|
From:
|
NTSB
|
|
To:
|
FAA
|
|
Date:
|
3/28/2019
|
|
Response:
|
From the Aircraft Accident Report: “Departure from Controlled Flight Trans-Pacific Air Charter, LLC, Learjet 35A, N452DA, Teterboro, New Jersey, May 15, 2017.” Report Number AAR-19-02, Notation 58039, adopted March 12, 2019 and published March 28, 2019, PB2019-100271: Section 2.4 Flight Data Monitoring
As discussed in sections 2.2 and 2.3, the flight crew repeatedly deviated from company policy and procedures. If the flight had not ended in an accident, Trans-Pacific would not have a way to identify this crew’s deviations from policy and SOPs, and the company had no way to determine whether this (or any) crew’s previous operations were conducted in accordance with company policy and SOPs. As discussed in the NTSB’s report on a 2014 accident involving a Gulfstream G-IV at BED, procedural drift and normalization of procedural deviance can pose a significant threat to the safety of flight operations, particularly for small operators (including Trans-Pacific) with limited operational oversight and consistent crew pairings (NTSB 2015). Flight data monitoring (FDM) can be a very useful tool for combating these problems.52
As a result of an increase in fatal helicopter air ambulance (HAA) accidents in 2008, the NTSB recommended that the FAA “require helicopter emergency medical services operators to install flight data recording devices and establish a structured flight data monitoring program that reviews all available data sources to identify deviations from established norms and procedures and other potential safety issues” (Safety Recommendation A-09-90). On February 21, 2014, the FAA issued a comprehensive final rule, “Helicopter Air Ambulance, Commercial Helicopter, and Part 91 Helicopter Operations” (79 Federal Register 9932), addressing many aspects of these operations. The final rule included 14 CFR 135.607, “Flight Data Monitoring System,” which required that helicopters used for Part 135 HAA operations be equipped with an approved FDM system capable of recording flight performance data (FAA 2014). However, the final rule did not require that all HAA operators establish an FDM program.
In a November 1, 2017, response to Safety Recommendation A-09-90, the FAA said that it endorsed using voluntary flight operational quality assurance programs to continuously monitor and evaluate operational practices and procedures. However, because the protections provided in Part 193, “Protection of Voluntarily Submitted Information,” pertain only if data are collected by operators as part of a voluntary FAA-approved program, the FAA did not intend to initiate rulemaking to mandate that HAA operators establish FDM programs. In a January 25, 2018, response, the NTSB pointed out that the intent of Safety Recommendation A-09-90 was for HAA operators to establish an internal program that analyzes recorded FDM system data and monitors trends in their operations. Because the data collected would not need to be shared with the FAA, there would be no need to protect the data. Because the FAA did not intend to take any additional actions regarding this recommendation, the NTSB classified Safety Recommendation A-09-90 “Closed—Unacceptable Action.”
During our investigation of the November 10, 2015, accident involving an Execuflight Hawker 700A that departed controlled flight while on an instrument approach to Akron Fulton International Airport, Akron, Ohio, the NTSB found that operational FDM programs could provide Part 135 operators with objective information regarding the manner in which their pilots conduct flights (NTSB 2016). Our investigation also found that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from company SOPs (NTSB 2016). Therefore, the NTSB recommended that the FAA “require all 14 Code of Federal Regulations Part 135 operators to install flight data recording devices capable of supporting a flight data monitoring program” (Safety Recommendation A-16-34). We also recommended that the FAA, “after the action in Safety Recommendation A-16-34 is completed, require all 14 Code of Federal Regulations Part 135 operators to establish a structured flight data monitoring program that reviews all available data sources to identify deviations from established norms and procedures and other potential safety issues” (Safety Recommendation A-16-35).
In a January 9, 2017, response addressing Safety Recommendation A-16-34, the FAA stated that it would evaluate the costs and benefits of requiring all Part 135 operators to install flight data recording devices. The FAA also stated that, in advance of the 2014 rule change to 14 CFR 135.607, it conducted a similar study of the costs and benefits to require data recording devices for HAA operators. The FAA determined, through a financial analysis, that the proposed rule change “did not meet the cost-benefit requirements for safety” but noted that the proposed change, as mandated, applied only to Part 135 operators providing air ambulance services.
In an April 6, 2017, response to the FAA, the NTSB expressed surprise that the FAA’s published regulatory evaluation of the rule change to 14 CFR 135.607 showed costs of about $20.4 million over a 10-year period but that the benefits determination amounted to $0. The NTSB’s response provided the results of our review of major aviation accident investigations from 2000 to 2015 involving Part 135 on-demand operators to identify accidents with findings related to pilot performance. The review identified seven such accidents in which a total of 53 people died and 4 people were seriously injured. Our response restated that an effective FDM program could help an operator identify issues with pilot performance (such as noncompliance with SOPs) and, through an SMS, could lead to mitigations that would prevent future accidents. The NTSB asked that the FAA, in its review of Safety Recommendation A-16-34, consider likely benefits from such a mandate instead of determining that there would be no quantifiable benefit. Pending completion of the FAA’s review and actions, the NTSB classified Safety Recommendation A-16-34 “Open—Acceptable Response.”
In its January 9, 2017, response concerning Safety Recommendation A-16-35, the FAA stated that it planned to review Part 135 operators’ level of participation in voluntary programs and evaluate additional actions needed to increase the level of participation; however, the FAA also stated that “maintaining a voluntary nature is paramount to the success of [FDM] programs.” In our April 6, 2017, response, the NTSB stated that, based on our review of major aviation accident investigations involving Part 135 on-demand operators (as discussed above), FDM programs are not common among Part 135 operators; as a result, we disagreed that the implementation of voluntary programs was successful. The NTSB further stated that the FAA’s planned review might be a basis for an acceptable alternate action to satisfy Safety Recommendation A-16-35 if the review identified additional actions to encourage and periodically evaluate the level of Part 135 operators’ voluntary compliance. However, the NTSB cautioned that any acceptable response must measure the level of voluntary participation in FDM programs and must find widespread participation among Part 135 operators. Pending completion of the FAA’s review of its voluntary FDM programs and the identification and implementation of additional activities to encourage and measure Part 135 operators’ level of voluntary participation in FDM programs, the NTSB classified Safety Recommendation A-16-35 “Open—Acceptable Alternate Response.”
Another recent accident investigation that demonstrated the benefits of FDM programs for Part 135 operators involved a Cessna 208B operated by Hageland Aviation Services, which collided with terrain in low-visibility conditions near Togiak, Alaska, on October 2, 2016 (NTSB 2018). The NTSB found that the company had safety programs in place—including an aviation safety action program (ASAP), an online internal reporting system, and an anonymous safety hotline—and that safety program deficiencies did not play a role in the accident.53 However, the investigation also identified two instances of the flight crew’s noncompliance with SOPs on the day of the accident that were not related to the accident and found that the company did not have a process to ensure compliance with SOPs and regulations. The NTSB concluded that operational FDM programs could provide Part 135 operators with objective information on how their pilots conduct flights and that a periodic review of such information could assist operators in detecting and correcting unsafe deviations from company SOPs. As a result, the NTSB reiterated Safety Recommendations A-16-34 and -35 to the FAA.
As with the operators involved in the accidents in BED, Akron, and Togiak, the NTSB’s investigation of the TEB accident found a Part 135 operator that had no means to monitor flights to identify and mitigate operational deficiencies (such as noncompliance with established SOPs) before the accident occurred. An FDM program would have enabled Trans-Pacific to identify issues, such as airspeed deviations and unstable approach profiles, and address them. Such a program could have led to corrective actions before the accident. Thus, the NTSB concludes that an FDM program could help Part 135 operators identify and mitigate procedural noncompliance, including the operational deficiencies identified in this accident investigation. Therefore, the NTSB reiterates Safety Recommendations A-16-34 and A-16-35. In addition, the NTSB notes that, on February 4, 2019, we announced our 2019-2020 Most Wanted List of Transportation Safety Improvements, and Safety Recommendations A-16-34 and -35 were associated with one of the issue areas on the Most Wanted List, “Improve the Safety of Part 135 Aircraft Flight Operations.”
|
|