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Safety Recommendation Details

Safety Recommendation A-09-011
Details
Synopsis: On July 27, 2007, about 1246 mountain standard time, two electronic news gathering (ENG) helicopters, N613TV and N215TV, collided in midair while maneuvering in Phoenix, Arizona. The Eurocopter AS350B2 helicopters, from local channels 3 and 15, had been covering a police pursuit. N613TV, the channel 3 helicopter, was operated by KTVK-TV, and N215TV, the channel 15 helicopter, was operated by U.S. Helicopters, Inc., under contract to KNXV-TV. Each helicopter had a pilot-reporter and a photographer on board. The occupants on board both helicopters were killed, and the helicopters were destroyed by impact forces and postcrash fire. The helicopters were operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91. No flight plans had been filed. Visual meteorological conditions prevailed at the time of the accident.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require all existing turbine-powered, nonexperimental, nonrestricted-category aircraft that are not equipped with a flight data recorder and are operating under 14 Code of Federal Regulations Parts 91, 121, or 135 to be retrofitted with a crash-resistant flight recorder system. The crash-resistant flight recorder system should record cockpit audio (if a cockpit voice recorder is not installed), 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 to be specified in European Organization for Civil Aviation Equipment document ED-155, Minimum Operational Performance Specification for Lightweight Flight Recorder Systems, when the document is finalized and issued. (Supersedes Safety Recommendation A-03-065)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: Phoenix, AZ, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: LAX07MA231AB
Accident Reports: Midair Collision of Electronic News Gathering Helicopters KTVK-TV, Eurocopter AS350B2, N613TV, and U.S. Helicopters, Inc., Eurocopter AS350B2, N215TV
Report #: AAR-09-02
Accident Date: 7/27/2007
Issue Date: 2/9/2009
Date Closed: 6/11/2012
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Image Recorders

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/11/2012
Response: The FAA replied that, although crash-resistant flight recorder systems provide additional data that would be useful in investigations, the number of lives that could be saved or the number of future accidents that could be prevented if all aircraft were equipped with recording systems as recommended is unknown. The FAA indicated that, without having such information, it cannot determine a quantitative benefit for mandating image recorder equipage. We had previously advised the FAA that issuance of Technical Standard Order (TSO) C197, “Information Collection and Monitoring Systems,” standardizes the design and production certification requirements for lightweight recording systems for equipment manufacturers. Although issuance of the TSO constitutes progress, we indicated that the FAA would need to mandate the equipage of TSO-approved lightweight recording systems for all turbine-powered aircraft in order to fully satisfy these recommendations. However, because the FAA indicated that its actions in response to these recommendations are complete and it will take no further action, Safety Recommendations A-09-9 through -11 are classified CLOSED—UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 1/27/2012
Response: -From Michael P. Huerta, Acting Administrator: The Federal Aviation Administration (FAA) does not intend to mandate the equipage of additional recording systems on all turbine-powered, nonexperimental, nonrestricted-category aircraft because of significant costs and limited ability to assess benefits. The FAA's position, as stated in our letter dated February 15, 2011, to the board, has not changed. On November 15, 2010, the FAA published Technical Standard Order (TSO) C197, Information Collection and Monitoring Systems. This TSO provides the minimum operational performance standards for lightweight recording systems 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. Our analysis shows that the number of aircraft that would be impacted by a new regulation is approximately 9,000. In recent rulemaking activity, the FAA estimated that the cost for a TSO-CI97 compliant system is $7,000. Equipment costs with associated labor and certification costs of $8,000 makes the installation of one recording system approximately $15,000 per aircraft. If the industry is capable of meeting these costs, the total cost for modification of these target aircraft is estimated at $135 million. However, we believe the cost estimates may be low and the total costs for installation on these aircraft could be as high as $20,000 or more per aircraft with a total cost to the industry of $180 million. 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, 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 image recorder 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. We believe that these systems may be able to be used for implementing a flight data monitoring program to help the operators identify problems that could be precursors to an accident or incident. This data would also provide recorded data for investigators should an accident or incident occur. I believe that the FAA has effectively addressed these recommendations, and I consider our actions complete.

From: NTSB
To: FAA
Date: 6/9/2011
Response: From the greensheet published on 6/9/2011 issuing A-11-048 through -051 to the FAA, generated by the August 9, 2010 accident of a DHC-3T in Aleknagik, Alaska, where Senator Ted Stevens was killed. The NTSB is disappointed that the FAA does not intend to require crash-resistant flight recorder systems for turbine-powered airplanes engaged in 14 CFR Part 91 passenger-carrying operations (like the accident airplane’s operation). The NTSB notes that if the accident airplane had been equipped with a recorder system that captured cockpit audio, images, and parametric data, the recorder would have enabled investigators to determine additional information about the accident scenario, including the airplane’s heading, airspeed, and other systems information. Further, recorded images could have provided information on the pilot’s actions and weather conditions, such as cloud conditions or restrictions to flight visibility. The NTSB concludes that a crash-resistant flight recorder system that captures cockpit audio, images, and parametric data would have substantially aided investigators in determining the circumstances that led to this accident. The NTSB believes that the challenges experienced during this accident investigation highlight the need for such recorders; recorders can help investigators identify safety issues (some of which may not otherwise be detectable), which is critical for the prevention of future accidents. The NTSB is hopeful that the FAA, in consideration of this accident investigation that serves as yet another example of the need for recorder systems, will reconsider its stance that it will not require crash-resistant flight recorder systems for turbine-powered, nonexperimental, nonrestricted-category aircraft. As a result, the NTSB reiterates Safety Recommendations A-09-10 and -11.

From: NTSB
To: FAA
Date: 5/18/2011
Response: The FAA indicated that Technical Standard Order (TSO) C197, “Information Collection and Monitoring Systems,” was published on November 15, 2010. The NTSB notes that the TSO standardizes the design and production certification requirements for lightweight recording systems for equipment manufacturers; however, the FAA indicated that it does not plan to require these additional recording systems on all turbine-powered, nonexperimental, nonrestricted-category aircraft, as recommended. The NTSB would like to highlight some recent investigations that reinforce the importance of these safety recommendations: The July 2008 accident involving East Coast Jets flight 81, a Hawker Beechcraft Corporation 125-800A airplane that crashed while attempting to go around after landing on runway 30 at Owatonna Degner Regional Airport, Owatonna, Minnesota: The nonscheduled, domestic passenger flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 135. The NTSB concluded that a lightweight recording system conforming to ED-155, “Minimum Operational Performance Specification for Lightweight Flight Recorder Systems,” would have helped determine the flight crew’s actions during the landing and subsequent go-around attempt, including, but not limited to, whether they silently conducted checklists (partially or completely), which flap settings they selected, and how much braking effort they made upon landing. The August 2009 midair collision involving a Piper PA-32R-300 airplane and a Eurocopter AS350BA helicopter, operated by Liberty Helicopters, over the Hudson River near Hoboken, New Jersey: The airplane flight was operating under the provisions of 14 CFR Part 91, and the helicopter flight was operating under the provisions of 14 CFR Parts 135 and 136. The accident aircraft were not required to have a cockpit voice recorder or a flight data recorder installed, but the helicopter would have been subject to the requirements for a crash-resistant flight recorder system if the FAA had implemented Safety Recommendation A-09-10. A crash-resistant flight recorder system would have helped the NTSB determine additional information about the accident scenario, including the helicopter’s precise locations, altitudes, headings, and airspeeds, as well as the traffic information displayed in the cockpit. The June 2007 accident involving a Cessna Citation 550 that impacted Lake Michigan shortly after departure from General Mitchell International Airport, Milwaukee, Wisconsin (MKE): The airplane was being operated by Marlin Air under the provisions of 14 CFR Part 135. Although the accident airplane was not required to have an FDR installed, had the FAA implemented previous NTSB recommendations, the airplane would have been subject to the requirements for a cockpit image recorder. The NTSB concluded that cockpit images and parametric data captured by a recorder system would have provided investigators with additional information that would have allowed them to have been better able to determine the circumstances that led to this accident. In addition, the NTSB believes that these recommendations are relevant to two ongoing investigations. The first accident involved a single-engine, turbine-powered, amphibious-float-equipped de Havilland DHC-3T airplane that impacted mountainous tree-covered terrain about 10 miles northeast of Aleknagik, Alaska, on August 9, 2010. The second accident involved a Pilatus PC-12/45 that crashed while diverting to Bert Mooney Airport, Butte, Montana, on March 22, 2009. The NTSB points out that, following the Butte accident, Pilatus Aircraft began installing new-production PC-12 airplanes with a lightweight data recorder that complies with ED-155 standards. Pilatus also issued a safety bulletin to retrofit existing PC-12 airplanes with the recorder. The NTSB believes that these accidents further demonstrate the need to require that all turbine-powered, nonexperimental, nonrestricted-category aircraft be equipped with the additional recording systems that we have recommended. Therefore, we urge that the FAA reconsider its position on implementing such requirements. Pending the FAA’s taking the actions recommended, Safety Recommendations A-09-9, A-09-10, and A-09-11 remain classified OPEN – UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 2/15/2011
Response: On November 15, 2010, the Federal Aviation Administration published Technical Standards Order (TSO) C197, Information Collection and Monitoring Systems (enclosed). TSO-C197 is for lightweight recording systems and invokes certain requirements of European Organization for Civil Aviation Electronic (EUROCAE) document ED-ISS. This standardizes the design and production certification requirements for equipment manufacturers in an effort to streamline aircraft installation and integration. In light of this effort, the FAA does not intend to mandate the equipage of additional recording systems on all turbine-powered, nonexperimental, nonrestricted-category aircraft. I believe that the FAA has effectively addressed these safety recommendations, and I consider our actions complete.

From: NTSB
To: FAA
Date: 1/10/2011
Response: Notation 8272: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration's (FAA) Notice of Proposed Rulemaking (NPRM) titled "14 CFR [Code of Federal Regulations] Parts 1, 91, 120, and 135 Air Ambulance and Commercial Helicopter Operations, Part 91 Helicopter Operations, and Part 135 Aircraft Operations; Safety Initiatives and Miscellaneous Amendments; Proposed Rule," which was published at 75 Federal Register 62640 on October 12, 2010. The FAA states in the NPRM that it is considering requiring certificate holders conducting helicopter air ambulance operations to install lightweight aircraft recording systems (LARS) in their helicopters. The requirement for such a device is not, however, incorporated into the proposed rule. The NTSB is pleased that the FAA appears to be moving toward a flight recorder requirement for EMS helicopters but is disappointed that it is not part of this proposed rule for all helicopters. Safety Recommendations A-06-17 and -18 recommended the installation and use of cockpit voice recorders (CVR) and flight data recorders (FDR) for transport-category rotorcraft, as well as ending exemptions that have been granted by the FAA to large transport category rotorcraft that carry 10 or more passengers. Specific to HEMS operations, the NTSB also issued Safety Recommendation A-09-90, asking the FAA to “require helicopter emergency medical services operators to install flight data recording devices and establish a structured flight data monitoring program that reviews all available data sources to identify deviations from established norms and procedures and other potential safety issues.” Safety Recommendations A-09-9, -10, and -11 are also pertinent to the issue of LARS use in HEMS operation. These recommendations would propose the required installation of crash-resistant recorders capable of audio, video, and data recording, as specified in European Organization for Civil Aviation Equipment (EUROCAE) document ED-155, in both newly manufactured and existing turbine-powered, non-experimental, non-restricted-category aircraft. While these recommendations are not specific to HEMS operations, they address the target population of helicopters. A considerable amount of work has been done by EUROCAE (with full participation by both the FAA and the NTSB) to develop the standards for flight recorder devices, which would fulfill the requirements enumerated in the NPRM for LARS devices. EUROCAE ED-155 is a manufacturing standard, issued in July 2009, for a lightweight, low-cost, robust aircraft recording device. The ED-155 standard covers FDR-like data recording, CVR-like audio recording, cockpit video, and data-like message recording. It also specifies parameters that should be recorded for both airplanes and helicopters and the details of range, resolution, and accuracy that should be required. Several manufacturers are producing ED-155-compliant recorders, even though the FAA has not adopted the ED-155 specification as an approved technical standard order (TSO). The cost of these recorders is less than $10,000. ED-155, in fact, defines a LARS device, and the NTSB believes that it should promptly and efficiently be incorporated into a TSO to unambiguously establish appropriate standards for LARS. In addition to being a valuable aid to accident investigation, an ED-155-compliant recorder would also be fully capable of supporting a structured flight data monitoring program, whether it is implemented as a formal FAA-approved flight operations quality assurance (FOQA) program or a monitoring program that is part of a company safety management system. The benefits of data monitoring programs have been evaluated and documented for commercial airlines. The General Accountability Office (GAO) conducted an evaluation of airline-based data collection and monitoring programs in 1998, shortly after adoption of such programs. The GAO highlighted that such programs provide enhanced safety as well as financial benefits due to increased efficiency of operations. It is likely that the HEMS community, as well as all commercial helicopters, will experience similar benefits. The NTSB continues to believe that recording devices on aircraft can have a significant impact on safety and encourages the FAA to include a requirement for LARS in the final rule. Safety Recommendations A-09-9 and A-09-11 are currently classified “Open—Acceptable Response.” Safety Recommendation A-09-10 is currently classified “Open—Unacceptable Response.”

From: NTSB
To: FAA
Date: 12/23/2010
Response: The FAA's plan to develop and publish a technical standard order (TSO) for a lightweight recording system that will incorporate certain requirements documented in EUROCAE document ED-155 is a positive step, but the NTSB is disappointed that the FAA is considering a requiren1ent for this systen1 only for certain aircraft, based on specific types of operation. We emphasize that retrieving valuable recorded data from all turbine-powered aircraft during an accident investigation is essential, regardless of the aircraft's type of operation or the number of engines, pilots, or passenger seats. In its notice of proposed rulemaking (NPRM) addressing helicopter emergency medical services, issued October 12, 2010, the FAA proposes the installation of lightweight aircraft recording systems for all emergency medical service operations and subsequent flight operational quality assurance/flight data management (FDM) programs. The issuance of this NPRM is a good step toward ensuring that all turbine-powered helicopters have this technology. We are encouraged by one rotorcraft manufacturer's plan to voluntarily include FDM systen1s as standard equipment on all future U.S.-produced models and the efforts of other manufacturers to make FDM systems available as optional equipment. The NTSB points out that these developments show that data recording, as well as audio and image recording, are available and affordable for smaller aircraft. Therefore, upon the FAA's issuance of a TSO that includes the specifications of ED-155, the NTSB urges that the FAA mandate the equipage of TSO-approved lightweight recording systems for all turbine-powered aircraft as recommended. Pending the FAA's reconsideration of its position and completion of the recommended actions in a timely n1anner, Safety Recon1ffiendations A-09-9, A-09-10, and A-09-11 are classified OPEN – UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/25/2010
Response: Letter Mail Controlled 6/3/2010 9:28:44 AM MC# 2100186 - From J. Randolph Babbitt, Administrator: As indicated in the Board's August 2009 letter, the European Organization for Civil Aviation Electronics working group, WG-77, published ED-1 55, Minimum Performance Specification for Lightweight Recording Systems, on August 17, 2009. The FAA has reviewed the document and decided to develop and publish a Technical Standard Order (TSO) for a lightweight recording system that invokes certain requirements of ED-1 55. This TSO will standardize the design and production certification requirements for equipment manufacturers in an effort to streamline aircraft installation and integration. We anticipate completion of this TSO by March 20 11. The general aviation community is continuing its work in the development of flight data monitoring (FDM) systems. The FAA met with two rotorcraft manufacturers and three airplane manufacturers to promote installation of FDM systems. One rotorcraft manufacturer has indicated that all future production models will be equipped with an FDM system. The other rotorcraft manufacturer and three airplane manufacturers are making an FDM system available as optional equipment on future aircraft deliveries. The FAA has no plans to mandate the equipage of these recording systems on all turbine-powered, non-experimental, non-restricted-category aircraft. However, the FAA is considering mandating equipage of ED-1 55-like recording systems on certain aircraft based on specific types of operation, for example, air ambulance operations.

From: NTSB
To: FAA
Date: 8/27/2009
Response: The NTSB is aware of the FAA’s participation in two proof-of-concept studies that evaluated the installation of image recorders on (1) an FAA aircraft that was compliant with European Organization for Civil Aviation Electronics (EUROCAE) document ED-112 and (2) a transport-category Boeing 737 flight simulator. The published findings for those studies has provided valuable information on the potential uses of cockpit image recording systems on aircraft that require a digital flight data recorder and/or a cockpit voice recorder and for those aircraft that are currently not required to carry any type of data-recording equipment. The FAA’s involvement with the EUROCAE working group, WG-77, was noted in the NTSB’s February 19, 2009, letter that issued these safety recommendations, as was the June 2009 publication date that was anticipated for the ED-155 document. The NTSB understands that ED-155 was approved and published by EUROCAE in August 2009; however, the FAA must still develop a technical standard order (TSO). We would appreciate receiving an update on the development of the TSO. The NTSB is encouraged by the efforts of the general aviation community and its commitment to developing flight data management (FDM) systems. The FAA indicated that it plans to meet with two rotorcraft manufacturers that are developing FDM systems to discuss issues related to certification and installation approval. In addition, three airplane manufacturers have expressed interest in meeting with the FAA to discuss current FDM technology. Accordingly, pending the FAA’s issuance of a TSO that includes the specifications of ED-155, Safety Recommendations A-09-9, A-09-10, and A-09-11 are classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 4/17/2009
Response: Letter Mail Controlled 4/27/2009 2:52:43 PM MC# 2090266: - From Lynne A. Osmus, Acting Administrator: The FAA has been actively collecting data on the installation of crash protected cockpit image recorders. The FAA and the Board accomplished a proof-of-concept study to evaluate the installation of an image recorder on an FAA aircraft that was compliant with European Organization for Civil Aviation Electronics (EUROCAE) document ED-112. The United Kingdom Civil Aviation Authority also accomplished a proof-of-concept study, Research Project CAP 762, which evaluated the installation of an ED- 1 12 compliant image recorder on a transport category airplane using a Boeing 737 flight simulator. The published findings for both of those studies have provided valuable information on the potential use of a cockpit image recording system on aircraft that require a digital flight data recorder, and/or a cockpit voice recorder, and for those aircraft that are currently not required to carry any type of data recording equipment. In addition to the proof-of-concept studies, a EUROCAE Working Group, WG-77, has been developing a minimum operational performance specification for lightweight recording systems that can be installed on unequipped aircraft. This document, ED-1 55, is scheduled to be published in June 2009 and will provide performance considerations for lightweight aircraft data recording systems, cockpit audio recording systems, aircraft image recording systems, and data link recording systems. After publication, the FAA will conduct a comprehensive review of the document and consider developing a technical standard order. In addition to the work being conducted by the FAA and other regulatory agencies, manufacturers from the general aviation community have been developing flight data management (FDM) systems, some that include image recording capabilities, which can provide valuable information that can be used by investigators in the event of an accident. The FAA will be meeting with two rotorcraft manufacturers that are developing FDM systems, which include image recording capabilities, to discuss issues related to certification and installation approval. There are also three airplane manufacturers that are interested in discussing current FDM technology. We will provide an update on the progress of these flight recorder recommendations by December 2009.