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On July 31, 2008, about 0945 central daylight time, East Coast Jets flight 81, a Hawker Beechcraft Corporation 125-800A airplane, N818MV, crashed while attempting to go around after landing on runway 30 at Owatonna Degner Regional Airport (OWA), Owatonna, Minnesota. The two pilots and six passengers were killed, and the airplane was destroyed by impact forces. The nonscheduled, domestic passenger flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 135. An instrument flight rules flight plan had been filed and activated; however, it was canceled before the landing. Visual meteorological conditions prevailed at the time of the accident. The National Transportation Safety Board (NTSB) determined that the probable cause of this accident was the captain’s decision to attempt a go-around late in the landing roll with insufficient runway remaining. Contributing to the accident were (1) the pilots’ poor crew coordination and lack of cockpit discipline; (2) fatigue, which likely impaired both pilots’ performance; and (3) the failure of the Federal Aviation Administration (FAA) to require crew resource management (CRM) training and standard operating procedures (SOPs) for 14 CFR Part 135 operators.
TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to ensure that terrain avoidance warning system-equipped aircraft in their fleet have the current terrain database installed.
Original recommendation transmittal letter:
Closed - Unacceptable Action
Owatonna, MN, United States
Crash During Attempted Go-Around After Landing East Coast Jets Flight 81 Hawker Beechcraft Corporation 125-800A, N818MV
Addressee(s) and Addressee Status:
FAA (Closed - Unacceptable Action)
Safety Recommendation History
You stated that operators are alerted to TAWS database revisions via the database manufacturer’s Service Bulletins, Service Letters, and through the Internet, and that these methods allow all operators to review the changes within a revision and determine whether the revision applies to their geographic area of operation. We point out that, at the time of this accident, the terrain database installed in the airplane’s enhanced ground proximity warning system (EGPWS) was version 421 (released in March 2000). The current terrain database was version 450 (released in April 2008), which was an upgrade to version 421. However, no change occurred to the OWA data between the old and current versions of the EGPWS terrain database. We continue to believe that it is critical for the EGPWS to contain updated information to maximize the safety benefits of such a system, because terrain and obstacle data may change over time. However, because you indicated that FAA action in response to this recommendation is complete, Safety Recommendation A-11-31 is classified CLOSED—UNACCEPTABLE ACTION.
-From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) reviewed current regulations and policy regarding Terrain Awareness and Warning System (TAWS) database revisions. After reviewing this information, the recommendation, and the accident that triggered this recommendation, the FAA has determined that mandating the installation of all TAWS database revisions is unnecessary for continued operational safety. Operators are alerted to TAWS database revisions via the database manufacturer's Service Bulletins, Service Letters, and through the Internet. These methods allow all operators to review the changes within a revision and determine whether the revision applies to their geographic area of operation. For example, if an operator only flies in the Northeastern United States, they may not need a revision that only consists of updates on the west coast of the United States. Likewise, if that same operator received notice that a revision is available for their area of operation, but determined after review that no changes in the data apply, the operator could decline the revision and still have the most up-to-date TAWS information for the area in which they fly. In both examples, whether general or specific to an operator's area of operation, the most current revision would not apply to the operator. Therefore, a requirement to have the most current database revision installed in the aircraft would not necessarily enhance safety. The accident that triggered this recommendation is an example of having the most up-to-date relevant TAWS information but not having the most current database revision. In this case, the Board noted that the TAWS database did not play a role in the accident. The FAA believes the maximum safety benefit of TAWS was maintained in this case even though the most current terrain database revision for their area of operation was not installed. A requirement for operating with the most current revision of a terrain database does not necessarily maximize the safety benefit of TAWS and does not warrant rulemaking activity, which would be required to mandate installation of the most current TAWS database revision. I believe that the FAA has effectively addressed this safety recommendation and I consider our actions complete.
Our last update from the FAA regarding these recommendations was its June 10, 2011, letter. We are concerned that, although more than 2 years have passed since then, we have received no additional information regarding the agency’s efforts to address Safety Recommendations A-11-18 through -20, -24 through -27, -30, or -31. Pending our timely receipt of an update and completion of the recommended actions, these recommendations remain classified OPEN—ACCEPTABLE RESPONSE.
The NTSB notes that the FAA will review and evaluate applicable regulatory and policy guidance and will collaborate with the terrain database providers in determining what actions to take in response to this recommendation. Pending completion of the recommended action, Safety Recommendation A-11-31 is classified OPEN—ACCEPTABLE RESPONSE.
CC# 201100245: - From J. Randolph Babbitt, Administrator: The FAA will review and evaluate applicable regulatory and policy guidance and collaborate with the terrain database providers to determine whether revisions are necessary to ensure that terrain avoidance equipped aircraft have the current database installed. I will keep the Board informed of the FAA's progress on this safety recommendation and I will provide an update by July 2012.
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