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Safety Recommendation Details

Safety Recommendation A-07-013
Details
Synopsis: On February 16, 2005, about 0913 mountain standard time,1 a Cessna Citation 560, N500AT, operated by Martinair, Inc., for Circuit City Stores, Inc.,2 crashed about 4 nautical miles east of Pueblo Memorial Airport (PUB), Pueblo, Colorado, while on an instrument landing system (ILS) approach to runway 26R. The two pilots and six passengers on board were killed, and the airplane was destroyed by impact forces and postcrash fire. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91 on an instrument flight rules flight plan. Instrument meteorological conditions (IMC) prevailed at the time of the accident.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require that all pilot training programs be modified to contain modules that teach and emphasize monitoring skills and workload management and include opportunities to practice and demonstrate proficiency in these areas.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Pueblo, CO, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA05MA037
Accident Reports: Crash During Approach to Landing, Circuit City Stores, Inc., Cessna Citation 560, N500AT
Report #: AAR-07-02
Accident Date: 2/16/2005
Issue Date: 2/27/2007
Date Closed: 9/21/2017
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Flightcrew

Safety Recommendation History
From: NTSB
To: FAA
Date: 9/21/2017
Response: We are aware that, on November 12, 2013, you published a final rule titled “Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers.” This rule, which becomes fully effective on March 12, 2019, requires pilot monitoring training to be incorporated into existing Part 121 requirements for scenario-based training, and establishes an operational requirement that flightcrew members follow air carrier procedures regarding pilot monitoring. Although this provision was responsive to our recommendation, we are also pleased to learn that, on January 10, 2017, you published advisory circular (AC) 120-71B, “Standard Operating Procedures and Pilot Monitoring Duties for Flight Deck Crewmembers,” which contains guidance on developing and reviewing pilot training programs that respond to the requirement. These actions satisfy the intent of Safety Recommendation A-07-13, which is classified CLOSED--ACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 4/27/2017
Response: -From Michael P. Huerta, Administrator: In the Board's previous letter to the Federal Aviation Administration (FAA) dated August 12, 2014, it was noted that the Board had reclassified this recommendation as "Open Acceptable Response," pending the issuance of guidance for the development of pilot monitoring and risk management training. The FAA is pleased to infom1 the Board that the requested guidance has been published. Advisory Circular (AC) 120-71B, Standard Operating Procedures and Pilot Monitoring Duties for Flight Deck Crewmembers. was published on .January 10, 2017. AC 120-7lB included an entire chapter dedicated to pilot monitoring and the development of training and pilot performance standards. AC 120-71 B can be accessed at: http://wwvv.faa.gov/documentLibrary/media/ Advisory_ Circular/ AC_ 120-71 B.pdf. Based on the information discussed above, I believe the FAA has satisfactorily addressed this safety recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 8/12/2014
Response: On November 12, 2013, you published a final rule titled “Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers.” This rule, which becomes fully effective on March 12, 2019, requires training on pilot monitoring, to be incorporated into existing Part 121 requirements for scenario-based training, and establishes an operational requirement that flightcrew members follow air carrier procedures regarding pilot monitoring. We are pleased with this provision, as it directly addresses our recommendation. Typically, when the FAA establishes new requirements, you also develop and issue guidance that carriers use in developing programs that respond to the requirement and that FAA inspectors use when reviewing and approving these programs. You typically include such guidance in an advisory circular (AC) issued in conjunction with the final rule; however, we are not aware of any ACs or other FAA guidance that you have issued for carriers or inspectors to use in developing or reviewing pilot training programs regarding monitoring skills and workload management. Accordingly, please describe your plans to develop and issue such guidance. Pending issuance of the requested guidance, Safety Recommendation A-07-13 is classified OPEN—ACCEPTABLE RESPONSE.

From: NTSB
To: FAA
Date: 7/3/2012
Response: From the report of the December 29, 2010 runway overrun of American Airlines flight 2253, Boeing 757-200, N668AA in Jackson Hole, Wyoming, published on July 3, 2012: American Airlines‘ procedures indicate that the pilot monitoring (in this case, the captain) is to monitor the automatic speedbrake and thrust reverser deployment during the landing roll, whereas the pilot flying (in this case, the first officer) is to deploy the thrust reversers, apply manual brakes as required, and stow the thrust reversers as the airplane decelerates. However, in this case, CVR data showed that about 0.8 second after the first officer stated ?no reverse,? the captain was taking command of the thrust reverser levers. By assuming control of the thrust reversers before the first officer could attempt to resolve the situation, the captain deviated from normal company procedures regarding the pilot flying/pilot monitoring responsibilities during the landing roll. Specifically, if the captain had adhered to his monitoring responsibilities during the landing roll, it is more likely that he would have recognized that the speedbrakes had not automatically deployed and corrected the situation by manually deploying them, increasing the airplane‘s braking effectiveness significantly. The NTSB has previously issued safety recommendations related to pilot workload management and monitoring skills, including Safety Recommendation A-07-13,55 which asked the FAA to do the following: Require that all pilot training programs be modified to contain modules that teach and emphasize monitoring skills and workload management and include opportunities to practice and demonstrate proficiency in these areas. On January 12, 2009, the FAA published an NPRM titled ?Qualifications, Service and Use of Crewmembers and Aircraft Dispatchers.? Based on comments that the FAA received on this NPRM, on May 20, 2011, the FAA published a supplemental notice of proposed rulemaking (SNPRM) that proposed additional training requirements for flight crewmembers, including the use of flight simulators for training of flight crewmembers. On July 15, 2011, the NTSB submitted comments to the FAA on the SNPRM and noted its general support for the requirements proposed in the SNPRM. In its comments, the NTSB noted that proposed section 121.1213 partially addressed Safety Recommendation A-07-13 by requiring that pilot training include opportunities to practice and demonstrate proficiency in monitoring skills and workload management. However, the SNPRM did not propose a requirement for modules that teach and emphasize these subjects. The NTSB indicated that the FAA would need to require pilot training programs to include appropriate training modules on these subjects during which crews would be required to practice and demonstrate proficiency. On November 7, 2011, the FAA published Safety Alert for Operators (SAFO) 11011, ?Runway Excursions at Jackson Hole Airport (JAC),? which ?emphasizes the importance of implementing and following SOPs and training for flightcrews.?56 The related supplement provided best practices and mitigation strategies that include emphasis on pilot monitoring responsibilities and the manual deployment of speedbrakes if they do not automatically deploy. However, the information in the SAFO is only guidance, and this incident demonstrates the need for the changes proposed in the SNPRM. The NTSB concludes that, if the importance of adhering to pilot monitoring responsibilities were included in flight crew training, the incident captain would have been less likely to assume control of the reverse thrust levers (a pilot flying responsibility) during the landing roll and remained focused on his pilot monitoring duties; as a result, he most likely would have observed that the speedbrakes had not automatically deployed. This incident reinforces the need for the FAA to move as quickly as possible to issue a final rule based on the SNPRM. Thus, the NTSB reiterates Safety Recommendation A-07-13.

From: NTSB
To: FAA
Date: 7/15/2011
Response: Notation 8106A: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration's (FAA) supplemental notice of proposed rulemaking (SNPRM) titled "Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers," published at 76 Federal Register 29336-29526 on May 20, 2011. The notice proposes to amend the regulations for flight and cabin crewmember and aircraft dispatcher training programs in domestic, flag, and supplemental operations. The proposed regulations are intended to contribute significantly to reducing aviation accidents by requiring the use of flight simulation training devices (FSTD) for flight crewmembers and including additional training and evaluation requirements for all crewmembers and aircraft dispatchers in areas that are critical to safety. The proposal also reorganizes and revises the qualification, training, and evaluation requirements. The SNPRM is based on the FAA's review of comments submitted in response to the January 12, 2009, notice of proposed rulemaking (NPRM) on these issues and its determination that the NPRM did not adequately address or clarify some topics; it is also based on provisions of the Airline Safety and Federal Aviation Administration Extension Act of 2010. Proposed Section 121.1213 partially addresses this recommendation by requiring that pilot training include opportunities to practice and demonstrate proficiency in monitoring skills and workload management. However, the SNPRM does not include a requirement for modules that teach and emphasize these subjects. Such modules are needed as part of any training program that will include the opportunities to practice and demonstrate proficiency in these areas. To fully address this recommendation, the FAA will need to require pilot training programs to provide appropriate training modules on these subjects before crews are required to practice and demonstrate proficiency.

From: NTSB
To: FAA
Date: 2/23/2010
Response: From the accident report: Loss of Control on Approach Colgan Air, Inc. Operating as Continental Connection Flight 3407, Bombardier DHC-8-400, N200WQ, Clarence Center, New York, Febraru 12, 2009, issued on February 23, 2010. The National Transportation Safety Board reiterates the following recommendations to the Federal Aviation Administration: The importance of monitoring was referenced in some of Colgan‘s guidance to its pilots and was discussed and evaluated during simulator training and IOE. However, the company did not provide specific pilot training that emphasized the monitoring function. Further, the company‘s CRM training did not explicitly address monitoring or provide pilots with techniques and training for improving their monitoring skills. During public hearing testimony, the National Aeronautics and Space Administration (NASA)-Ames Research Center chief scientist for aerospace human factors stated that people have limited attention and must select from among those features in their environment to direct their attention. Also, distractions and interruptions can increase workload and redirect attention, thus complicating the monitoring task. As a result, effective monitoring requires active effort. To improve monitoring skills, pilots must proactively seek information and ask questions. The NASA chief scientist testified that current pilot training programs do not typically train these skills in a systematic manner. The NTSB concludes that the monitoring errors made by the accident flight crew demonstrate the continuing need for specific pilot training on active monitoring skills. Almost 3 years have passed since Safety Recommendation A-07-13 was issued, and more than 2.5 years have passed since the FAA described to the NTSB the planned actions to address the recommendation. Since that time, the FAA has reported no further action on this recommendation, even after receiving the NTSB‘s September 2008 response letter. Therefore, the NTSB reiterates Safety Recommendation A-07-13 and reclassifies it OPEN -- UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 1/21/2010
Response: Letter Mail Controlled 1/25/2010 10:00:08 AM MC# 2100025 - From Tony Fazio, Office of Accident Investigation and Prevention, AVP 420: The FAA published InFO 09007 on May 5, 2009, which also addressed this recommendation by recommending that operators modify training and check programs to teach and emphasize monitoring skills and workload management during operations in icing conditions. We anticipate incorporating this information into FSIMS directing FAA inspectors to implement and/or validate these changes.

From: NTSB
To: FAA
Date: 9/10/2008
Response: The FAA stated that monitoring skills and workload management are part of crew resource management (CRM) and that current CRM regulations adequately address these issues. The FAA indicated that it will consider identifying in its work program a list of required inspections, reemphasizing to the regional and flight standards district office managers the need to validate the training that is already required and to verify its effectiveness. Although current CRM regulations cover the issues addressed in this recommendation, the Safety Board has investigated a number of accidents and incidents, such as the Pueblo accident, where improved monitoring and workload management skills might have interrupted the chain of events that led to the accident, and thus prevented its occurrence. The FAA’s proposal to identify a list of required inspections as described above is responsive to the recommendation provided that the list includes a strong emphasis on monitoring and workload management components of the CRM program. Pending the development of a list that includes monitoring and workload management components and its incorporation into FAA work programs for regional and flight standards district offices, Safety Recommendation A-07-13 is classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/17/2007
Response: Letter Mail Controlled 5/31/2007 8:48:32 AM MC# 2070240: - From Marion C. Blakey, Administrator: 5/17/07 The FAA believes that training in CRM is adequately addressed for Title 14 Code of Federal Regulation (14 CFR) part 91 operations through the provisions of 14 CFR part 61 (61,55(b)(2)(iii), 61.58(d)) and the PTS (FAA-S-8081-5E). Both 14 CFR part 61 and the PTS specifically address the requirement for CRM in airman certification and checking. Some examples of the current requirements that FAA has that address this recommendation are: ·14 CFR 61.155 ©(13), Aeronautical knowledge test for ATP, requires CRM training; ·The ATP & Aircraft Type Rating PTS addresses Aeronautical Decision Making (ADM) and CRM and states in part …the examiner must evaluate the applicant’s ability throughout the practical test to use good aeronautical decision making procedures in order to evaluate risks. The examiner must accomplish this requirement by developing scenarios that incorporate as many TASKS as possible to evaluate the applicant’s risk management in making safe aeronautical decisions; ·14 CFR 61.58, Pilot-in-command proficiency check: Operation of aircraft requiring more than one pilot flight crewmember. Section 61.58 requires the practical test to be administered to PTS Type Rating standards (see above); 14 CFR 61.55, Second -in-command qualifications: Section 61.55 (b)(2)(iii) requires CRM training within the previous 12 months; ·14 CFR part 61 subpart E -Private Pilot requirements and 14 CFR part 6 1 subpart F -commercial pilots requirements identify the need to demonstrate knowledge of ADM (aeronautical decision making and judgment); and ·Private Pilot PTS and commercial pilot PTS requires knowledge of and testing of ADM and CRM. The FAA will consider identifying in its work program a list of required inspections that would reemphasize to the regional and flight standards district office (FSDO) managers the need to validate the training that is already required and to verify its effectiveness.