FAA’s Response to NTSB’s “Most Wanted” Safety Recommendations
The Federal Aviation Administration (FAA) and the National Transportation Safety Board (NTSB) share a common goal — promoting safety in aviation and preventing aircraft accidents. The record shows the NTSB and FAA agree on a course of action about 80 percent of the time. Of the safety recommendations made to the FAA, the NTSB has classified about 80 percent closed acceptable, and approximately 5 percent remain open in acceptable status.
We have made substantial progress in meeting the safety intent of the NTSB’s “Most Wanted” recommendations.
REDUCE FATIGUE-RELATED ACCIDENTS
Recommendations A-94-194/A-95-113/A-14-72: Set working hour limits for flight crews, aviation mechanics, and air traffic controllers based on fatigue research, circadian rhythms, and sleep and rest requirements. Require that aviation safety inspectors brief the threat of fatigue before each departure.
FAA Action: The FAA will publish an advance Notice of Proposed Rulemaking (NPRM) addressing Part 91 tail-end ferry operations for Part 135 operators and an NPRM to extend Part 121 flight, duty, and rest limits to tail-end ferry flights that follow an all-cargo flight.
Recommendation A-13-3: Require that personnel performing maintenance or inspections under 14 CFR Parts 121, 135, 145, and 91 Subpart K receive initial and recurrent training on human factors affecting maintenance that includes a review of the causes of human error, including fatigue, its effects on performance, and actions individuals can take to prevent the development of fatigue.
FAA Action: The FAA is updating FAA Order 8900.1 and Advisory Circular (AC) 120-72, Maintenance Human Factors Training, to address this recommendation.
END DRUG AND ALCOHOL IMPAIRMENT
Recommendation A-07-43: Require that all airmen clinically diagnosed with substance dependence…who are medically certified by the FAA subsequent to such diagnosis, are followed under guidelines for special issuance of medical certificates for the period that they hold such certificates.
FAA Action: The FAA’s Office of the Chief Counsel opined that the Code of Federal Regulations in this recommendation allows the Office of Aerospace Medicine to require ongoing monitoring of an airman with substance dependence for any duration that is deemed appropriate based on each individual airman’s case. The FAA is currently and actively following airmen who have an Authorization for Special Issuance of a medical certificate.
Recommendation A-14-92: Develop, publicize, and periodically update information to educate pilots about the potentially impairing drugs identified in your toxicology test results of fatally injured pilots, and make pilots aware of less impairing alternative drugs if they are available.
FAA Action: The FAA’s Office of Aerospace Medicine produced a series of articles titled DrugTalk for educating pilots and the aviation community about legal and illegal drugs. The first article in the series, written by Allison Veitenheimer, PhD and Russell Lewis, PhD, is titled DrugTalk: Antihistamines and Flying, and can be found in the Federal Air Surgeon’s Medical Bulletin, Vol. 55, No. 1.
Recommendation A-14-95: Conduct a study to assess the prevalence of over-the-counter, prescription, and illicit drug use among flying pilots not involved in accidents, and compare those results with findings from pilots who have died from aviation accidents to assess the safety risks of using those drugs while flying.
FAA Action: The FAA has obtained its first shipment of necessary supplies to conduct the research project and is finalizing the mechanisms needed for transporting to the Aviation Medical Examiners (AME). Currently, we are deciding which AMEs to invite to participate in the project. Pilot organizations such as the Aircraft Owners and Pilots Association, the Air Line Pilots Association (ALPA), and the Experimental Aircraft Association, in addition to FAA Regional Flight Surgeons and executives, have all been briefed on this developing project. Their input resulted in more discussion between researchers, senior management at the Civil Aerospace Medical Institute, and FAA executives regarding the status of the project, which has delayed implementation.
The FAA updated NTSB staff on August 7, 2019, and discussed the scope of the project. As a result, the FAA expects to complete this project by the end of Fiscal Year 2022.
STRENGTHEN OCCUPANT PROTECTION
Recommendation A-15-12: Require, for all newly manufactured rotorcraft regardless of the design’s original certification date, that the fuel systems meet the crashworthiness requirements of 14 CFR 27.952 or 29.952, “Fuel System Crash Resistance.”
FAA Action: The Aviation Rulemaking Advisory Committee (ARAC) established the Rotorcraft Occupant Protection Working Group, which presented its recommendations to the ARAC on March 15, 2018. Further rulemaking action is pending issuance of a rulemaking slot. The FAA Reauthorization Act of 2018, signed October 5, 2018, requires the FAA to revise 49 U.S. Code Chapter 447 to require crash resistant fuel systems on rotorcraft.
Recommendation A-16-25: Require 14 CFR Part 121 operators to provide (1) guidance that instructs flight attendants to remain at their assigned exits and actively monitor exit availability in all non-normal situations in case an evacuation is necessary and (2) flight attendant training programs that include scenarios requiring crew coordination regarding active monitoring of exit availability and evacuating after a significant event that involves a loss of communications.
FAA Action: The FAA is reviewing AC 120-48, Communication and Coordination Between Flight Crewmembers and Flight Attendants, and we may revise it to include scenario-based training involving a communication loss.
Recommendation A-16-26: Develop best practices related to evacuation communication, coordination, and decision-making during emergencies through the establishment of an industry working group and then issue guidance for 14 CFR Part 121 air carriers to use to improve flight and cabin crew performance during evacuations.
FAA Action: The FAA is considering establishing a working group, including representatives from ALPA, the Association of Flight Attendants, the Association of Professional Flight Attendants, Airlines for America, and the FAA’s Flight Standards Service to examine the issue and make recommendations on additional ways of enhancing communication, coordination and decision-making during emergencies.
The FAA has long-standing regulations on the protection of passengers in commercial and private aircraft, based on the operation of the aircraft. The FAA is continuously strengthening occupant protection for aviation passengers, ensuring the safety of new cabin designs, promoting safe transport in new and dangerous environments, and looking at how existing rotorcraft airworthiness standards can be improved.
No NTSB recommendations to the FAA were identified.
The FAA and the general aviation (GA) community’s national #FlySafe campaign helps educate GA pilots about the best practices to calculate and predict aircraft performance and to operate within established aircraft limitations, including a focus on eliminating distractions. The FAA emphasizes minimizing distractions from every source, such as the pilot explaining sterile cockpit procedures to passengers, self-briefing if the pilot is alone, and establishing a focused, no-nonsense mindset you need for critical phases of flight.
The FAA specifically prohibits personal use of electronic devices on the flight deck. The use of personal wireless communication devices or laptop computers for personal use while at a duty station on the flight deck while the aircraft is being operated, is strictly prohibited.
IMPROVE PART 135 OPERATIONS SAFETY
Recommendation A-07-18: In cooperation with Hawaii commercial air tour operators, aviation psychologists, and meteorologists, among others, develop a cue-based training program for commercial air tour pilots in Hawaii that specifically addresses hazardous aspects of local weather phenomena and in-flight decision-making.
Recommendation A-07-19: Once a cue-based training program that specifically addresses hazardous aspects of local weather phenomena and weather-related, decision-making issues is developed (as requested in Safety Recommendation A-07-18), require all commercial air tour operators in Hawaii to provide this training to newly hired pilots.
FAA Action: The FAA is revising Operations Specification (OPSS) B048 and Letter of Authorization (LOA) B548 to require cue-based weather training. The cue-based weather training required by the revised OPSS B048 and LOA B548 may be provided via pictorial description, actual video, or PowerPoint presentations of each commercial air tour site specific area showing examples of acceptable and unacceptable weather at each critical point within the route along with industry-recommended course reversal maneuvers. The Hawaii air tour industry participants will have location-specific training products for each island where air tour operations are conducted.
All newly hired pilots and transferred pilots flying air tours for the first time on any island will be required to receive the cue-based weather training for the pertinent island/site prior to initiating flight operations on each island. Following completion of the training, § 135.293 initial and recurrent checks will include verification of the Part 135 pilot’s knowledge of weather-related decision making pertinent to the pilot’s assigned area of operation.
Recommendation A-07-112:Ensure that the minimum equipment lists for helicopters used in helicopter emergency medical services operations require that radar altimeters be operable during flights conducted at night.
FAA Action: The FAA is in the process of amending rotorcraft Master Minimum Equipment Lists (MMEL) to allow for operations under Part 135 with inoperative radar altimeters with certain limitations. Operations with an inoperative radar altimeter prohibits flights using night-vision goggles, night off-airport landings or landings at unimproved areas, and flights conducted over water or terrain without surface lights. For night flights pilots are required to evaluate terrain and obstacles along the route and fly at such an altitude to ensure all terrain and obstacles along the route of flight are cleared vertically by no less than 500 feet.
Additionally, a Global Change Policy Letter is in draft that would allow for all operators of affected aircraft to amend their Minimum Equipment List before the MMELs are amended.
Recommendation A-09-92: Permit the Helicopter Emergency Medical Services (HEMS) Aviation Digital Data Service Weather Tool to be used by HEMS operators as an official weather product.
FAA Action: The FAA transitioned our HEMS tool to operational and published AC 00-45H, Change 1, Chapter 6, Aviation Weather Tools.
Recommendation A-10-29: Require 14 CFR Part 121, 135, and 91K operators to (1) routinely download and analyze all available sources of safety information, as part of their flight operational quality assurance program, to identify deviations from established norms and procedures; (2) provide appropriate protections to ensure the confidentiality of the de-identified aggregate data; and (3) ensure that this information is used for safety-related and not punitive purposes.
FAA Action: The FAA will update relevant guidance to inspectors in FAA Order 8900.1.
Recommendation A-13-12: Require the installation of a crash-resistant flight recorder system on all newly manufactured turbine-powered, non-experimental, non-restricted-category aircraft that are not equipped with a flight data recorder and a cockpit voice recorder and are operating under 14 CFR Parts 91, 121, or 135. The crash-resistant flight recorder system should record cockpit audio and images with a view of the cockpit environment to include as much of the outside view as possible, and parametric data per aircraft and system installation, all as specified in Technical Standard Order C197, “Information Collection and Monitoring Systems.”
Recommendation A-13-13: Require all existing turbine-powered, non-experimental, non-restricted-category aircraft that are not equipped with a flight data recorder or cockpit voice recorder and are operating under 14 CFR Parts 91, 121, or 135 to be retrofitted with a crash-resistant flight recorder system. The crash-resistant flight recorder system should record cockpit audio and images with a view of the cockpit environment to include as much of the outside view as possible, and parametric data per aircraft and system installation, all as specified in Technical Standard Order C197, “Information Collection and Monitoring Systems.”
FAA Action: The FAA is not considering rulemaking at this time for these recommendations. The FAA will examine possible ways of polling operators through our aviation safety inspectors to identify voluntary flight data monitoring (FDM) system equipage rates.
Recommendation A-15-7: Require that all existing aircraft operated under Title 14 CFR Part 121 or 135 and currently required to have a cockpit voice recorder and a flight data recorder be retrofitted with a crash-protected cockpit image recording system compliant with Technical Standard Order TSO-C176a, “Cockpit Image Recorder Equipment,” TSO-C176a or equivalent. The cockpit image recorder should be equipped with an independent power source consistent with that required for cockpit voice recorders in 14 CFR section 25.1457.
Recommendation A-15-8: Require that all newly manufactured aircraft operated under Title 14 CFR Part 121 or 135 and required to have a cockpit voice recorder and a flight data recorder also be equipped with a crash-protected cockpit image recording system compliant with Technical Standard Order TSO-C176a, “Cockpit Image Recorder Equipment,” or equivalent. The cockpit image recorder should be equipped with an independent power source consistent with that required for cockpit voice recorders in 14 CFR 25.1457. (Supersedes Safety Recommendation A-00-31).
FAA Action: The FAA is not considering requiring aircraft to record images of the cockpit per TSO-C176a. Instead, the FAA will consider a forward fit requirement for a recording system that captures display and switch information once we see the full effect of Amendment 43 to International Civil Aviation Organization Annex 6.
Recommendation A-16-34: Require all 14 CFR Part 135 operators to install flight data recording devices capable of supporting a flight data monitoring program.
FAA Action: The FAA will conduct a review to determine the feasibility of requiring all Part 135 certificate holders to install FDM systems on their aircraft.
Recommendation A-16-35: After the action in Safety Recommendation A-16-34 is completed, require all 14 CFR 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.
FAA Action: The FAA will conduct a review of the level of participation of Part 135 certificate holders in voluntary programs and evaluate additional actions that can increase awareness and participation.
Recommendation A-16-36: Require all 14 CFR Part 135 operators to establish safety management system programs.
FAA Action: The FAA recently required Part 121 certificate holders to have a Safety Management System (SMS) when it published the final rule, on January 8, 2015 (80 FR 1307). In the NPRM, the FAA considered that SMS could be applied to Part 135 certificate holders in the future. The FAA would like to highlight that while SMS is not currently required for Part 135 operators, the FAA has a formal SMS voluntary program in which Part 135 operators may participate. The FAA will conduct a review and hold meetings to determine the feasibility of recommending SMS for Part 135 certificate holders and determine if further action is needed.
Recommendation A-17-35: Implement ways to provide effective terrain awareness and warning system (TAWS) protections while mitigating nuisance alerts for single-engine airplanes operated under 14 CFR Part 135 that frequently operate at altitudes below their respective Terrain Awareness and Warning Systems (TAWS) class design alerting threshold.
FAA Action: The FAA actively participates in the General Aviation Joint Steering Committee (GAJSC) Controlled Flight Into Terrain (CFIT) workgroup, which will likely provide a final report by December 2020 concerning CFIT accidents.
In addition, the FAA is actively participating in quarterly meetings of RTCA’s Special Committee (SC) 231 on TAWS. SC-231 is attempting to produce solutions to enhance TAWS protections and determine if further standards are necessary for RTCA/DO-367, Minimum Operational Performance Standards (MOPS) for TAWS Airborne Equipment. The FAA will review the SC-231 recommendations and determine the next appropriate actions.
Recommendation A-17-37: Work with members of the Ketchikan air tour industry to improve existing training programs aimed at reducing the risk of weather-related accidents involving continuation of flight under Visual Flight Rules (VFR) into instrument meteorological conditions, with special attention paid to the human factors issues identified in this investigation, including (1) the need to help pilots better calibrate what constitutes safe weather conditions to conduct flights based on objective standards and requirements, such as set criteria for what landmarks must be clearly visible from which locations in order to proceed on a particular route; (2) the need to help pilots who are new to the area recognize dynamic local weather patterns that can place them in a dangerous situation; and (3) operational influences on pilot decision-making.
FAA Action: The FAA will conduct customized surveillance specifically focused on operator training programs and the manner in which the training is implemented and delivered.
Recommendation A-17-38: Expand the application of Federal Aviation Administration Order 8900.1, volume 3, chapter 19, section 6, “Safety Assurance System: Flight Training Curriculum Segments,” paragraphs 3-1251(B) and 3-1252, which address controlled flight into terrain-avoidance training programs for 14 CFR Part 135 helicopter operations, to all 14 CFR Part 135 operations.
FAA Action: The FAA will evaluate our current guidance, regulations, and policy, for Part 135 operators to determine potential options to satisfy this safety recommendation.
Recommendation A-17-42: Analyze Automatic Dependent Surveillance-Broadcast (ADS-B) data from Ketchikan air tour operations on an ongoing basis and meet annually with Ketchikan air tour operators to engage in a non-punitive discussion of any operational hazards reflected in the data and collaborate on mitigation strategies for any hazards identified.
FAA Action: The FAA determined that there are several portions of Ketchikan air tour flight paths where ADS-B data is not available. However, discussions with industry stakeholders indicate that their use of “Spider Tracks” technology, a commercially available GPS tracking tool, allows the air carriers to have full coverage of the entire flight path. Spider Track information has been openly shared with the FAA, and is routinely incorporated into the bi-annual air tour safety meetings.
Safety Recommendation A-17-43: Develop and implement special operating rules for the Ketchikan air tour industry that nclude en route visual flight rules weather minimums that are tailored to the industry’s unique requirements and are more conservative than those specified in 14 CFR Part 135.
FAA Action: The FAA is evaluating policy and rulemaking options regarding the full adoption of this recommendation.
Recommendation A-18-13: Although CFIT-avoidance training programs are not required by federal regulation for Title 14 CFR Part 135 fixed-wing operations, work with Part 135 operators in Alaska to improve any voluntarily implemented training programs aimed at reducing the risk of CFIT accidents involving continuation of flight under Visual Flight Rules (VFR) into instrument meteorological conditions, with special attention paid to the human factors issues identified in recent Alaska accident investigations, including, but not limited to, (1) the challenges of flying in mountainous terrain in Alaska and low-altitude VFR flight in an area subject to rapid changes in weather; and (2) limitations of the Alaska infrastructure, particularly weather observations, communications, and navigation aids.
FAA Action: An FAA team partnered with the GAJSC CFIT workgroup. The team, in conjunction with its joint efforts with GAJSC, will focus on improving voluntary programs implemented by Part 135 operators/certificate holders to reduce CFIT accidents. Special emphasis will be placed on Alaska and the human factors issues identified by the NTSB.
Recommendation A-18-14: Work with Title 14 CFR Part 135 certificate holders that operate under visual flight rules in mountainous terrain at altitudes below the required terrain clearance of the aircraft’s required TAWS class to (1) ensure that management and pilots are aware of the risks associated with distraction (from continuous nuisance alerts) and complacency (brought about by routine use of the terrain inhibit feature); (2) develop plans for mitigating those risks and minimizing nuisance alerts; and (3) develop procedures that specifically address when pilots should test, inhibit, and uninhibit the TAWS alerts, considering the operator’s typical operations and the TAWS manufacturer’s guidance.
FAA Action: The FAA is developing a Safety Alert for Operators to address this recommendation.
Recommendation A-18-16: Install communications equipment throughout Alaska, after determining what would be most effective, to allow increased access to the instrument flight rules system, giving priority to those areas used by Title 14 CFR Part 135 operators.
Recommendation A-18-17: Ensure that Alaska airports that are served by Title 14, CFR Part 135 operators and have instrument approaches are equipped with weather-reporting capabilities to enable instrument flight rules operations in accordance with § 135.225(a).
FAA Action: The FAA is coordinating the review of how to best address these recommendations with multiple FAA lines of business. Based on this review, we will determine how best to proceed.
You can find NTSB safety recommendations and FAA responses at: https://ntsb.gov/_layouts/ntsb.recsearch/RecTabs.aspx
Status of Open Recommendations as of March 6, 2020
|NTSB Classification||Number of Recommendations|
|Open Acceptable/Open Acceptable Alternate Response||173|
|Open Unacceptable Response||51|
|Open Awaiting Further Response-The NTSB received the FAA’s initial response but asked for more information.||3|
|Open Response Received-Has not been classified by the NTSB yet.||0|
|Open Awaiting Response-Initial 90-day cycle (FAA working on initial response).||27|
Total Open Recommendation: 254