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Safety Recommendation Details

Safety Recommendation A-12-056
Details
Synopsis: On April 2, 2011, about 0934 mountain daylight time, an experimental Gulfstream Aerospace Corporation GVI (G650), N652GD, crashed during takeoff from runway 21 at Roswell International Air Center, Roswell, New Mexico. The two pilots and the two flight test engineers were fatally injured, and the airplane was substantially damaged by impact forces and a postcrash fire. The airplane was registered to and operated by Gulfstream as part of its G650 flight test program. The flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Work with the Flight Test Safety Committee to develop and issue flight test safety program guidelines based on best practices in aviation safety management.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Roswell, NM, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA11MA076
Accident Reports: Crash During Experimental Test Flight, Gulfstream Aerospace Corporation GVI (G650), N652GD
Report #: AAR-12-02
Accident Date: 4/2/2011
Issue Date: 10/23/2012
Date Closed: 6/27/2016
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/27/2016
Response: We issued Safety Recommendation A-12-60 to the FTSC as a companion recommendation to Safety Recommendation A-12-56, requesting that the committee take the lead in this work. On April 25, 2016, we wrote to you that the FAA had substantially completed the work we requested, and that the remaining work, which was nearly completed, was the responsibility of the FTSC. The FTSC has informed us that it used FAA advisory circular 120-92, “Safety Management Systems [SMS] for Aviation Service Providers,” FAA Order 4040.26, “Aircraft Certification Service Flight Test Risk Management Program,” and FAA Order 8000.369 “Safety Management System Guidance” in developing the FTSC best practices SMS protocols. The FTSC has also indicated that an FAA Aircraft Certification Service office played an important role in evaluating the SMS protocols as they were developed and tested. The FTSC has placed “Flight Test SMS Protocols” in the Best Practices section of its website, and on May 5, 2016, FTSC Board Member Tom Huff presented these protocols and the results of the evaluations conducted to the Flight Test Safety Workshop held in Melbourne, Florida. These actions satisfied Safety Recommendation A-12-60, which is classified “Closed—Acceptable Action.” Consequently, Safety Recommendation A 12 56 is classified CLOSED—ACCEPTABLE ACTION. Thank you for work with the FTSC to develop these SMS audit protocols and to satisfy these important safety recommendations.

From: NTSB
To: FAA
Date: 4/25/2016
Response: We agree that you have substantially completed the work we requested, and that the remaining work is the responsibility of the FTSC. We issued Safety Recommendations A-12-59 and 60 to the FTSC as companion recommendations to Safety Recommendations A-12-55 and 56, requesting that the committee take the lead in this work, which it has now nearly completed. Pending issuance of the recommended guidance for manufacturers and program guidelines, Safety Recommendations A-12-55 and -56 remain classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 3/9/2016
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) continues to support the Flight Test Safety Committee (FTSC) in developing detailed flight test operating guidance for manufacturers and safety program guidelines based on best practices in aviation safety management. FAA personnel serve on the FTSC as flight test and aviation safety professionals, and we expect to remain actively involved in a limited capacity. The FAA worked with the FTSC to establish the Flight Test Safety Database, which is available on the Internet at ftsdb.grc.nasa.gov, and is hosted by the National Aeronautics and Space Administration (NASA). The NASA-hosted database provides a repository for test maneuvering descriptions, test hazards, and hazard mitigation techniques. Also, an FTSC working group, which included FAA personnel, developed a letter to aircraft manufacturers requesting that they share their organization's flight test operations and flight test safety risk management documents to provide a comprehensive and easily accessible resource for all flight test organizations. Although an all-volunteer organization, the FTSC is comprised of dedicated experts from government and industry committed to flight test safety. The FAA is but one of many technically proficient organizations involved in the FTSC, and by no means is the primary actor. Along with NASA, Boeing, Bell Helicopters, Gulfstream, Airbus, Northrop Grumman, and other valued members of FTSC, the FAA adds to the collective discussion of flight test safety but does not define that discussion. The successful implementation of the intent of these recommendations (also the FTSC's Safety Recommendations A-12-59 and -60) is best served by the FTSC, a group that produces thorough policy through a collective approach. By assigning these recommendations solely to the FAA, the Board has placed the FAA above other FTSC groups, which is not warranted based on the FAA's limited contributions to the FTSC. The FAA will continue to contribute to the FTSC as a member, adding its voice to the many other valuable organizational voices that make up the FTSC. In addition to participating in the FTSC, the FAA will continue to promote aviation safety by developing and publishing safety policy and guidance, which currently include: • FAA Advisory Circular 1 02-92A, Safety Management Systems for Aviation Service Providers; • FAA Order 4040.26B, Aircraft Certification Service Flight Test Risk Management Program; and • FAA Order 8000.369A, Safety Management System. I believe that the FAA has effectively addressed Safety Recommendations A-12-55 and A-12-56 and consider our actions complete.

From: NTSB
To: FAA
Date: 6/18/2015
Response: The FTSC’s November 25, 2014, letter to us regarding Safety Recommendation A-12-60, a companion recommendation to A-12-56, discussed the FTSC’s actions to adapt safety management system (SMS) auditing protocols from the International Business Aircraft Council’s International Standard for Business Aircraft Operations (IS-BAO) and the Safety Management International Collaborative Group. In addition, the FTSC is incorporating key elements of FAA Advisory Circular 120-92, “Safety Management Systems for Aviation Service Providers,” FAA Order 4040.26, ”Aircraft Certification Service Flight Test Risk Management Program,” and FAA Order 8000.369, “Safety Management System Guidance.” We are aware that the FTSC plans to complete some sample audits to evaluate the system after it develops auditing protocols. Finally, it plans to distribute the tested protocols through the FTSD and at meetings of the Society of Experimental Test Pilots and the Society of Flight Test Engineers. Pending completion and testing of the SMS audit protocols, Safety Recommendation A-12-56 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 3/23/2015
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration's (FAA) previous work with the Flight Test Safety Committee (FTSC) established a Flight Test Safety Database, which is available at the following Web site: ftsdb.grc.nasa.gov/. The database is an easily accessible repository for test maneuvering descriptions, test hazards, and hazard mitigation techniques. The FAA funded the development of this database, but difficulty has been experienced in populating the database with the best flight test safety program guidelines available in flight test safety management. The FTSC is taking action to reinvigorate the database to provide safety data for flight testing to industry and is currently in the process of soliciting additional industry input. The FAA will continue to support the FTSC with its efforts to populate the database with material for flight test best practices.

From: NTSB
To: FAA
Date: 3/26/2013
Response: Pending completion of the FAA’s work with the FTSC to develop and issue the recommended guidelines, Safety Recommendations A-12-55 and -56 are classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 1/15/2013
Response: -From Michael P. Huerta, Administrator: The FAA agrees that the actions recommended in these two safety recommendations may provide significant fljght test safety benefits to aircraft manufacturers. FAA representatives began discussions with the Chairman of the Flight Test Safety Committee. We will request that the Flight Test Safety Committee develops guidance addressing the deficiencies documented in Accident Report NTSB/AAR-12/02 and a timeline for developing flight test safety program guidelines on best practices in aviation safety management. We expect the Flight Test Safety Committee will complete the recommended actions by September 30, 2013. I will keep the Board informed of the FAA’s progress on these safety recommendations and provide an updated response by November 2013.