Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation A-09-025
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: Once the best practices for both single and multiple emergency and abnormal situations training asked for in Safety Recommendation A-09-24 have been established, require that these best practices be incorporated into all operators’ approved training programs.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: St. Louis, MO, United States
Is Reiterated: Yes
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: 6/13/2014
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Flightcrew,

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/13/2014
Response: You previously told us that you would be establishing best practices for training on single and multiple emergencies through data collection and procedures associated with requirements proposed in the SNPRM, and that the SNPRM proposed the authorities needed by your inspectors to require adequate treatment of these subjects in carriers’ approved training programs. The final rule issued on November 12, 2013, did not contain any of the relevant requirements that had been proposed in the SNPRM. We do not agree with you that you have effectively addressed these recommendations. Because you plan no further action, Safety Recommendations A-09-24 and -25 are classified CLOSED—UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 4/9/2014
Response: -From Michael P. Huerta, Administrator: fn a notice of proposed rulemaking (NPRM) titled Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers published on January 12, 2009 (74 FR I 280), and a supplemental notice of proposed rulemaking (SNPRM) published on May 20, 2011 (76 FR 29335), the Federal Aviation Administration (FAA) proposed to revise crewmember and aircraft dispatcher qualification, training, and evaluation requirements in the existing subparts N and 0 of part 12 1. After reviewing the changes proposed in the NPRM and the SNPRM, the FAA determined it was necessary to move forward with a final rule to address certain safety-critical provisions proposed in the SNPRM that enhance pilot training for rare, but high risk scenarios that provide the greatest safety benefit. The final rule was published on November 12, 2013 (78 FR 67799). The remaining proposals in the SNPRM require further deliberation. This includes proposed requirements that would have addressed the recommendations listed above, which were included in the SNPRM and were discussed in our previous letters to the Board. On January 21, 2014, the FAA chartered an Air Carrier Training Aviation Rulemaking Committee (ARC), which will consider these recommendations in its deliberations. The first meeting of the ARC is scheduled for April 14-16, 2014. The FAA has taken additional steps to address A-08-16 by publishing a Safety Alert for Operators (SAFO) on October 20, 2009. SAFO 09016, titled Rejected Landing Due to Loss of Visibility, is applicable to operators under parts 121 , 135, and 91 subpart K. The FAA does not intend to survey operators for compliance as suggested in the Board's letter dated June 22, 2009, since we are not requiring these actions. In previous responses to A-09-25, the FAA stated that it planned to revise Order 8900.1, Flight Standards Information Management System, to comply with the proposed requirements in the Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers SNPRM as they pertained to th is recommendation. Given that the provisions in the SNPRM pertinent to A-09-25 were not in the final rule, the FAA does not plan on updating Order 8900.1. I believe that the FAA has effectively addressed these recommendations and consider our actions complete.

From: NTSB
To: FAA
Date: 2/7/2013
Response: The FAA indicated that it has reviewed the existing and proposed regulatory and policy framework for Part 121 pilot training and has determined that the proposed requirements included in (1) the supplemental notice of proposed rulemaking (SNPRM) titled “Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers;” (2) existing guidance; and (3) planned changes to FAA Order 8900.1 are responsive to Safety Recommendations A-09-24 and -25. The FAA stated that the SNPRM proposes to expand the air transportation oversight system (ATOS) tools and procedures to include a Continuous Analysis Process. The document also states that these scenario-based training events constitute the establishment of industry best practices for single and multiple emergency and abnormal situations training. Because we continue to believe that the SNPRM would give the FAA the regulatory framework for requiring such training, Safety Recommendation A-09-25 remains classified OPEN—ACCEPTABLE RESPONSE pending issuance of the final rule.

From: FAA
To: NTSB
Date: 9/24/2012
Response: -From Michael P. Huerta, Acting Administrator: The Federal Aviation Administration (FAA) developed the Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers Supplemental Notice of Proposed Rulemaking (SNPRM) to propose requiring the inclusion of scenario-based training for all part 121 air carriers. The SNPRM was published for public comment on May 20, 2011, and the final rule is anticipated to be published in 2013. The FAA's intent is that such scenarios will be both operationally relevant and a test of the flight crew's decision-making skills and abilities to integrate and apply learned skills to unexpected circumstances. Data regarding the overall success and compliance of part 121 air carrier training programs are collected and evaluated on a regular basis using the Air Transportation Oversight System tools and procedures and will be expanded by the proposed Continuous Analysis Process, also included as a proposed requirement in the referenced SNPRM. In our August 11, 2009, letter, we proposed revising Order 8900.1 , Flight Standards Information Management System, to comply with the requirements in the Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers SNPRM. The FAA still plans to modify FAA Order 8900.1 after the final rule is published. However, the FAA does not plan to issue a notice. The FAA also reviewed the existing and proposed regulatory and policy framework for part 121 pilot training and believes the proposed requirements included in the Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers SNPRM, existing guidance, and planned changes to FAA Order 8900.1 are adequate to address these recommendations. In its April 2, 2010, letter, the Board was concerned with how scenarios would be developed. The FAA provides extensive guidance in scenario development in FAA Order 8900.1, Volume 3, Chapter 21, Section 1. This 48-page section provides, for example, a checklist for developing line operational simulation (LOS) scenarios. Paragraph 3-1498J amplifies crew oriented scenario-based training and evaluation procedures. Additionally, Advisory Circular (AC) 120-35C, Line Operational Simulations: Line Oriented Flight Training, Special Purpose Operational Training, Line Operational Evaluation, issued September 27, 2004, provides guidance for conducting line oriented flight training, special purpose operational training, and line operational evaluations. It defines the role of instructors and evaluators and provides guidance for designing LOS scenarios. The order and AC are available to operators as well as inspectors. I will keep the Board informed of the FAA's progress on these recommendations, and I will provide an update by September 30, 2013.

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: The NTSB evaluated possible explanations for the captain‘s erroneous and premature speedbrake and thrust reverser callouts and his failure to monitor and notice that the speedbrakes had not automatically deployed as expected. The only positive indication available to the captain to verify extension of the speedbrakes would have been the aft position of the handle, which was visible from and within reach of both pilots’ seating positions. FDR data showed that the speedbrake handle was in the armed position for landing and began to move within 1 second of landing but did not continue to move to the aft (extended) position as expected. The NTSB concludes that the captain‘s erroneous speedbrakes ?deployed? callout was likely made in anticipation (not in confirmation) of speedbrake deployment after he observed the speedbrake handle‘s initial movement; after the ?deployed? callout was made, both pilots likely presumed that the reliable automatic speedbrakes were functioning normally and focused on the thrust reverser problem. About the same time that the speedbrake handle started to move, the amber annunciation lights on the engine indication and crew alerting system (EICAS) display would have provided the captain with a cue that the thrust reversers were in transition.41 Although the captain called out ?two in reverse,? this callout was not based on the illumination of the green annunciation since the air/ground sensing system cycling to ?air? mode prevented the reversers from deploying at that time. (Immediately following the captain‘s ?two in reverse? callout, the CVR recorded the first officer stating, ?no reverse? in a voice that sounded strained.) Given the typical reliability of the thrust reverser system,42 it is likely that the captain made the callout because he expected normal thrust reverser deployment after seeing the amber EICAS annunciation. The NTSB considered whether operational stress during the approach and landing might have resulted in the captain‘s erroneous callouts, his failure to monitor, and both pilots’ failure to notice that the speedbrakes had not deployed. Under normal circumstances, landing at JAC can be challenging; it is located at an elevation of 6,451 feet, it is surrounded by mountainous terrain, and runway 19 is relatively short (6,300 feet) and has a downward slope of 0.6 percent. On the day of the incident, additional challenges were present; there was snow on the runway, the approach was flown to published minimums, and the airplane was near its maximum landing weight. Although operating into JAC in such conditions can be demanding and requires pilots to maintain a heightened alertness throughout the approach and landing, the operational conditions encountered by the incident pilots were typical for JAC in winter. CVR data showed that the incident pilots had prepared thoroughly for the landing and accurately determined they had sufficient performance to land safely on the runway. Despite the challenges of the approach and landing, the pilots seemed alert but not stressed. During postincident interviews, the pilots stated they had no concerns about landing at JAC as they were both experienced flying into the airport, they were familiar with the conditions that existed, and they felt comfortable with the approach. Therefore, the NTSB considers it unlikely that those challenges created operational stress during the incident landing. However, despite their experience flying into JAC and their adequate preparation for the landing, the flight crew tunneled their attention on deploying the thrust reversers. Although the CVR recorded both pilots commenting that the airplane was not slowing on the runway, the captain did not return to his monitoring duties. Neither pilot was able to broaden his focus enough to look at the big picture and notice that the speedbrakes (the more crucial deceleration tool) had not deployed. The NTSB notes that the captain‘s expectation that the speedbrake and thrust reverser systems would function reliably and routinely as the pilots had observed them function during multiple previous landings might have led to less vigilant monitoring of those systems. Research has shown that reliable automated systems can lead pilots to have trust and confidence that the system will function as designed. In some cases, this expectation of proper system functioning can lead to poor system monitoring and failure to detect automation malfunctions.43 Further, pilots are often required to divide their attention between multiple tasks in routine flight operations, and the challenges involved in managing multiple tasks is heightened during unexpected or abnormal situations. In this incident, the pilots encountered an abnormal situation when both the speedbrake and thrust reverser systems did not deploy as expected. The NTSB has previously issued safety recommendations addressing issues related to pilots handling multiple emergency and/or abnormal situations. For example, Safety Recommendations A-09-24 and -2544 asked the FAA to do the following: Establish best practices for conducting both single and multiple emergency and abnormal situations training. (A-09-24) Once the best practices for both single and multiple emergency and abnormal situations training asked for in Safety Recommendation A-09-24 have been established, require that these best practices be incorporated into all operators‘ approved training programs. (A-09-25) On August 11, 2009, the FAA indicated that it published a notice of proposed rulemaking (NPRM), titled ?Qualifications, Service, and Use of Crewmembers and Aircraft Dispatchers,? on January 12, 2009 (74 Federal Register 1280). The FAA stated that the NPRM addressed these recommendations by requiring the inclusion of scenario-based training. The FAA indicated its belief that these scenario-based training events constituted the establishment of industry best practices for single and multiple emergency and abnormal situations training. The FAA also planned to revise FAA Order 8900.1 and/or issue a notice to require FAA inspectors to withdraw approval of 14 CFR Part 121 training programs that do not incorporate scenario-based training and practices. The FAA further indicated that training programs conducted under its Advanced Qualification Program45 were already required to make use of scenario-based line operational evaluations. Finally, the FAA stated that it planned to review the existing and proposed regulatory and policy framework to determine whether additional guidance or requirements were necessary. On April 2, 2010, the NTSB replied that the use of scenario-based training would address the intent of Safety Recommendations A-09-24 and -25 but asked how the training scenarios will be developed, noting that the collection of best practices related to such scenarios would remain necessary. The NTSB noted that issuance of the final rule proposed in the January 12, 2009, NPRM would give the FAA the regulatory framework to require such training but that, without a guide to best practices, inspectors and operators would have difficulty creating effective programs. The NTSB stated that the FAA‘s planned review of the regulatory and policy framework to determine whether additional guidance or requirements were necessary might include the collection and dissemination of the recommended best practices. Pending the outcome of that review and issuance of the final rule proposed in the NPRM,46 Safety Recommendations A-09-24 and-25 were classified ?Open—Acceptable Response.? Although pilots are typically trained to handle a single emergency, the reality is that pilots are sometimes faced with situations that include multiple abnormalities or emergencies. Training for multiple emergency and abnormal situations would provide pilots the opportunity to practice the processes and skills needed to handle such events so that the pilots would be better prepared to handle them in flight. Trained pilots would have better situational awareness and would be better equipped to adapt a learned process to the specific circumstances and time constraints of the event they encounter. This increased situational awareness is even more important in time-critical situations when pilots must respond quickly. The NTSB has investigated a number of accidents and incidents in which pilots have focused their attention on one emergency or abnormal situation at the exclusion of another, which ultimately resulted in an accident.47 The incident at JAC shows that even experienced pilots with adequate preparation for a given situation (in this case, landing) can become distracted and narrow their attention when multiple abnormal situations occur. If the incident pilots had received training for multiple emergency or abnormal events, they likely would have evaluated the situation as a whole rather than focusing on the most salient cue, which was the thrust reversers not deploying. During the landing at JAC, two qualified, experienced pilots encountered simultaneous system abnormalities when neither the thrust reversers nor the automatic speedbrakes deployed as expected. Although the pilots were not aware of the specific solution to the thrust reverser abnormality (which they only resolved through persistent efforts and luck), all pilots know that they could manually deploy the speedbrakes at any time during a landing. However, because of their focus on and efforts to resolve the thrust reverser anomaly, neither pilot noticed the abnormal speedbrake situation until the airplane had come to a stop off the end of the runway. The NTSB concludes that if the incident pilots had received specific pilot training on the handling of multiple emergency or abnormal situations, they might not have focused exclusively on the thrust reverser nondeployment and might have been more likely to recognize and properly resolve the speedbrake nondeployment during the landing. Therefore, the NTSB reiterates Safety Recommendations A-09-24 and -25.

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: 4/2/2010
Response: On January 12, 2009, the FAA published a notice of proposed rulemaking (NPRM) titled “Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers. The NTSB reviewed this NPRM and provided comments to the docket supporting the proposed revisions. The NPRM proposes to require the inclusion of scenario-based training for all 14 CFR Part 121 air carriers. The FAA intends that such scenarios will be both operationally relevant and a test of flight crews’ decision-making skills and abilities to integrate and apply learned skills to unexpected circumstances. Data regarding the overall success and compliance of 14 CFR Part 121 training programs are collected and evaluated on a regular basis using air transportation oversight system (ATOS) tools and procedures. The NPRM includes a proposal to expand these to include a continuous analysis process. The FAA believes that these scenario-based training events constitute the establishment of industry best practice for single and multiple emergency and abnormal situations training. The FAA also plans to revise FAA Order 8900.1 and/or issue a notice to require FAA inspectors to withdraw approval of Part 121 training programs that do not incorporate scenario-based training and practices. Finally, the FAA plans to review the existing and proposed regulatory and policy framework to determine whether additional guidance or requirements are necessary. This review will include data acquired through ATOS, the Aviation Safety Reporting System, aviation safety action programs, flight operations quality assurance programs, and other voluntary reporting mechanisms, as well as an assessment of the effectiveness of scenario-based training and evaluation events, incorporating input from air carriers. The FAA indicated that training programs conducted under the Advanced Qualification Program (AQP) are already required to make use of scenario-based line operational evaluations (LOE), which incorporate content designed to test pilot integration of technical and crew resource management skills. During such LOE training exercises, if a flight crewmember compounds an emergency by failing to perform the appropriate task or procedure satisfactorily, the instructor will allow additional problems that would logically result from the unsatisfactory response. The NTSB believes this is an important aspect of such training that partially addresses the intent of these recommendations. During the training, if the crew does not follow proper procedures, or misdiagnoses a problem, the crew will experience cascading problems. Such an exercise may train crews that if things are getting worse they should (1) follow procedures, (2) reconsider whether they are following the correct procedure, or (3) reconsider their diagnosis of the cause of a problem. Although the use of scenario-based training will address the intent of these recommendations, the NTSB asks how the scenarios will be developed. The collection of best practices related to such scenarios will remain necessary. Issuance of the final rule proposed in the January 12, 2009, NPRM will give the FAA the regulatory framework to require such training, but the NTSB is concerned that, without a guide to best practices, inspectors and operators will have difficulty creating effective programs. The FAA’s planned review of the regulatory and policy framework to determine whether additional guidance or requirements are necessary may include the collection and dissemination of the recommended best practices. Pending the outcome of this review, Safety Recommendation A-09-24 is classified Open Acceptable Response. Pending issuance of the final rule in response to the NPRM, Safety Recommendation A-09-25 is classified OPEN -- ACCEPTABLE 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: The FAA is interested in continually advancing the art and science of pilot training. Toward that end, the FAA supports realistic, scenario-based training that serves to develop pilot psychomotor skills as well as critical thinking and decision-making abilities in response to the range of unusual or unanticipated events that may occur during flight operations. The FAA believes that an objective of flight training is to provide an opportunity for flight crewmembers to acquire and practice the skills and knowledge necessary to perform normal, non-normal, and emergency procedures with the degree of proficiency necessary to meet or exceed an objective standard. A secondary but equally important objective is to provide the opportunity for pilots to develop the skills required to correlate previously learned tasks to obtain a satisfactory outcome when faced with an unexpected malfunction or anomaly. Training programs conducted under the FAA's Advanced Qualification Program (AQP) are already required to make use of scenario-based line operational evaluations (LOE), which incorporate content designed to test pilot integration of technical and crew resource management skills. While LOE scenarios are not designed to saturate a flight crew or impose an unrealistic level of difficulty or complexity, if a flight crew compounds an emergency by failing to accomplish a task or procedure satisfactorily, the instructor will allow additional problems that would logically result from the unsatisfactory accomplishment of the earlier task. The FAA has also developed a Notice of Proposed Rulemaking (NPRM) Qualification, Service, and Use of Crewmembers and Aircraft Dispatchers (Enclosure 3), to require the inclusion of scenario-based training for all part 121 air carriers. The public comment period for this NPRM closed on August 10, 2009. The FAA's intention is that such scenarios will be both operationally relevant and a test of the flight crew's decision-making skills and abilities to integrate and apply learned skills to unexpected circumstances. Data regarding the overall success and compliance of part 121 air carrier training programs are collected and evaluated on a regular basis using the Air Transportation Oversight System (ATOS) tools and procedures and will be expanded by the proposed Continuous Analysis Process, also included as a requirement in the referenced NPRM. The FAA believes that these scenario-based events, which are already a part of AQP programs, and will soon be required as a component of all part 121 training programs, constitute the establishment of industry best practice for single and multiple emergency and abnormal situations training. The FAA will revise Order 8900.1 and/or issue a Notice by February 2010 to require air carrier operations inspectors to withdraw approval of any part 121 training programs that do not incorporate scenario-based training and practices that resemble the LOE requirements of AQP and/or the requirements contained in the NPRM. In addition, we will review our existing and proposed regulatory and policy framework for part 121 pilot training to determine whether additional guidance or requirements are necessary. This review will include data acquired through ATOS, the Aviation Safety Reporting System, Aviation Safety Action Programs, Flight Operations Quality Assurance Programs, and other voluntary reporting mechanisms. The review will also include an assessment of the effectiveness of scenario-based training and evaluation events, incorporating input from air carriers.