An Assessment of the Effectiveness of 

Public Law 111-216 in Reducing Accident Risk1

Office of Accident Investigation and Prevention

Federal Aviation Administration

November 9, 2012

 

1 The original assessment was completed by the Office of Accident Investigation and Prevention, Federal Aviation 

Administration, November 22, 2010. 
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This document presents the results of a safety analysis of proposed rulemaking by the Federal 

Aviation Administration (FAA) on Pilot Certification and Qualification Requirements for Air 

Carrier Operations, pursuant to Public Law 111-216, The Fiscal Year 2010 Federal Aviation 

Administration Extension Act. Section 209(b) of the Act mandates that FAA convene a panel of 

experts to establish the best methods and required training time, plus recurrent training 

requirements, to ensure that flight crewmembers of Part 121 air carriers and Part 135 air carriers 

“master aircraft systems, maneuvers, procedures, takeoffs and landings, and crew coordination.“

Section 216 of the Act directs FAA to undertake rulemaking to ensure that Part 121 air carriers 

“develop and implement means and methods for ensuring that flight crewmembers have proper 

qualifications and experience.” Section 216 also requires the rulemaking to ensure at least the 

following.

Comprehensive pre-employment screening of prospective flight crewmembers,

“including an assessment of the skills, aptitudes, airmanship, and suitability of each 

applicant” to function effectively in an air carrier environment.

All flight crewmembers must obtain an airline transport pilot (ATP) certificate and have 

“appropriate multi-engine aircraft experience.” 

Section 217 of the Act requires rulemaking to amend minimal requirements under Part 61 of the 

Federal Aviation Regulations for obtaining an ATP to ensure that a pilot can “function 

effectively in an air carrier operational environment. Amendments to Part 61 must ensure that 

applicants for an ATP have received flight training, academic training, or operational experience 

that effectively prepares them for a multi-pilot environment, adverse weather conditions, 

including icing conditions, high altitude operations, and adherence “to the highest professional 

standards.” Finally, Section 217 retains the required minimum of 1,500 hours before a pilot can 

qualify for an ATP, including “sufficient flight hours” in difficult operating conditions. 

Based on a detailed review of 417 accidents over 10 years, the analysis found that the 

rulemaking would be most effective against accidents involving turbojets in on-demand Part 135 

operations and against twin-engine aircraft accidents in Part 135 commuter operations. The 

rulemaking would have a significant effect against Part 121 accidents, but less so than against 

Part 135 accidents. The rulemaking would have had little to no effect on the small number of 

Part 125 accidents that occurred over the 10-year study period. 

Anticipated Rulemaking

An ATP license is currently required to operate as a pilot-in-command (PIC) during Part 121 

operations. The Act and the rulemaking would retain the minimum of 1,500 hours to qualify for 

an ATP. In addition, as directed by the Act, the rulemaking will require an ATP and an aircraft 

type rating for all pilots in Part 121 operations, and will require that at least 50 of the minimum 

1,500 hours to qualify for an ATP be in multi-engine aircraft. The rulemaking also will include a 

restricted-privileges ATP which allows credit for appropriate academic and classroom training 

and credit for military flight experience. For example, the rule may require 1,000 hours total 

time as a pilot for a graduate of an accredited aviation degree program, or a minimum of 750
Assessment of PL 111-216

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hours total time for a military pilot. The restricted-privileges ATP also would have to be a 

minimum age of 21. 

The rule also will require time in a flight simulation training device to obtain an ATP as part of 

the effort to ensure “sufficient flight hours” in difficult operating conditions and to incorporate 

the additional experience requirements defined in Section 217 of the Act. 

In addition, the proposed rule will require either a straightforward minimum of 2,500 hours of 

pilot experience to qualify as a PIC in Part 121 operations, or the rule may alter that by requiring 

that a prospective PIC has at least 1,000 hours of experience in air carrier operations, plus the 

1,500-hour minimum to qualify for an ATP. Though the net effect of these 2 variations on PIC 

eligibility is not exactly synonymous, the effect on accident reduction is essentially the same.

Safety Analysis

Analytical Approach

The analysis assesses the likely capacity of the proposed rules to reduce the total number of 

accidents as well as fatal accidents in the future. It will address all operations in which the PIC

must have an ATP or in which the rulemaking will require an ATP of the first officer (FO). 

Therefore the analysis will address all Part 121 and Part 125 operations; all operations involving 

twin-engine aircraft as Part 135 commuters; and all on-demand Part 135 or Part 91K operations 

involving turbojets or other airplanes configured with 10 or more seats. The analysis is based on 

all accidents that meet the above criteria from fiscal year (FY) 2001 through and including FY 

2010 as follows:

Part 121 Operations 354 accidents and 370 aircraft

Part 125 Operations 5 accidents and 5 aircraft

Part 135 Commuter 14 accidents and 14 aircraft

Part 135 On-Demand 44 accidents and 44 aircraft

The preferred approach would be to assess each element of any rulemaking as a discrete item. 

However, the statutory directions include elements that are difficult to isolate. Where possible 

the elements are addressed separately, but they are not assigned discrete scores. Instead scores

are assigned for the entire rulemaking as a single proposal.

 

Scores represent the likelihood that the proposed rules could have prevented the accident had the 

rules been in place at the time of each accident as a result of the rule’s capacity to have precluded 

or corrected a contributing condition. The rule was first scored against each accident 

qualitatively with the following categories of effectiveness: none; low; moderate; moderate-tohigh; high; and very high. Those categories correspond to ranges in the following order: 0%, 

15%, 35%, 55%, 75% and 90%.The end result was a quantified set of benefits in which, for 

example, a score of 35% against an accident would have reduced the risk by a theoretical .35 

fatal accidents and a theoretical 35 fatalities. All scores were reviewed by a 3-person panel.
Assessment of PL 111-216

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Note that the mere presence of some condition such as a pilot with less than the proposed flight 

hours did not necessarily mean that the rulemaking would have been effective against a 

particular accident scenario. Many accidents simply do not reflect at all on pilot performance. 

Where a pertinent issue was influential in an accident, its score depended on an assessment both 

of the degree to which the factor influenced the accident and the degree to which a new rule 

realistically could be expected to have changed the outcome of a particular accident, based on the 

details of each accident flight. Finally, as a matter of analytical principle, no accident received a 

score higher than 0.9 based on the assumption that we can never be certain that any intervention 

would eliminate all risk in a particular scenario. With these caveats, the analysis focused on the 

following factors:

Part 121 PIC with less than 2,500 hours

Part 121 FO with less than 1,500 hours, 1,000 hours, and 750 hours

Part 121 FO operating without an ATP

Part 121 FO operating without a rating in the aircraft being flown

Crew Resource Management

Sterile Cockpit Procedures

Professionalism

Weather (thunderstorm, icing, turbulence, gusty crosswinds etc.)

Stall-upset or unusual attitude

Part 121 operators had 354 accidents involving 370 Part 121 aircraft in the 10-year study period. 

The majority of the 354 Part 121 accidents involved low-level outcomes or isolated risk that did 

not affect most aircraft occupants. For example, turbulence accounted for 102 of the 354 

accidents, all but a few of which involved single injuries, while gate-ramp accidents accounted 

for 88 accidents. Most of those accidents did not reflect on crew performance. Similarly, 

miscellaneous on-board events and deer strikes on runways accounted for another 10 accidents, 

and 12 more events qualified as accidents only because an injury occurred during a precautionary 

evacuation. These types of events account for 60 percent of the total accident set for Part 121 

operators, while still others involved maintenance and other issues not related to crew 

performance. Many of the remainder involved relatively low-level outcomes, though with 

varying levels of risk, while others involved high-time PICs with high-time FOs with ATP 

ratings who likely would not be reached by this rulemaking. The point here is not to dismiss 

these events but to suggest that benefits, as measured by avoided accidents, fatalities, and serious 

injuries, often will be more modest than advocates might anticipate.

Data Sources and Data Quality

Accident reports and structured accident data from the National Transportation Safety Board 

(NTSB) were the primary data source, supplemented where necessary and possible with data 

from FAA. Accident data will be limited to 10 years due to the poor quality of data available in 

either NTSB or FAA reports on pilot experience for earlier accidents. FY 2001 was selected as 

the starting point because that was the point at which NTSB data on pilot flight hours began to 

capture co-pilots at least somewhat systematically. 
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However, several issues limit the applicability of some accidents even within this 10-year 

dataset. In the case of accidents involving U.S. operators in foreign countries, foreign 

governments do not always release the factual information, probable cause statement, and 

contributing factors. Information that is available through the NTSB for these accidents rarely 

include pilot data. Pilot data is also limited for domestic accidents that have relatively low-level 

outcomes, such as turbulence or ramp-gate accidents. In addition, other records randomly 

involve blank data cells for PIC or FO flight hours and FO certificates and type ratings. 

Where any of these problems existed, the text of each NTSB accident report was reviewed, as 

were files in the FAA’s Office of Accident Investigation and Prevention. That exercise added or 

corrected data for some or all pertinent fields for more than 200 pilots, but some or all pertinent 

data on some pilots and causal factors is simply not available.

Useful flight-hour data was identified for 332 PICs among the 370 accident aircraft. All but 4 of 

the 332 PICs had more than 2,500 hours. Of the other 38 PICs, damage to 2 aircraft was found 

during maintenance, and the respective air carriers could not associate either accident with 

specific crews. Consistent with comments above about the frequent absence of flight-hour data 

in certain categories of accidents, 24 of the remaining 36 accidents for which PIC flight-hour 

data was not available did not reflect on pilot performance. Those 24 accidents involved 

maintenance issues, ramp events caused by ground staff, and turbulence injuries in clear air 

turbulence or after adequate warnings were ignored. Eight of the other 12 accidents involved 

large jets operating international flights and 3 involved large jets on domestic flights by major air 

carriers. Most or all of those captains would have had significant flight experience. 

Consequently, the absence of data on those PICs does not affect the findings in this report.

Useful data on flight hours or ratings was available for 326 FOs (88%). The 45 cases for which 

no data was available included the same 38 cases noted above. Consequently, again, the absence 

of data in the 45 records will not affect the findings of this report.

Results of the Analysis, Part 121 Operations

All but 4 PICs exceeded the straightforward 2,500-hour minimum. The alternate approach of 

requiring an ATP plus at least 1,000 hours of experience in air carrier operations likely would 

have affected the eligibility of a fifth PIC, whose total flight time marginally exceeded 2,500 

hours. All 5 of those PICs operated with FOs who had commercial ratings rather than ATPs. 

Crew performance was a primary issue in 4 of those 5 accidents. The fifth accident was caused 

by a tug operator who struck a stationary regional jet at the gate. Though the rule would have 

affected the eligibility of both pilots to operate that flight, the rule would not have influenced the 

accident. 

The proposed PIC minimum hours and the required ATP certificate to operate as an FO in Part 

121 operations would have affected the eligibility of 83 accident crews in the 10-year accident 

set. However, crew performance was an issue in just 34 of those cases, and the outcome of some 

of those 34 would not have been affected by this rulemaking. For example, 2 fatal accidents in 

which FOs did not have ATP ratings illustrate how the rule could have affected the eligibility of 

the FOs without influencing the outcome: Air Midwest Flight 5481 (21 fatal) crashed 
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immediately after lift off from Charlotte, NC due to an improperly-rigged elevator; and Chalks

Ocean Airways Flight 101, (20 fatal) crashed into the Atlantic Ocean when the wing failed in 

normal flight. Though both FOs would have been affected by the requirement to have an ATP, 

the rule would not have prevented the accidents, and they would have scored a “zero.” 

Conversely, some of the other elements in the rulemaking, such as screening pilot applicants, 

preparing pilots better for the complex environment of air carrier operations, better training in 

stall recognition, and the importance of professionalism would have had some minimal chance of 

influencing additional accident outcomes. 

The rulemaking was found to be effective in varying degrees against just 31 accidents, and in 

most cases the scores were “low” to “moderate-to-high” categories. There were no accidents 

that received scores of “very high.” Appendix 1 shows the scoring for each of the 31 Part 121 

accidents against which the rulemaking received positive scores. Table 1, summarizes the 

scoring of the complete rulemaking against all 354 Part 121 accidents from FY 2001 through FY 

2010.

Table 1: Scoring Summary in Part 121 Operations

FY 2001 Through FY 2010

Qualitative 

Effectiveness 

Score

Quantified 

Score

Number of 

Accidents

Accidents 

Avoided

None 0 323 0

Low 0.15 17 2.55

Moderate 0.35 6 2.1

Moderate-to-High 0.55 7 3.85

High 0.75 1 0.75

Very High 0.90 0 0

Total 354 9.25

In the accidents that received a “high” score (75% reduction in the likelihood of the accident) or 

“moderate-to-high” (55%), crew performance was a significant role in the accident. These

accidents are summarized below:

High (75%)

On October 16, 2001, an Embraer ERJ-145 operated by Mesa Airlines landed 

hard in Roanoke, VA. The PIC briefed a visual approach to runway 33 and 

indicated to the FO that a go-around was not an option due to surrounding terrain. 

The crew noted a quartering crosswind at 15 mph gusting to 21 mph. The FO said 

the approach was normal until 300 above the ground, where he called "one dot 

high" and Vref +5. Airspeed dropped abruptly, the stick shaker activated, and the 

PIC added power, but the aircraft landed hard before the engines could spool up. 

Damage included broken and cracked frames and stringers, popped rivets, and

skin worn through in the lower aft pressure vessel, plus scraped skin on the lower 
Assessment of PL 111-216

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aft fuselage. The NTSB identified the probable cause as the PIC's failure to 

maintain airspeed. Factors included the failure of both pilots to follow company 

CRM and flight manual procedures and the PIC's improper approach briefing.

Both pilots were hired during a period of rapid expansion for the carrier and 

moved through what the NTSB report described as a “rushed’ upgrade program. 

The PIC had 2,548 hours with 200 in make-model. The commercially-rated FO 

had 1,850 hours with 90 hours in make-model. The PIC was hired 21 months 

prior to the accident and had been flying as an active flight instructor. The PIC 

had accrued 600 hours as an FO in the BE-1900 and qualified for upgrade to PIC 

in the ERJ based on seniority. The FO was hired with 400 hours, flew as an FO on 

the Beech 1900, then upgraded to the ERJ as an FO based on seniority. 

Neither pilot had any prior experience in swept-wing aircraft nor had the carrier 

provided any jet indoctrination or training on swept wing aerodynamics. The 

rule’s emphasis on screening pilot applicants, professionalism, preparing pilots 

better for Part 121 operating environments, and more training in stall recognition 

would have likely prevented this accident.

Moderate-to-High (55%)

1. On August 13, 2004, a Convair 580 cargo flight operated by Air Tahoma 

crashed on approach into Cincinnati, OH. The FO was killed, the PIC was 

seriously injured, and the aircraft was destroyed. During the flight from Memphis 

to Cincinnati, the FO was the flying pilot. Approximately 20 minutes before the 

accident, he noticed that there was a problem with the handling characteristics of 

the airplane. In a six-minute span, he commented five times that he was 

experiencing abnormal forces on the control yoke. He said, “Feels like I need a lot 

of force. It is pushing to the right for some reason. I don't know why...I don't 

know what's going on.” With the runway in sight, the FO again noted “What is 

wrong with this plane? It’s really funny. I got something all messed up here."

The PIC, who was preoccupied for most of the flight with reconciling his preflight weight and balance miscalculations, eventually advised the FO that they had 

a fuel imbalance because he, as the non-flying pilot, had erroneously left the 

cross-feed open. This oversight caused a prolonged and unintended fuel transfer 

that was prohibited in the Aircraft Flight Manual (AFM) and the company Flight 

Operations Manual and was placarded in the cockpit. The FO then stated that, 

"We're going to flame out." However, the PIC responded, "I got the cross-feed 

open. Just keep the power on." Despite having adequate total fuel on board, the 

aircraft lost power due to fuel starvation and crashed one mile short of the 

runway.

The PIC had 2,500 hours of flight time (not including the hours accumulated from 

20 years of experience as a flight engineer on the Lockheed Electra, Douglas DC8, and Lockheed L-1011). The commercially rated FO had 2,488 total flight 
Assessment of PL 111-216

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hours, which included 1,564 hours as a Boeing 727 flight engineer and 924 hours 

as either PIC or FO of mostly single-engine airplanes. He had 3 months of 

experience as an air carrier pilot. The rule would have required more experience 

and seasoning for both pilots, especially for the FO, which might have enabled 

him to identify that a rather large fuel imbalance between the left and right wing 

fuel tanks was the cause of his lateral control problem. Additional experience 

may have also led the PIC to reconcile his weight and balance prior to departure, 

complete his checklists at the times prescribed in the operations manual, and 

respond with more urgency when he finally recognized the fuel imbalance. 

2. On July 6, 2008 a McDonnell-Douglas (Boeing) DC-9, operated by USA Jet on 

a cargo flight, crashed in heavy fog while on approach in mountainous terrain to 

Saltillo, Mexico. The captain, who was the flying pilot, was killed, and the first 

officer sustained serious injuries. The flight data recorder shows the aircraft 

alternating above and below the glide slope and left and right of the localizer 

throughout the approach. The aircraft ultimately stalled and crashed 1,000 feet 

short and 500 feet right of the extended runway centerline. 

The captain had 6,630 total flight hours and 2,111 in the DC-9. The FO on that 

flight was an experienced flight engineer but had just 830 flight hours and 75 

hours as a part 121 pilot. The deficiencies in piloting skill, decision-making, 

CRM, and operations in a multi-crew environment that contributed to this 

accident are addressed in the proposed rulemaking. Had the first officer been 

more experienced and better trained, he would have been more likely to have 

intervened or called for the go around as the approach became increasingly 

unstable. Either form of intervention would have possibly averted this accident. 

3. On February 10, 2001, a Beechcraft BE-1900D operated by Great Lakes 

Aviation landed unintentionally gear-up on runway 4R at Chicago’s O’Hare 

International Airport. Seven of the 15 passengers and two pilots received minor 

injuries, and the aircraft was substantially damaged. According to the PIC, the 

crew was executing the “Flaps-Up Landing Checklist” abnormal procedure 

because the wing flap system was inoperative. Neither the PIC nor the FO 

reported hearing the landing gear warning horn, and the FO indicated that, “No 

gear horn sounded nor did we ever think the landing gear were not down.” 

When the aircraft was craned off the runway and electrical power applied, the 

landing gear warning horn sounded, a red light illuminated in the gear handle, and 

all three landing gear position lights illuminated red. The NTSB determined that 

the probable cause of the accident was the flight crew not lowering the landing 

gear or verifying its position with three separate checklists. Contributing to the 

accident was the flight crew’s failure to comply with the minimum equipment list 

placard that prohibited the silencing of the landing gear warning horn.

The PIC held an ATP certificate with 2,400 flight hours with 600 hours in the BE1900D, 580 of which were PIC. The FO held a commercial license with 1449 
Assessment of PL 111-216

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flight hours, 191 of which were SIC. With the additional experience required by 

the proposed rulemaking and the emphasis on crew coordination, leadership, and 

pilot professionalism, it is possible that the flight crew would have been more 

vigilant in their completion of checklists especially when flying with inoperative 

equipment. 

4. On June 20, 2007, a Beechcraft BE-1900D operated by Great Lakes Aviation 

landed long and bounced in visual conditions at Laramie, WY. The crew tried to 

slow the aircraft but turned onto a taxiway at high speed, where the right propeller

struck an electrical box. A propeller blade then broke off and struck the right side 

of the fuselage. The PIC later noted that the approach was about 14 knots above 

the targeted speed, and the airplane was one dot high on the glide slope. No 

injuries occurred to the 2 pilots and 9 passengers, but the aircraft was substantially 

damaged. The NTSB determined the probable cause of the accident was the 

PIC’s improper decision making, his misjudgment of speed and distance, and his 

failure to go around during an unstable approach. Contributing to the accident 

was improper crew coordination, and the FO's failure to intervene during the 

unstable approach and landing.

The PIC had 2,250 hours of pilot experience and the commercially-rated FO had 

774 hours. The rule would have required more experience and seasoning for both 

pilots in an air carrier environment which may well have led the PIC to go around 

upon recognizing an unstable approach or might have compelled the FO to 

intervene. 

5. On January 6, 2003, an Embraer EMB-145LR operated by ExpressJet Airlines 

was substantially damaged when it overran the end of a snow-covered runway 

during landing in Cleveland, OH. The captain, who was the flying pilot, allowed 

the aircraft to float excessively and was unable to stop the aircraft on the 

remaining runway after touchdown. There were no reports of injuries to the crew, 

the flight attendant, or the passengers. 

The flight left the departure airport with a computerized flight plan, weather, and 

the Notices to Airman (NOTAMs) for their route of flight. While being vectored 

for the approach, the controller informed the flight crew that the runway visual 

range (RVR) was had decreased from 4,500 feet to 4,000 feet, which was the 

minimum listed on the approach plate used by the flight crew. However, the FAA 

had released a NOTAM a month prior which had raised the landing minimums to 

5,000 feet. This NOTAM was not received by the airline from their weather 

service provider and was consequently not issued to the flight crew. The approach 

controller was in possession of this NOTAM, but was not required to inform the 

flight crew that the approach was below landing minimums. 

The flight crew conducted an instrument approach briefing, but did not discuss 

the runway conditions or the amount of runway required to land (nor was it 

required). They were, however, in possession of a local NOTAM that described 
Assessment of PL 111-216

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the landing runway as “covered with thin wet snow.” Landing distance charts 

indicate that EMB-145 flight crews should add 20 percent to the normal landing 

distance when using a wet runway. The captain reported that he used a rule of 

thumb computation to determine the landing distance because he did not have 

enough time to ask the first officer to compute it. 

The NTSB determined the probable cause of the accident was the captain's failure 

to attain a proper touchdown on runway, and his subsequent failure to perform a 

go-around, both of which resulted in a runway overrun. Factors were the 

company's inadequate dispatch procedures with their failure to provide current 

NOTAMs, and the snow covered runway.

The captain held an Airline Transport Pilot certificate with 3,765 hours and 661 in 

the EMB-145. The first officer held a commercial pilot certificate with 2,550 

hours and 804 in make and model. While there were several contributing factors 

to this accident beyond the flight crew’s control, they would have benefitted from 

enhanced CRM and a better understanding of transport airplane performance 

(specifically contaminated runway considerations for takeoff and landing). Had 

they been exposed to the rigors of the training outlined in the proposed 

rulemaking they would have been more likely to consider all factors in their 

approach planning and more likely to call for and execute a go around. 

6. On August 14, 2008, the tail section of an Embraer EMB-145LR operated by 

Trans States Airlines struck the runway during landing in St. Louis, MO. There 

were no reported injuries to the crew or the passengers, and the aircraft was 

substantially damaged. 

According to the accident report, the first officer indicated during the en-route 

portion of the flight that his landings with the flaps set at 45-degrees were, “a little 

extreme...a little non-standard, but way more fun.” As the aircraft entered the 

landing flare, approximately 34 feet above the touchdown zone, the flight data 

recorder indicated that the pitch angle during the landing flare increased to 13 

degrees and the angle of attack to 17 degrees. Moments later the stick shaker/stall 

warning system activated at which time the tail section impacted the runway. 

The NTSB determined that the probable cause of the accident was the FO’s 

excessive angle of attack during the landing flare resulting in abnormal runway 

contact. Both pilots held ATP certificates. The captain had 13,000 total hours and

4,000 in the EMB-145. The first officer had 1,800 total hours and 1,000 in type. 

Despite his certification and hours, the first officer’s statements reflect a lack of 

understanding of aerodynamics, stalls, and professionalism that is expected of air 

carrier pilots. His lack of flying skills and professionalism could have been offset 

by a captain who heeded the warnings and exercised the kind of enhanced 

leadership and CRM skills outlined in the proposed rulemaking. This additional 

training and experience would have increased the performance of both the captain 

and the first officer and might have helped to prevent this accident. 
Assessment of PL 111-216

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7. On November 20, 2000, an ATR-72 operated by Atlantic Southeast Airlines 

(ASA) Inc., encountered moderate turbulence while maneuvering for landing at 

10,000 feet above mean sea level. The fasten seat belt sign was “ON,” and the two 

flight attendants were preparing the cabin for landing. During the encounter, one 

of the two flight attendants was seriously injured. No other injuries were reported 

by the flight crew, the other flight attendant, or the 36 passengers on board. 

Prior to the flight, hazardous weather advisories (SIGMET and AIRMET) were 

issued calling for large areas of moderate turbulence along the route of flight. The 

captain was in possession of these weather reports and was required by company 

policy to brief the entire flight crew on the expected weather along the route and 

any forecasts of turbulence. According to the accident report, however, the 

captain briefed only one of the two flight attendants at which time he related that, 

“it would be a little rough getting out of Atlanta.” 

The captain held an ATP certificate with 4,234 flight hours and 2,510 in the ATR72, and the first officer held a commercial pilot’s license. The NTSB determined 

that the probable cause of this accident was an in flight encounter with forecasted 

turbulence which resulted in serious injury to a flight attendant. Contributing to 

the accident was the captain’s inadequate briefing to the cabin crew, which was 

required by the airline’s Standard Practice manual. Had the captain and the first 

officer been exposed to the enhanced meteorology, CRM, and leadership training 

of the proposed rulemaking, they likely would have taken the forecasted 

turbulence listed in the hazardous weather reports more seriously and ensured that

both flight attendants were briefed accordingly prior to the flight. These actions 

could have prevented the injuries sustained by the flight attendant. 

The remaining 23 accidents in the 10-year accident set against which the rulemaking scored 

positively were limited to “low” and “moderate” scores. They included 2 fatal accidents (Colgan 

in Buffalo, NY and Corporate Airlines in Kirksville, MO), plus 3 serious injuries and hull losses 

to 3 turboprops and 1 cargo jet. The two fatal accidents received a score of “moderate” (35% 

reduction in the likelihood of the accident) and are summarized below:

1. On February 12, 2009, a Bombardier DHC-8-400, operated by Colgan Air, 

Inc., was on an instrument approach to Buffalo-Niagara International Airport, 

New York, when it crashed into a residence about five miles short of the runway 

after the PIC lost control of the aircraft killing the PIC, FO, two flight attendants, 

and all 45 passengers. One person on the ground was also killed, and the airplane 

was destroyed. 

The NTSB determined that the probable cause of the accident was the PIC’s 

“inappropriate response to activation of the stick shaker, which led to an 

aerodynamic stall from which the airplane did not recover.” The PIC’s response 

was inappropriate because he pulled back on the control column rather than 

pushing it forward to reduce the angle of attack. As a result, the airplane’s pitch 
Assessment of PL 111-216

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increased and its airspeed decreased resulting in the stall. One contributing factor 

was both pilots’ failure to monitor airspeed via their primary flight displays 

(PFDs), and thus their failure to recognize the impending stick shaker onset as 

airspeed fell and pitch increased. The NTSB noted that the “failure of both pilots 

to detect this situation was the result of a significant breakdown in their 

monitoring responsibilities and workload management.” The PIC’s poor response 

suggests he was surprised by stick shaker activation. Another contributing factor 

was the crew’s lack of professionalism in failing to follow FAA regulations for 

sterile cockpit rules below 10,000 feet.

The crash might have been prevented by this rule’s emphasis on foundational 

training in pilot monitoring responsibilities, in particular, as well as foundational 

training in CRM, stall recognition and recovery, multi-crew operations, and 

professionalism.

2. On October 19, 2004, a BAE Systems BAE-J3201, operated by Corporate 

Airlines struck trees on final approach and crashed short of the runway in 

Kirksville, Missouri. The PIC, SIC, and 11 of the 13 passengers were killed. The

two surviving passengers received serious injuries, and the aircraft was destroyed.

The airplane struck trees short of the runway threshold after the flight crew 

continued an unstabilized approach below the minimum descent altitude (MDA) 

without adequate visual reference of the runway environment. The crew failed to 

follow FAA regulations for non-precision approach procedures and failed to 

implement proper division of duties between the flying pilot and the monitoring

pilot. The NTSB determined from the cockpit voice recorder (CVR) that both 

pilots were looking outside the cockpit window for the runway when they reached 

the MDA, which meant that no one was monitoring the airplane’s altitude. It was 

also determined that the crew engaged in unprofessional, non-essential 

conversation during the approach, which was a violation of regulations that 

prohibit such activity during flight below 10,000 feet.

The NTSB determined that the probable cause of the accident was the pilots’ 

failure to follow established procedures, properly conduct a non-precision 

approach, and their failure to adhere to established division of duties between the 

flying and non-flying pilot. Contributing factors in the accident were: the pilots’

failure to make standard callouts; failure to establish a professional demeanor and 

adhere to sterile cockpit rules; and fatigue.

The captain held an ATP certificate with 4,234 total flight hours and 2,510 in the 

BAE-J3201. The co-pilot held a commercial pilot certificate with 2,856 total 

flight hours and 107 hours in the BAE-J3201. Had the crew benefitted from the 

rulemaking’s emphasis on foundational training in multi-crew operations CRM, 

energy management, knowledge-based decision-making, leadership, and 

professionalism, it is possible that the accident might have been prevented. 
Assessment of PL 111-216

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In sum, the rulemaking would require a minimum of 2,500 hours for Part 121 captains, an ATP 

for Part 121 FOs, and an emphasis on screening pilot applicants, preparing pilots better for Part 

121 operating environments, professionalism, and more training in stall recognition. These 

provisions would have had some degree of influence on 31 of the 354 accidents in the Part 121 

data set (8.8%), but likely would have reduced the risk of accidents by a theoretical score of just 

9.25 accidents among 354 accidents over 10 years (2.6%). The rulemaking also would have 

averted a theoretical 23.1 fatalities (5.3%), 3.7 serious injuries (1.9%), and 11 minor injuries 

(2.9%) over the 10-year accident set.

Part 125 Operations.

A PIC on a Part 125 flight must have an ATP. The rulemaking would not require FOs to have an 

ATP. Therefore, the net effect of the rulemaking would be limited to the various emphasis areas 

that the rule specifies.

Part 125 operators had 5 accidents in the 10-year study period. They resulted in 4 hull losses, 1 

fatality and 1 serious injury. All 5 captains had total flight time in excess of the proposed 1,500-

hour minimum to obtain an ATP. Four of the 5 captains had more than 9,000 hours.

Two of the four hull losses were caused by uncontrollable engine fires in flight, and a third was 

caused by an engine failure that prevented the prop from feathering. One of these accidents led 

to an emergency landing and post-crash fire on snow-covered tundra in Alaska, while the other 

two led to intentional ditching. In the fourth hull-loss accident, the crew undershot the runway 

while landing to deliver fuel at a remote mining site in Alaska. The DC-4 had been modified 

with a raised cockpit above fuselage to accommodate an upward swinging, modified nose door, 

which “presented a different sight picture” than a normal DC-4. The FO had only a commercial 

certificate but the captain, who was the pilot flying, had nearly 22,000 hours and 13,600 in makemodel. The rulemaking would not have influenced these scenarios.

The fifth accident involved wing-to-wing contact with a parked aircraft on a general aviation 

ramp in Newark, NJ. The NTSB cited the Part 125 crew’s visual misjudgment of clearing 

distance between aircraft. The accident report does not identify which pilot was flying the Part 

125 Boeing 737-700, but the PIC had nearly 13,000 hours and 1,245 in type, and the FO held an 

ATP. The rulemaking is unlikely to affect visual perception of wing clearance. In sum, the 

proposed rulemaking would have had no effect on the 5 Part 125 accidents over the past 10 

years.

Part 135 Commuters.

For Part 135 commuters, the rulemaking would affect only the requirements to obtain an ATP for 

pilots-in-command of multi-engine airplanes. Part 135 commuters had 14 accidents involving 

multi-engine airplanes over the 10-year study period. They resulted in 1 fatal accident with 2 

fatalities, plus 4 hull losses. Just 2 of the 14 crews included FO’s, one of whom was an ATP. 

Total flight hours for these PICs ranged from 2,942 to nearly 25,000 hours.
Assessment of PL 111-216

14

Of the 14 accidents in the past 10-year dataset involving multi-engine commuter aircraft, 3 were 

caused by faulty maintenance and a fourth accident was caused by unforecast and unexpected 

turbulence, which was the only accident in which an FO was flying. Among the remaining 10

accidents, the broader elements in the rulemaking may have influenced 8 accidents, which 

included 1 hull loss and 7 aircraft with substantial damage. However, the rule scored highly 

against just one accident. The emphasis on professionalism, particularly the need to complete 

checklists and to follow procedures, plus the emphasis on weather were the primary sources of 

effectiveness in these accidents.

Overall, the rulemaking would have averted a theoretical 1.8 of the 14 accidents in 10 years. It 

also would have avoided a theoretical 0.35 fatalities and 0.45 serious injuries. Appendix 2 shows 

the scoring for the 8 commuter accidents against which the rulemaking received a positive score. 

Part 135 On-Demand

In principle, the rulemaking would affect all PICs operating on-demand Part 135 services 

involving either turbojet airplanes or airplanes configured with 10 or more passenger seats. 

However, the latter category was not involved in any on-demand Part 135 accidents in the 10-

year study period. Consequently, the on-demand accident set was limited to 41 of 44 accidents 

involving turbojet airplanes. (Three of the accidents occurred outside the United States and

accident data was unavailable. Useful data was available on 38 of the 41 PICs and 37 of the 41

FOs.

As with other segments of commercial aviation outlined above, many accidents did not reflect on 

crew performance. The rulemaking received positive scores against 19 of the 44 accidents. 

There were 8 accidents that received a score of “moderate” (35%) and 11 accidents that received 

a score of “low” (15%). Scores were mostly a result of the targeted emphasis on professionalism, 

weather, and the value of recognizing go-around gates during unstable approaches (airmanship). 

The most significant accident to receive a “moderate” score involved an approach-to-landing 

accident in Aspen, CO. The accident is summarized below:

On March 29, 2001, N303GA, a Gulfstream III operated as a part 135 on-demand

flight by the Avjet Corporation, crashed while on final approach into Aspen, CO. 

The airplane crashed 2,400 feet short of the runway threshold after the flight crew 

continued an unstabilized approach below the minimum descent altitude without 

having adequate visual reference to the runway. The two pilots, one flight 

attendant, and all 15 passengers were killed, and the aircraft was destroyed.

The flight was late departing Los Angeles, CA and was in jeopardy of missing the 

noise restriction curfew that was in effect at the time of the accident. The weather 

brief which the co-pilot received during preflight as well as the weather obtained 

en-route indicated that a visual approach would likely be available at the 

destination. When the aircraft neared Aspen, however, ATC informed the flight 

crew that three of the preceding arrivals had executed missed approaches due to 

deteriorating visibility at the end of the runway. Despite this knowledge, the first 

officer called for, and the captain briefed a visual approach to the landing runway. 
Assessment of PL 111-216

15

According to the accident report, the flight crew made numerous procedural 

errors, demonstrated poor crew coordination, and the darkness and snow showers 

adversely affected the crew’s ability to avoid terrain. The NTSB also concluded 

that the presence of a passenger in the flight deck jump seat may have increased 

the pressure on the captain to complete the flight. 

The NTSB determined that the probable cause of this accident was the pilots’ 

operation of the aircraft below the minimum descent altitude without having 

visual reference with the runway. Contributing to the accident was the vague 

wording of a NOTAM regarding the limitations on circling approaches at night in 

Aspen, the deteriorating weather, and the pressure on the captain to complete the 

flight. 

The captain held and ATP certificate with 9,900 hours of total flight time and 

1,475 in the Gulfstream III. The first officer held an ATP certificate with 5,500

total hours and 913 hours in the Gulfstream II and III. In spite of the considerable

flight time and experience that both these pilots had, it is possible that the 

enhanced training requirements would have been effective in improving the

performance and situational awareness of the flight crew during this accident. 

In sum, the rulemaking would have avoided a theoretical 4.45 accidents (10.9%), 11 of a total of 

32 fatalities (34.3%), and 2.85 of 11 serious injuries (25.9%). Appendix 3 shows the scoring for 

the 19 on-demand accidents against which the rulemaking received a positive score.

Summary

Based on a detailed review of 417 accidents over 10 years, the analysis found that the 

rulemaking would be most effective against accidents involving turbojets in on-demand Part 135 

operations and against twin-engine aircraft accidents in Part 135 commuter operations. 

However, the rulemaking would have had a significant effect against only a small number of Part 

121 accidents, and the rulemaking would have had no effect against the small number of Part 

125 accidents that occurred over the 10-year study period. 

The analysis also noted that a large percentage of accidents had no reflection on crew 

performance, due to the prevalence of ramp accidents caused by others, turbulence accidents that 

involve either passenger behavior or conditions that could not be anticipated, and several types 

of miscellaneous events. Nevertheless, the rulemaking could save a total of about 1.55 accidents 

per year, plus 3.4 fatalities and 0.7 serious injuries per year in Part 121 and Part 135 operations.
Assessment of PL 111-216

16

Appendix 1: Scoring Against 31 Part 121 Accidents in Which the Rulemaking Received Positive 

Scores, FY 2001 – FY 2010

NTSB # Damage

High 

Injury Date Carrier Location Aircraft Service Fatal Score

NYC02LA013 Substantial Minor/None 10/16/2001 Mesa Roanoke, VA ERJ-145 Passenger 0 0.75

DEN07LA101 Substantial Minor/None 6/20/2007 Great Lakes Laramie, WY BE-1900D Passenger 0 0.55

DCA04MA068 Destroyed Fatal 8/13/2004 Air Tahoma Florence, KY CV-580 Cargo 1 0.55

CHI01FA084 Substantial Minor/None 2/10/2001 Great Lakes Chicago, IL BE-1900 Passenger 0 0.55

NYC03FA035 Substantial Minor/None 1/6/2003 ExpressJet Cleveland, OH ERJ-145LR Passenger 0 0.55

MIA01LA030 None Serious 11/20/2000 Atlantic Southeast Ashville, NC ATR-72 Passenger 0 0.55

DCA08RA077 Destroyed Fatal 7/6/2008 USA Jet Saltillo, Mexico DC-9-15F Cargo 1 0.55

DFW08CA215 Substantial Minor/None 8/14/2008 Trans States St. Louis, MO ERJ-145LR Passenger 0 0.55

FTW04LA225 Substantial Minor/None 8/30/2004

Custom Air 

Transport El Paso, TX B727 Cargo 0 0.35

DCA04MA045 Substantial Minor/None 5/9/2004 American Eagle San Juan, PR ATR-72 Passenger 0 0.35

ANC01FA011 Substantial Minor/None 10/22/2000

Frontier Flying 

Service Bethel, AK BE-1900 Passenger 0 0.35

DCA08WA071 Substantial Minor/None 5/16/2008 Asia Pacific Airlines

Phonpei, 

Micronesia B727-200F Cargo 0 0.35

DCA09MA027 Destroyed Fatal 2/12/2009 Colgan Air Buffalo, NY DHC-Q400 Passenger 50 0.35

DCA05MA004 Destroyed Fatal 10/19/2004 Corporate Airlines Kirksville, MO BAE-32 Passenger 13 0.35

DCA07FA037 Substantial Minor/None 4/12/2007 Pinnacle Traverse City, MI CL-600-2B19 Passenger 0 0.15

NYC06LA191 Substantial Minor/None 7/24/2006 American Eagle Newark, NJ ERJ-135LR Passenger 0 0.15

DCA05MA099 Substantial Minor/None 9/18/2005 Spirit

Fort Lauderdale, 

FL A321-231 Passenger 0 0.15

NYC05FA094 Substantial Minor/None 6/7/2005 UPS Louisville, KY MD-11F Cargo 0 0.15

DCA08FA018 Substantial Minor/None 12/16/2007 Air Wisconsin Providence, RI CL600-2B19 Passenger 0 0.15

DCA04MA082 Substantial Minor/None 9/19/2004 FedEx Memphis, TN MD-11 Cargo 0 0.15

DCA09FA048 Substantial Serious 5/6/2009 World Airways Baltimore, MD DC-10-30 Passenger 0 0.15

FTW03MA160 Substantial Minor/None 5/24/2003 Southwest Amarillo, TX B737-300 Passenger 0 0.15

CHI02LA170 Substantial Minor/None 6/16/2002 Vanguard Kansas City, MO MD-82 Passenger 0 0.15

LAX04LA050 Substantial Minor/None 11/14/2003 United San Francisco, CA B747-400 Passenger 0 0.15

CEN10LA363 None Serious 6/28/2010 American Eagle Longview, TX ERJ-145LR Passenger 0 0.15

DCA05MA071 None Serious 5/31/2005 Air Wisconsin Chicago, IL CL-600-2B19 Passenger 0 0.15

DFW05LA112 None Serious 4/29/2005 Southwest Little Rock, AR B737-700 Passenger 0 0.15

ERA09LA488 None Serious 8/27/2009 Airtran Inverness, FL B717-200 Passenger 0 0.15

CHI02LA111 None Serious 4/18/2002 ATA Springfield, MO B757 Passenger 0 0.15

CEN09MA142 Destroyed Serious 1/27/2009 Empire Lubbock, TX ATR-42-300 Cargo 0 0.15

DCA04WA043 Destroyed Minor/None 4/28/2004 Centurion Air Cargo Bogota, Colombia DC-10-30F Cargo 0 0.15
Assessment of PL 111-216

17

Appendix 2: Effectiveness of the Rulemaking Against 8 Part 135 Commuter Accidents in Which 

the Rulemaking Received Positive Scores, FY 2001 – FY 2010

Date Operator Damage Fatal Serious Location Aircraft Service Event Score

4/4/2004 Peninsula Airways Substantial 0 0 Unalaska, AK G-21 Commuter

Lost Control on 

Landing 0.75

3/13/2002

Warbelows Air 

Ventures Substantial 0 0 Fairbanks, AK PA-31 Commuter Landed Gear Up 0.15

8/24/2002 Cape Smythe Air Substantial 0 0 Nuiqsut, AK PA-31 Commuter Landed Gear Up 0.15

7/13/2003 Air Sunshine Substantial 2 0

Treasure Cay, 

Bahamas CE-402C Commuter

Ditched; Engine & 

Pilot Response 0.15

9/17/2004 Everts Air Alaska Substantial 0 0 Telida, AK PA-31-350 Commuter Landed Gear Up 0.15

2/19/2009

Frontier Flying 

Service Substantial 0 1 Nome, AK PA-31-350 Commuter CFIT, Flat Terrain 0.15

2/1/2010 Cape Air Substantial 0 0 Watertown, NY CE-402C Commuter Overran on Landing 0.15

3/15/2010 Servant Air Destroyed 0 2 Kodiak, AK BN-21-21 Commuter LOC on Climbout 0.15

Appendix 3: Effectiveness of the Rulemaking Against 19 Part 135 On-Demand Accidents in 

Which the Rulemaking Received Positive Scores, FY 2001 – FY 2010

Date Operator Damage Fatal Serious Location Aircraft Service Event

Sco

re

12/20/2000 Million Air Dallas Substantial 0 0 Jackson, WY HS-125-700 Passenger App & Landing 0.15

3/29/2001 Avjet Destroyed 18 0 Aspen, CO

Gulfstream 

III Passenger CFIT 0.35

8/28/2001 Grand Aire Express Substantial 0 0 Detroit Falcon Cargo RE-Landing 0.35

3/25/2002

Corporate Flight 

Management Substantial 0 0 Anderson, IN MU-300 Passenger RE – Landing 0.15

8/13/2002

Corporate Flight 

International Destroyed 0 0 Big Bear City, CA CE-S550 Passenger RE – Landing 0.35

8/30/2002

Care Flight 

International Destroyed 1 4 Lexington, KY Lear 25C Medical RE – Landing 0.15

4/8/2003 Grand Aire Express Destroyed 0 2 St Louis, MO Falcon Cargo Ditched, Fuel 0.35

11/11/2003

West Coast 

Charters Substantial 0 0 Wheeling, IL CE-560XL Passenger RTO Overrun 0.15

2/20/2004

Aztec Captital 

Corporation Substantial 0 1 Ft. Lauderdale Lear 25B Passenger RE – Landing 0.35

3/19/2004 Airnet Systems Substantial 0 0 Utica, NY Lear 35A Passenger Hard Landing 0.15

11/28/2004

Air Castle 

Corporation Destroyed 3 3 Montrose, CO CL-600 Passenger LOC – Climbout 0.35

7/15/2005

Aspen Base 

Operations Substantial 0 1 Eagle, CO Lear 35A Passenger Hard Landing 0.15

1/5/2006

Netjets as 

Executive Substantial 0 0 Woodruff, WI CE-560 Passenger RE – Landing 0.15

6/2/2006

International Jet 

Charter Destroyed 2 0 Groton, CT Lear 35A Passenger CFIT – Water 0.35

1/10/2007 Airnet Systems Substantial 0 0 Columbus, OH Lear 35 Cargo LOC – Flight 0.15

3/17/2007 Air Trek Substantial 0 0 Beverly, MA CE-500 Med App & Landing 0.15

8/23/2007 Jet Share US Substantial 0 0 Westhampton, NY Lear 60 Passenger App & Landing 0.15

7/31/2008 East Coast Jets Destroyed 8 0 Owatonna, MN HS-125-800 Passenger App & Landing 0.35

2/24/2009 Bankair Substantial 0 0 Kansas City, MO Lear 35A Cargo App & Landing 0.15