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Safety Recommendation Details

Safety Recommendation A-91-093
Details
Synopsis: ON APRIL 4, 1991, AROUND 12:10 EASTERN STANDARD TIME, A LYCOMING AIR SERVICES PIPER PA-60, N3645D, AND A BELL HELICOPTER, MODEL 412, N78S OPERATED BY SUN COMPANY AVIATION DEPARTMENT, WERE INVOLVED IN A MIDAIR COLLISION OVER LOWER MERION TOWNSHIP, PENNSYLVANIA. THE FLIGHTCREWS ABOARD THE AIRCRAFT, INCLUDING THE PASSENGER ABOARD THE AIRPLANE, WERE FATALLY INJURED. THERE WERE NO PASSENGERS ABOARD THE HELICOPTER. THE AIRCRAFT CRASHED ONTO THE GROUNDS OF AN ELEMENTARY SCHOOL, FATALLY INJURING TWO CHILDREN AND SERIOUSLY INJURING ONE CHILD. FOUR OTHER PERSONS RECEIVED MINOR INJURIES.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: DISSEMINATE MORE AGGRESSIVELY AVAILABLE INFORMATION AND MATERIALS PERTAINING TO AERONAUTICAL DECISION MAKING TRAINING AND ACTIVELY PROMOTE ITS IMPLEMENTATION FOR ALL CATEGORIES OF PILOTS IN THE CIVIL AVIATION COMMUNITY.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: MERION, PA, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA91MA031AB
Accident Reports: ​Midair Collision involving Lycoming Air Services Piper Aerostar PA-60 and Sun Company Aviation Department Bell 412
Report #: AAR-91-01-SUM
Accident Date: 4/4/1991
Issue Date: 10/11/1991
Date Closed: 5/8/1992
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Flightcrew, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 5/8/1992
Response: In Safety Recommendation A-91-93 we asked the FAA to disseminate more aggressively available information and materials pertaining to Aeronautical Decision Making training and actively promote its implementation for all categories of pilots in the civil aviation community. We note that on 12/13/91, the FAA issued Advisory Circular 60-22, Aeronautical Decision Making. The Safety Board believes that FAA actions to promote wider dissemination of this vital material will have a positive effect on safety. In view of the actions taken, this safety recommendation is classified as "Closed--Acceptable Action." Although the FAA's Accident Prevention Program has been disseminating information pertaining to aeronautical decision- making, many pilots are still unaware of this important information. The Safety Board, therefore, requests that the FAA consider the inclusion of such information in air carrier training programs, Part 141 pilot schools, flight instructor seminars, and discussions in biennial checks.

From: NTSB
To: FAA
Date: 3/3/1992
Response: From the accident report of L’Express Airlines, Inc., flight 508, Beech C99, N7217L, Weather encounter and crash near Birmingham, Alabama on July 10, 1991. The Board adopted this report on 3/3/1992. In addition, the National Transportation Safety Board reiterates the following recommendation to the FAA: A-91-93.

From: FAA
To: NTSB
Date: 12/27/1991
Response: ON 12/13/91 THE FAA ISSUED AC 60-22, AERONAUTICAL DECISION MAKING. THE AC PROVIDES A SYSTEMATIC APPROACH TO RISK ASSESSMENT AND STRESS MANAGEMENT IN AVIATION, AND ILLUSTRATES HOW PERSONAL ATTITUDES CAN INFLUENCE DECISIONMAKING AND HOW THOSE ATTITUDES CAN BE MODIFIED TO ENHANCE SAFETY IN THE COCKPIT. THE FAA'S ACCIDENT PREVENTION PROGRAM HAS BEEN ACTIVELY DISSEMINATING INFORMATION AND MATERIALS PERTAINING TO AERONAUTICAL DECISIONMAKING. THE TOPIC OF HUMAN FACTORS, INCLUDING DECISIONMAKING, WAS COVERED IN JANUARY 1991. DECISIONMAKING WILL AGAIN BE THE EMPHASIZED TOPIC IN 1994. FILMS, PAMPHLETS, AND ADVISORY CIRCULARS SUPPORT ONGOING "BACK TO BASICS" PRESENTATIONS GIVEN AT PILOT SAFETY SEMINARS. MATERIALS AND INFORMATION ON AERONAUTICAL DECISIONMAKING ARE WIDELY AVAILABLE TO THE FLYING PUBLIC AND ARE AGGRESSIVELY MARKETED BY THE ACCIDENT PREVENTION PROGRAM MANAGERS IN EACH DISTRICT AND REGION.