years old. On October 17, 2005, the Board sent the FAA a letter listing these seven recommendations, indicating our concern with the lack of progress on the rulemaking, and requesting an updated status. Although the rulemaking was briefly discussed at an FAA briefing for the Board on June 13, 2006, the FAA has not yet responded formally to that request. The Safety Board does not believe it acceptable to tie the response to this recommendation to a rulemaking project on which the FAA has not made any progress. In addition, while the Part 135 comprehensive revision under discussion may be an appropriate venue to implement the recommended action for Part 135, the Board is concerned that this rulemaking program may be subject to the same unacceptable delays encountered with the Part 121, Subparts N and O, rulemaking. Pending a timely response to this recommendation, Safety Recommendation A-06-8 is classified OPEN -- UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/31/2006
Response: Letter Mail Controlled 6/13/2006 10:06:23 AM MC# 2060284: - From Marion C. Blakey, Administrator: Constant angle-of-descent is the essence of stabilized approach technique. That technique, while flying all instrument approaches including nonprecision approaches, has been explicitly recommended to air carriers operating under 14 CFR Parts 121 and 135 since August 2000, when Advisory Circular (AC) 120-71, "Standard Operating Procedures for Flight Deck Crewmembers," was issued. Appendix 2 of the AC, "Stabilized Approach: Concepts and Terms," is devoted entirely to that recommended technique. Rulemaking is in progress now in 14 CFR Part 121, Subparts N and O, that would require that technique in training and in operations. Rulemaking in 14 CFR Part 135 is not so well developed as that in 14 CFR Part 121, but it is expected to produce a requirement that stabilized approach be required in pilot training and in operations. Additionally, as air carriers increasingly equip their airplanes with flight management systems with vertical navigation capability and other modem avionics, this technique is being adopted voluntarily by air carriers and their pilots, who welcome vertical guidance during nonprecision approaches. That vertical guidance, in turn, causes the pilot to fly a constant angle-of-descent, as the Board and the FAA both recommend. I will keep the Board informed on the FAA's progress on this safety recommendation.