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Safety Recommendation Details

Safety Recommendation A-09-022
Details
Synopsis: On September 28, 2007, about 1313 central daylight time, American Airlines flight 1400, a McDonnell Douglas DC-9-82 (MD-82),2 N454AA, experienced an in-flight engine fire during departure climb from Lambert-St. Louis International Airport (STL), St. Louis, Missouri. During the return to STL, the nose landing gear failed to extend, and the flight crew executed a go-around, during which the crew extended the nose gear using the emergency procedure. The flight crew conducted an emergency landing, and the 2 flight crewmembers, 3 flight attendants, and 138 passengers deplaned on the runway. No occupant injuries were reported, but the airplane sustained substantial damage from the fire. The scheduled passenger flight was operating under the provisions of 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require principal operations inspectors to review their operators’ pilot guidance and training on task allocation and workload management during emergency situations to verify that they state that, to the extent practicable, the pilot running the checklists should not engage in additional nonessential operational tasks, such as radio communications.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: St. Louis, MO, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA07MA310
Accident Reports: In-Flight Left Engine Fire, American Airlines Flight 1400, McDonnell Douglas DC-9-82
Report #: AAR-09-03
Accident Date: 9/28/2007
Issue Date: 5/19/2009
Date Closed: 2/7/2013
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Checklist, Oversight, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 2/7/2013
Response: The NTSB notes that, on July 2, 2010, the FAA updated Order 8900.1, “Flight Standards Information Management System,” Volume 3, Chapter 32, Section 12, to direct inspectors to review their operators’ training curriculums for emphasis of the importance of the emergency/abnormal checklist. We are pleased that the revised order states that completion of these checklists should be deliberate and methodical, and not rushed or interrupted for routine events until the checklist has been completed, and that this information is applicable to all emergency/abnormal checklists. Because this action satisfies the intent of Safety Recommendation A-09-22, the recommendation is classified CLOSED—ACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 9/27/2012
Response: -From Michael P. Huerta, Acting Administrator: As indicated in our August 11, 2009 letter the Federal Aviation Administration (FAA) published Safety Alert for Operators (SAFO) 09008, Proper Identification and Procedures During In-Flight Engine Failures on April 6, 2009, prior to the issuance of this recommendation. The SAFO emphasizes the importance of the emergency/abnormal checklist and that flightcrew members should not interrupt the checklist for routine events until completing the checklist. We also indicated in our August 11, 2009 response that we would update FAA Order 8900.1, Flight Standards Information Management System (FSIMS), to reflect the intent of SAFO 09008 and this recommendation. After further review we put this information in Chapter 10, "Operational Emphasis Items.” The change was made on July 2, 2010 and can be found in volume 3 chapter 10 section 1 paragraph 3-275 (enclosed). Paragraph 3-275 states that. "it is important to stress that interrupting an emergency checklist should be strongly discouraged as a matter of safety policy unless a greater emergency exists." Paragraph 3-275 also states that FAA inspectors should "[e]mphasize the importance of the emergency/abnormal checklist. Completion of its checklist should be deliberate and methodical, it should not be rushed or interrupted for routine events until it has been completed." While the information in this area of FAA Order 8900.1 does focus on engine failures, the information on check list procedures is applicable to all emergency/abnormal checklists. Operators are expected to train using these same principles. I believe the FAA has effectively addressed this safety recommendation, and I consider our actions complete.

From: NTSB
To: FAA
Date: 4/30/2012
Response: Notation 8406: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) notice of proposed rulemaking (NPRM) titled “Pilot Certification and Qualification Requirements for Air Carrier Operations,” which was published at 77 Federal Register (FR) 12374 on February 29, 2012. The notice proposes to create new certification requirements for pilots in air carrier operations, including requiring that first officers in 14 Code of Federal Regulations (CFR) Part 121 operations hold an airline transport pilot (ATP) certificate and type rating for the aircraft to be flown; allowing pilots with an aviation degree or military pilot experience but fewer than 1,500 hours total time as a pilot to obtain an ATP certificate with restricted privileges; and requiring at least 1,000 flight hours in air carrier operations to serve as pilot in–command (PIC) in Part 121 air carrier operations. The notice also proposes to modify the requirements for obtaining an ATP certificate with an airplane category multiengine class rating or type rating to require 50 hours of multiengine flight experience and completion of a new FAA-approved ATP certificate training program that would include academic training and training in a flight simulation training device. According to the NPRM, these changes would help to ensure that pilots entering an air carrier environment have the training and aeronautical experience necessary to adapt to a complex, multicrew environment in a variety of operating conditions. The NPRM cites the 2009 Colgan Air accident near Buffalo, New York, as an event that focused public, congressional, and industry attention on flight crew experience requirements and training for conducting Part 121 air carrier operations. In February 2010, the FAA published an advance notice of proposed rulemaking (ANPRM), titled “New Pilot Certification Requirements for Air Carrier Operations” (75 FR 6164, February 8, 2010) that sought input on current Part 121 eligibility, training, and qualification requirements for seconds-in-command (SICs). The current NPRM is based on comments in response to the ANPRM, input received from an aviation rulemaking committee established in July 2010, and statutory requirements for modifying ATP certification outlined in the Airline Safety and Federal Aviation Administration Extension Act of 2010 (Public Law 111-216). Adding to that foundation, the NPRM states that the FAA conducted a study of 61 NTSB investigation reports from fiscal year (FY) 2001 through FY 2010 (31 Part 121 accidents and 30 Part 135 air carrier accidents, with 107 fatalities, 28 serious injuries, and 44 minor injuries). The study showed that the accidents examined involved pilot deficiencies in aircraft handling, including stall and upset recognition and recovery, high altitude training, active pilot monitoring skills, effective crew resource management (CRM), stabilized approaches, operations in icing conditions, and hypoxia training. The NPRM asserts that the changes to air carrier pilot qualification would address, in part, 21 NTSB safety recommendations in the following areas: Safety Issue Recommendations Training flight crews to respond to sudden, unusual, or unexpected aircraft upsets: A-96-120, A-04-62, A-07-3, and A-09-113 Developing and conducting stall recovery training and providing stickpusher familiarization training for pilots of stickpusher-equipped aircraft: A-10-22 and -23 Training in high altitude operations: A-07-1 and -2 Training and guidance for rudder use in transport-category aircraft: A-02-2 Airport situational awareness: A-07-44 Stabilized approach concept: A 01 69 and A-08-18 Landing performance calculations: A-07-59 and A-08-41 CRM training: A-03-52 Pilot monitoring duties: A-10-10 Requirements for flight crewmember academic training regarding leadership and professionalism: A-10-15 Training in icing conditions: A-07-14 Hypoxia awareness training: A 00 110 Training in landing and taking off in crosswinds with gusts: A 10-110 and -111 The NTSB is generally supportive of the proposed rule as it relates to many of the issues previously identified in our safety recommendations. Specific comments on several areas of the NPRM follow. Academic Credit To Reduce Flight Experience Requirements Although the NTSB has not made recommendations for flight hour minimums for air carrier pilots (instead focusing its recommendations on specific procedures and training, needed regulations, and needed guidance to crews and operators), we stated in our comments on the ANPRM that: Ensuring a high level of knowledge, skills, and professionalism for flight crewmembers is essential, but total flight hours or an airline transport pilot certificate does not necessarily equate to the level of knowledge, skills, and professionalism required for consistently safe flight operations. The comments went on to state that, “the NTSB recognizes the value of academic training for air carrier pilots, but the NTSB also believes that academic training is not a substitute for practical experience.” An important tenet in the recent NPRM is the concept that, “in certain circumstances, the combination of focused academic training and structured flight training can substitute for actual flight experience” (p. 12379). The NTSB concurs with the FAA’s acknowledgement that there may be multiple pathways to becoming a qualified air carrier pilot. However, there remain unresolved issues for how academic credit should be applied, including student performance within an accredited academic program and the type of degree conferred. These issues are not addressed in the NPRM and require more evaluation before this proposal is implemented. It is essential that the content and rigor involved in academic training be clearly defined and, most importantly, appropriate resources allocated to conduct evaluation and oversight of these alternative methods of qualification. ATP Certification Training Program The NPRM discusses the establishment of an FAA-approved ATP certificate training program for a multiengine class ATP or type rating. The proposed training program outlined under section 61.154 would include 24 hours of classroom training and 16 hours of simulator training (8 in a full flight simulator of at least Level C standards) and is intended to provide pilots with the core knowledge and understanding in areas critical to operating high performance aircraft in a complex and high altitude environment. The training would be provided by an authorized training provider and would be required to be completed before a pilot would be eligible to take the ATP knowledge test. Issued as part of the NPRM, draft Advisory Circular (AC) 61-ATP, “Airline Transport Pilot Certification Training Program for Airplane Category Multiengine Class Rating or Type Rating,” contains an outline of the curriculum topics and objectives for both the classroom and simulator training making up this training program. The AC is intended for use by training providers when developing the program and by the FAA when reviewing and approving the programs. Many of the topics contained in the draft AC address issues from NTSB safety recommendations; in fact, the FAA notes that most of the 21 recommendations cited in the NPRM are addressed, in part, by the proposed amendments and advisory material. Although the NTSB concurs with the FAA’s assessment that, in most cases, the topics addressed will serve to partially satisfy the action requested in existing recommendations, the amount of specificity provided in the proposed rule and AC does not allow a comprehensive review of the degree to which the FAA’s proposed actions would satisfy the intent of the NTSB’s recommendations. In some instances, neither document provides evidence that a recommendation topic is addressed. The NTSB notes that recent safety recommendations in this area have focused on attempts to improve crew response to in-flight emergencies, including task prioritization and training. While AC 61-ATP does include a classroom training objective named “differences between emergency and non-normal checklist procedures and checklists,” the guidance on emergency procedures should be made more explicit to incorporate the issues identified in these NTSB recommendations. CRM is another topic relevant to previous NTSB recommendations and outlined in AC 61-ATP. However, the list of proposed topics in the AC does not explicitly refer to the importance of first officer assertiveness, which is an issue addressed in Safety Recommendation A-11-39. This recommendation is not cited in the NPRM, but the NTSB believes that it is within the scope of the draft advisory material and suggests amending the AC to include information consistent with Safety Recommendation A-11-39 to help support this important aspect of CRM. The NTSB is encouraged that the NPRM proposes to centralize the process for approving ATP certification training programs. Specifically, the NPRM states that only authorized training providers can administer the training required under section 61.154. These providers can be certificate holders providing training and operating under Parts 141, 142, 121, or 135, and each provider must receive approval of their ATP certification training program by the FAA Air Transportation Division (AFS-200). The NTSB notes that, theoretically, centralization should help to ensure standardization of these programs, but suggests that additional guidance documentation with more specific and robust detail about the content of the proposed training is necessary to provide a solid foundation on which the FAA can evaluate the program content (and to assist training providers to develop courses likely to receive FAA approval). For example, additional detail, such as cross-referencing material from draft AC 120-STALL, would be appropriate in the discussion of stall training in AC 61-ATP. In addition, the FAA will need to provide the appropriate oversight resources to these programs—not only in their initial approval but also to conduct ongoing oversight to demonstrate that the content delivered is consistent with the approved program. The rigor with which these programs are implemented and overseen will determine their ultimate influence on improving safety in air carrier operations. Pilot-in-Command Requirements for Air Carrier Operations The NPRM proposes primarily experience-based requirements for new PICs in air carrier operations. However, the NTSB has previously issued safety recommendations addressing the need for a specific leadership training course for upgrading captains. Although the NPRM cites Safety Recommendation A-10-15 and describes it as applicable to leadership and professionalism training, it addresses only the latter topic. The NPRM does not mention Safety Recommendations A-10-13 and -14, which were issued with -15, but the NTSB believes that a leadership training course for upgrading captains is within the scope of the proposed rulemaking and that section 121.436 should be amended to include a specific requirement for such a course. In addition to the requirements already outlined in section 121.434, the NTSB has recommended that Part 135 pilots who need a type rating for the aircraft they fly be required to have a minimum level of initial operating experience. Given the applicability of the NPRM to Part 135 pilots who are engaged in air carrier operations, the NTSB believes it would be appropriate to incorporate similar experience requirements for these pilots as exist for Part 121 pilots. The NTSB supports the use of simulators in training environments and notes that the training program outlined in the NPRM specifies that training on topics such as low energy states/stalls and upset recovery techniques will be conducted in a Level C or higher full-flight simulator. Simulators, regardless of their fidelity, are dependent on their physical limits of motion, as well as the efficacy of the available computer programs (which are often limited in issues of upset training because of the lack of flight test data at the extreme areas of the flight envelope). Simulators are not always adequate in portraying upsets and stalls and may inadvertently introduce negative training. Consistent with Safety Recommendation A-04-62, the FAA should allow flexibility in determining what level of simulation or automation is appropriate for specific training. Summary Observations This NPRM addresses many training issues applicable to becoming an air carrier pilot, including some critical issues demonstrated in recent accident history to be responsible for accidents. The NTSB is encouraged that its recommendations were considered in the development of this proposed rule, especially as the issue areas relate to the core content to be provided to new entrant pilots through the ATP certification training program. However, the intent of our recommendations in this area is for all pilots to receive training in these topics. Therefore, it is important that air carriers provide equally robust training in these topic areas for their current air carrier pilots on a recurrent basis. The NTSB appreciates the opportunity to comment on this NPRM.

From: NTSB
To: FAA
Date: 12/15/2011
Response: Correspondence control #201100325 was closed administratively. No outgoing letter was sent using correspondence control #201100325.

From: NTSB
To: FAA
Date: 4/2/2010
Response: The FAA replied that on April 6, 2009, it published Safety Alert for Operators (SAFO) 09008, “Proper Identification and Procedures during In-Flight Engine Failures, which emphasizes (1) the importance of the emergency/abnormal checklist and (2) the importance of the crew’s completing the checklist without interruption. In addition, the FAA is updating the detailed section on aircraft checklists for 14 Code of Federal Regulations (CFR) Parts 121 and 135 in FAA Order 8900.1, Flight Standards Information Management System, Volume 3, Chapter 32, Section 12, to reflect the intent of the SAFO. The SAFO is not responsive to this recommendation. The purpose of the SAFO is to remind operators of the importance of accurately verifying the indications of a powerplant failure, and to appropriately respond with proper procedures while planning for the remainder of the flight. In contrast, the intent of Safety Recommendation A-09-22 is for POIs to ensure that airlines have adequate guidance and training for pilots on task allocation and workload management in an emergency. Although a powerplant failure may constitute an emergency, many other types of emergencies may also occur. In addition, the SAFO’s reminder to operators about the importance of following procedures is different from directing POIs to examine the adequacy of pilot training and guidance on this subject. This recommendation specifies that POIs should verify that pilot guidance and training on task allocation and workload management during emergency situations state that, to the extent practicable, the pilot running the checklist should not engage in additional nonessential operational tasks, such as radio communications, before completing the checklist. The SAFO does not address this important point. Pending a requirement that POIs conduct the recommended review, Safety Recommendation A-09-22 is classified OPEN -- UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/11/2009
Response: Letter Mail Controlled 8/31/2009 2:09:47 PM MC# 2090551: - From J. Randolph Babbitt, Administrator: On April 6, 2009, prior to the issuance of this safety recommendation, the FAA published Safety Alert for Operators (SAFO) 09008, Proper Identification and Procedures during In-Flight Engine Failures (Enclosure 1). The SAFO emphasizes the importance of the emergency/abnormal checklist and that the crew should not interrupt the checklist for routine events until completing the checklist. This would include completing the immediate actions for an engine fire or severe damage checklist. Additionally, we will update the detailed section on aircraft checklists for parts 121 and 135 in FAA Order 8900.1, Flight Standards Information Management System, volume 3, chapter 32, section 12, to reflect the intent of SAFO 09008. The change will also specify that non-essential items include radio communications. We anticipate publication of the change by December 2009