NTSB Safety Recommendations A-10-10 through -34

[NTSB Press Releases <NTSBPressReleases@xxxxxxxx>]

Title: NTSB Safety Recommendations A-10-10 through -34

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                   NTSB SAFETY RECOMMENDATION

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National Transportation Safety Board

Washington, DC 20594

February 23, 2010

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NTSB Safety Recommendations A-10-10 through -34, A-05-1, A-

05-14, and A-07-13 (Reiteration)

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The National Transportation Safety Board recommends that the

Federal Aviation Administration:

Require 14 Code of Federal Regulations Part 121, 135, and

91K operators to review their standard operating procedures

to verify that they are consistent with the flight crew

monitoring techniques described in Advisory Circular (AC)

120-71A, "Standard Operating Procedures for Flight Deck

Crewmembers"; if the procedures are found not to be

consistent, revise the procedures according to the AC

guidance to promote effective monitoring. (A-10-10)

Require that airspeed indicator display systems on all

aircraft certified under 14 Code of Federal Regulations Part

25 and equipped with electronic flight instrument systems

depict a yellow/amber cautionary band above the low-speed

cue or airspeed indicator digits that change from white to

yellow/amber as the airspeed approaches the low-speed cue,

consistent with Advisory Circular 25-11A, "Electronic Flight

Displays." (A-10-11)

For all airplanes engaged in commercial operations under 14

Code of Federal Regulations Parts 121, 135, and 91K, require

the installation of low-airspeed alert systems that provide

pilots with redundant aural and visual warnings of an

impending hazardous low-speed condition. (A-10-12)

(Supersedes Safety Recommendations A-03-53 and -54 and is

classified "Open-Unacceptable Response)

Issue an advisory circular with guidance on leadership

training for upgrading captains at 14 Code of Federal

Regulations Part 121, 135, and 91K operators, including

methods and techniques for effective leadership;

professional standards of conduct; strategies for briefing

and debriefing; reinforcement and correction skills; and

other knowledge, skills, and abilities that are critical for

air carrier operations. (A-10-13)

Require all 14 Code of Federal Regulations Part 121, 135,

and 91K operators to provide a specific course on leadership

training to their upgrading captains that is consistent with

the advisory circular requested in Safety Recommendation A-

10-13. (A-10-14)

Develop, and distribute to all pilots, multimedia guidance

materials on professionalism in aircraft operations that

contain standards of performance for professionalism; best

practices for sterile cockpit adherence; techniques for

assessing and correcting pilot deviations; examples and

scenarios; and a detailed review of accidents involving

breakdowns in sterile cockpit and other procedures,

including this accident. Obtain the input of operators and

air carrier and general aviation pilot groups in the

development and distribution of these guidance materials.

(A-10-15) (Supersedes Safety Recommendation A-07-8)

Require all 14 Code of Federal Regulations Part 121, 135,

and 91K operators to address fatigue risks associated with

commuting, including identifying pilots who commute,

establishing policy and guidance to mitigate fatigue risks

for commuting pilots, using scheduling practices to minimize

opportunities for fatigue in commuting pilots, and

developing or identifying rest facilities for commuting

pilots. (A-10-16)

Require 14 Code of Federal Regulations Part 121, 135, and

91K operators to document and retain electronic and/or paper

records of pilot training and checking events in sufficient

detail so that the carrier and its principal operations

inspector can fully assess a pilot's entire training

performance. (A-10-17)

Require 14 Code of Federal Regulations Part 121, 135, and

91K operators to include the training records requested in

Safety Recommendation A-10-17 as part of the remedial

training program requested in Safety Recommendation A-05-14.

(A-10-18)

Require 14 Code of Federal Regulations Part 121, 135, and

91K operators to provide the training records requested in

Safety Recommendation A-10-17 to hiring employers to fulfill

their requirement under the Pilot Records Improvement Act.

(A-10-19)

Develop a process for verifying, validating, auditing, and

amending pilot training records at 14 Code of Federal

Regulations Part 121, 135, and 91K operators to guarantee

the accuracy and completeness of the records. (A-10-20)

Direct 14 Code of Federal Regulations Part 121, 135, and 91K

operators of airplanes equipped with a reference speeds

switch or similar device to (1) develop procedures to

establish that, during approach and landing, airspeed

reference bugs are always matched to the position of the

switch and (2) implement specific training to ensure that

pilots demonstrate proficiency in this area. (A-10-21)

Require 14 Code of Federal Regulations (CFR) Part 121, 135,

and 91K operators and 14 CFR Part 142 training centers to

develop and conduct training that incorporates stalls that

are fully developed; are unexpected; involve autopilot

disengagement; and include airplane-specific features, such

as a reference speeds switch. (A-10-22)

Require all 14 Code of Federal Regulations Part 121, 135,

and 91K operators of stick pusher-equipped aircraft to

provide their pilots with pusher familiarization simulator

training. (A-10-23) (Supersedes Safety Recommendation A-07-

4)

Define and codify minimum simulator model fidelity

requirements to support an expanded set of stall recovery

training requirements, including recovery from stalls that

are fully developed. These simulator fidelity requirements

should address areas such as required angle-of-attack and

sideslip angle ranges, motion cueing, proof-of-match with

post-stall flight test data, and warnings to indicate when

the simulator flight envelope has been exceeded. (A-10-24)

Identify which airplanes operated under 14 Code of Federal

Regulations Part 121, 135, and 91K are susceptible to

tailplane stalls and then (1) require operators of those

airplanes to provide an appropriate airplane-specific

tailplane stall recovery procedure in their training manuals

and company procedures and (2) direct operators of those

airplanes that are not susceptible to tailplane stalls to

ensure that training and company guidance for the airplanes

explicitly states this lack of susceptibility and contains

no references to tailplane stall recovery procedures. (A-10-

25)

Develop more stringent standards for surveillance of 14 Code

of Federal Regulations (CFR) Part 121 135, and 91K operators

that are experiencing rapid growth, increased complexity of

operations, accidents and/or incidents, or other changes

that warrant increased oversight, including the following:

(1) verify that inspector staffing is adequate to accomplish

the enhanced surveillance that is promulgated by the new

standards, (2) increase staffing for those certificates with

insufficient staffing levels, and (3) augment the inspector

staff with available and airplane-type-qualified inspectors

from all Federal Aviation Administration regions and 14 CFR

Part 142 training centers to provide quality assurance over

the operators' aircrew program designee workforce. (A-10-26)

Require all 14 Code of Federal Regulations Part 121, 135,

and 91K operators to (1) develop and implement flight

operational quality assurance programs that collect

objective flight data, (2) analyze these data and implement

corrective actions to identified systems safety issues, and

(3) share the deidentified aggregate data generated through

these analyses with other interested parties in the aviation

industry through appropriate means. (A-10-27)

Seek specific statutory and/or regulatory authority to

protect data that operators share with the Federal Aviation

Administration as part of any flight operational quality

assurance program. (A-10-28)

Require 14 Code of Federal Regulations 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 deidentified aggregate data; and (3)

ensure that this information is used for safety-related and

not punitive purposes. (A-10-29)

Require 14 Code of Federal Regulations Part 121, 135, and

91K operators to incorporate explicit guidance to pilots,

including checklist reminders as appropriate, prohibiting

the use of personal portable electronic devices on the

flight deck. (A-10-30)

Implement a process to document that all 14 Code of Federal

Regulations Part 121, 135, and 91K operators have taken

appropriate action in response to safety-critical

information transmitted through the safety alert for

operators process or another method. (A-10-31)

Require 14 Code of Federal Regulations Part 121, 135, and

91K operators to revise the methodology for programming

their adverse weather phenomena reporting and forecasting

subsystems so that the subsystem-generated weather document

for each flight contains all pertinent weather information,

including Airmen's Meteorological Information, Significant

Meteorological Information, and other National Weather

Service in-flight weather advisories, and omits weather

information that is no longer valid. (A-10-32)

Require principal operations inspectors of 14 Code of

Federal Regulations Part 121, 135, and 91K operators to

periodically review the weather documents generated for

their carriers to verify that those documents are consistent

with the information requested in Safety Recommendation A-

10-32. (A-10-33)

Update the definitions for reportable icing intensities in

the Aeronautical Information Manual so that the definitions

are consistent with the more detailed intensities defined in

Advisory Circular 91-74A, "Pilot Guide: Flight in Icing

Conditions." (A-10-34)

The National Transportation Safety Board reiterates the

following recommendations to the Federal Aviation

Administration:

Require all Part 121 and 135 air carriers to obtain any

notices of disapproval for flight checks for certificates

and ratings for all pilot applicants and evaluate this

information before making a hiring decision. (A-05-1)

Require all 14 Code of Federal Regulations Part 121 air

carrier operators to establish training programs for flight

crewmembers who have demonstrated performance deficiencies

or experienced failures in the training environment that

would require a review of their whole performance history at

the company and administer additional oversight and training

to ensure that performance deficiencies are addressed and

corrected. (A-05-14)

Require that all pilot training programs be modified to

contain modules that teach and emphasize monitoring skills

and workload management and include opportunities to

practice and demonstrate proficiency in these areas. (A-07-

13)

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http://www.ntsb.gov/Recs/letters/2010/A10_010_034.pdf

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The complete recommendation letter is available on the Web

at the URL indicated above.

The letter is in the Portable Document Format (PDF) and can

be read using the Acrobat Reader 5.0 or later from Adobe

(http://www.adobe.com/prodindex/acrobat/readstep.html).

       

An archive of recommendation letters is available at

http://www.ntsb.gov/recs/letters/letters.htm.

Electronic versions of letters may or may not include

enclosures; however, related publications, accident

briefs, and aviation accident synopses may be found

on the NTSB website.

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