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Safety Recommendation Details

Safety Recommendation A-94-073
Details
Synopsis: ON APRIL, 29, 1993, AT 1555 CENTRAL DAYLIGHT TIME, AN EMBRAER EMB-120 RT, BRASILIA, N24706, WAS SUBSTANTIALLY DAMAGED WHEN IT COLLIDED WITH ROUGH TERRAIN DURING AN OVERRUN FOLLOWING A FORCED LANDING ON RUNWAY 17 AT THE GRIDER FIELD AIRPORT IN PINE BLUFF, ARKANSAS. THE FORCED LANDING WAS EXECUTED AFTER THE AIRPLANE STALLED AND WENT OUT OF CONTROL AT APPROXIMATELY 17,000 FEET DURING THE CLIMB TO CRUISE ALTITUDE. THE FLIGHTCREW REGAINED CONTROL OF THE AIRPLANE AFTER LOSING ABOUT 12,000 FEET OF ALTITUDE. HOWEVER, AFTER REGAINING CONTROL, THE FLIGHTCREW NOTED THAT THE LEFT ENGINE NACELLE WAS EXTENSIVELY DAMAGED, THREE OF THE FOUR PROPELLER BLADES WERE MISSING, AND THE AIRPLANE WAS UNABLE TO MAINTAIN LEVEL FLIGHT.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REQUIRE THAT 14 CFR PART 135 AIR CARRIERS PROVIDE AIRCREWS, AS PART OF THEIR INITIAL AND RECURRENT TRAINING, INFORMATION ON FATIGUE COUNTERMEASURES RELEVANT TO THE DUTY/REST SCHEDULES BEING FLOWN BY THE COMPANY.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: PINE BLUFF, AR, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: FTW93MA143
Accident Reports: ​In-Flight Loss of Control, Leading to Forced Landing and Runway Overrun, Continental Express, Inc., N24706, Embraer EMB-120 RT
Report #: AAR-89-02-SUM
Accident Date: 4/29/1993
Issue Date: 3/17/1994
Date Closed: 1/16/1996
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Fatigue, Flightcrew, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 1/16/1996
Response: THE GUIDANCE IN THE REVISED AC 120-51B MEET THE BOARD'S INTENT IN ISSUING A-94-5 & A-94-73, & THE BOARD COULD CONSIDER THIS REVISION AN ACCEPTABLE ALTERNATIVE TO THE REGULATORY CHANGE THAT THE BOARD ORIGINALLY REQUESTED. HOWEVER, BECAUSE OF YOUR PERSONAL COMMITMENT TO ACHIEVING A SINGLE OF LEVEL OF SAFETY IN ALL SCHEDULED PASSENGER AIR TRANSPORTATION, WE ARE CONFIDENT THAT THE FAA WILL FINALIZE ITS PROPOSED RULES TO REQUIRE AIR CARRIERS OPERATING UNDER BOTH PARTS 121 & 135 TO PROVIDE CAM TRAINING TO FLIGHTCREWS. ACCORDINGLY, A-94-5 & A-94-73 ARE CLASSIFIED "CLOSED--ACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 11/7/1995
Response: ON 9/8/95, THE FAA ISSUED CHANGE 1 TO AC 120-51B, CREW RESOURCE MANAGEMENT TRAINING. APPENDIX 3, PRAGRAPH 2H, OF THE REVISED AC RECOMMENDS CRM TRAINING ON A NUMBER TO TOPICS INCLUDING FACTUAL INFO ABOUT THE DETRIMENTAL EFFECTS OF FATIGUE & STRATEGIES FOR AVOIDING & COUNTERING ITS EFFECTS.

From: FAA
To: NTSB
Date: 5/10/1995
Response: The Federal Aviation Administration has asked the Aviation Rulemaking Advisory Committee to form a working group entitled Fatigue Countermeasures in Air Transportation to develop an advisory circular (AC) that will outline fatigue countermeasures and alertness management techniques that could improve safety in air transportation. The AC will discuss current knowledge associated with the physiological mechanisms underlying fatigue and demonstrate how this knowledge can be applied to improve flightcrew rest, alertness, and performance. Practical recommendations for use by crewmembers will also be provided. Additionally, this information will be referenced in an appendix to AC 120-51, Crew Resource Management (CRM) Training. This appendix will advise air carriers that training on fatigue and its countermeasures are subjects to include in CRM training. I will provide the Board with a copy of the AC as soon as it is issued.

From: NTSB
To: FAA
Date: 3/7/1995
Response: THE BOARD IS PLEASED THAT THE FAA PLANS TO FORM AN AVIATION RULEMAKING ADVISORY COMMITTEE (ARAC) ON FATIGUE COUNTERMEASURES IN AIR TRANSPORTATION. THE BOARD BELIEVES THAT THE ADVISORY CIRCULAR THAT IS TO BE DEVELOPED BY THIS COMMITTEE CAN BE AN EFFECTIVE EDUCATIONAL RESOURCE. ALSO, THE FAA'S DECISION TO INCLUDE INFO ABOUT FATIGUE & ITS COUNTERMEASURES IN THE CREW RESOURCE MANAGEMENT AC IS WELCOMED BY THE BOARD. WE LOOK FORWARD TO RECEIVING THE ADVISORY CIRCULARS. THE BOARD URGES THAT ARAC BE CONVENED IMMEDIATELY, & THAT IT COMPLETE ITS WORK WITHIN ONE YEAR. A-94-5 & A-94-73 ARE CLASSIFIED "OPEN--ACCEPTABLE ALTERNATE RESPONSE.

From: FAA
To: NTSB
Date: 12/21/1994
Response: THE FAA HAS ASKED THE AVIATION RULEMAKING ADVISORY COMMITTEE TO FORM A WORKING GROUP ENTITLE FATIGUE COUNTERMEASURES IN AIR TRANSPORTATION TO DEVELOP AN ADVISORY CIRCULAR THAT WILL OUTLINE FATIGUE COUNTERMEASURES & ALERTNESS MANAGMENT TECHNIQUES UNDERLYING FATIGUE & DEMONSTRATE HOW THIS KNOWLEDGE CAN BE APPLIED TO IMPROVE FLIGHTCREW REST, ALERTNESS, & PERFORMANCE. PRACTICAL RECOMMENDATIONS FOR USE BY CREWMEMBERS WILL ALSO BE PROVIDED. ADDITIONALLY THIS INFO WILL BE REFERENCED IN AN APPRENDIX TO AC 120-51, CREW RESOURCE MANAGEMENT TRAINING. THIS APPENDIX WILL ADVISE AIR CARRIERS THAT TRAINING ON FATIGUE & ITS COUNTERMEASURES ARE SUBJECTS TO INCLUDE IN CRM TRAINING. I WILL PROVIDE THE BOARD A COPY OF THE AC…

From: NTSB
To: FAA
Date: 6/30/1994
Response: THE BOARD CONCURS WITH THE FAA'S SUGGESTION THAT AN EDUCATIONAL PROGRAM ON FATIGUE & FATIGUE COUNTERMEASURES IS COMPATIBLE WITH CREW RESOURCE MANAGEMENT TRAINING, BUT IS DISAPPOINTED THAT THE FAA PROPOSES ONLY TO ISSUE AN AIR CARRIER OPERATIONS BULLETIN TO PRESENT A SUMMARY OF FATIGUE COUNTERING STRATEGIES. THE ISSUANCE OF A NEW ADVISORY CIRCULAR , OR AN ADDITION TO AC 120-51A, "CREW RESOURCE MANAGEMENT TRAINING ADVISORY CIRCULAR," WOULD PROVIDE THE AIR CARRIER INDUSTRY WITH MORE WIDELY DISSEMINATED, PERMANENT GUIDANCE ON A FATIGUE EDUCATION PROGRAM; REGULATORY CHANGE WOULD BE AN EVER STRONGER ACTION. THE BOARD CONTINUES TO BELIEVE THAT FATIGUE IS A CRITICAL SAFETY ISSUE IN AIR CARRIER FLIGHTCREW PERFORMANCE. THE BOARD'S INVESTIGATION OF THE 8/18/93, CRASH OF AN AMERICAN INTERNATIONAL AIRWAYS DOUGLAS DC-8-61 AT GUANTANAMO BAY, CUBA, HAS REINFORCED THE BOARD'S CONCERN ABOUT THE EFFECT OF FATIGUE ON AIR CARRIER FLIGHTCREW PERFORMANCE. ON 5/10/94, THE BOARD DETERMINED THAT IMPAIRED JUDGMENT, DECISIONMAKING, & FLYING ABILITIES OF THE CAPTAIN & FLIGHTCREW DUE TO THE EFFECTS OF FATIGUE WERE CAUSES OF THE ACCIDENT & REITERATED A-94-73 TO THE FAA. THE BOARD ASKS THE FAA TO CONSIDER TAKING STRONGER ACTION, SUCH AS ISSUING AN AC REGULATORY ACTION. PENDING FURTHER INFO ABOUT THE FAA'S INTENTIONS FOR A FATIGUE & FATIGUE COUNTERMEASURES EDUCATIONAL PROGRAM, A-94-73 IS CLASSIFIED "OPEN--ACCEPTABLE ALTERNATE RESPONSE."

From: FAA
To: NTSB
Date: 5/5/1994
Response: THE FAA AGREES WITH THE INTENT OF THIS RECOMMENDATION. HOWEVER, THE FAA BELIEVES THAT THE TOPIC OF FATIGUE AS IT RELATES TO DECISIONMAKING CAN BEST BE ADDRESSED DURING CREW RESOURCE MANAGEMENT TRAINING. CONSEQUENTLY, THE FAA WILL PUBLISH AN AIR CARRIER OPERATIONS BULLETIN (ACOB) TO ADDRESS THE DETRIMENTAL EFFECTS OF FATIGUE AND STRATEGIES FOR AVOIDING & COUNTERING ITS EFFECTS. THE FOUNDATION OF THE ACOB WILL BE VARIOUS RESEARCH PROJECTS THAT THE FAA HAS FUNDED SINCE 1985. THESE INCLUDE A TECHNICAL MEMORANDUM DEVELOPMENT BY THE FAA & THE NATIONAL AERONAUTICS & SPACE ADMINISRATION ENTITLED "CREW FACTORS IN FLIGHT OPERATION: X. STRATEGIES FOR ALTERNESS MANAGEMENT IN FLIGHT OPERATIONS."