Source: https://www.ntsb.gov/investigations/AccidentReports/_layouts/ntsb.recsearch/Recommendation.aspx?Rec=A-16-036
Timestamp: 2019-12-13 09:51:30
Document Index: 656697921

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Safety Recommendation A-16-036
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require all 14 Code of Federal Regulations Part 135 operators to establish safety management system programs.
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 2.5 Operational Safety Programs 2.5.1 Safety Management System Despite having a dedicated safety officer position within the organization, Trans-Pacific did not have any formal safety programs in place, such as an anonymous hazard reporting program. The director of operations (who was acting as safety officer) said that he was available to pilots if a safety concern developed and that he had an “open door” policy. The director of operations also provided anecdotal evidence that the company had addressed concerns that pilots reported but did not describe any means for identifying hazards beyond informal reports. The managing director stated that, at the time of the accident, the company had begun, but had not completed, the process of implementing an SMS. After the accident, the company planned to expedite the implementation of an SMS.54 However, Trans-Pacific provided no indication, as of February 2019, that the company’s SMS had been implemented. The NTSB recognizes the value of SMS for all operators and has recommended broadening requirements for SMS.55 In the Akron accident report, the NTSB stated that the company’s “casual attitude” toward compliance with standards “illustrates a disregard for operational safety, an attitude that likely led its pilots to believe that strict adherence to standard operating procedures was not required” (NTSB 2016). (That accident report also referenced three other accidents involving Part 135 operators that could have benefitted from an SMS.)56 As a result, the NTSB concluded that all Part 135 operators could benefit from an SMS because formal system safety methods would be incorporated into internal oversight programs and recommended that the FAA “require all 14 Code of Federal Regulations Part 135 operators to establish safety management system programs” (Safety Recommendation A-16-36). In a January 9, 2017, response concerning Safety Recommendation A-16-36, the FAA noted that Part 135 operators could participate in a formal voluntary SMS. The FAA also stated its intention to conduct a review and hold meetings to determine if further action was needed on SMS for Part 135 operators. Our April 6, 2017, response to the FAA concerning Safety Recommendation A-16-36 again cited the results of our review of major accident investigations involving Part 135 on-demand operators (see the discussion of Safety Recommendation A-16-34). We stated that these accidents involved a safety problem that an SMS could have mitigated. Given the FAA’s stated intention of reviewing Part 135 operations regarding voluntary SMS, we classified Safety Recommendation A-16-36 “Open—Acceptable Response.” The NTSB again recognized the benefits of SMS for Part 135 operators as a result of our investigation of the June 25, 2015, accident involving a de Havilland DHC-3 operated by Promech Air, which struck mountainous terrain northeast of Ketchikan, Alaska, in near-zero visibility conditions (NTSB 2017). The NTSB’s investigation found that Promech had an anonymous safety reporting system that company managers believed was effective. Promech’s director of operations stated his belief that the company’s informal flight risk assessment process accomplished the same objective as formal risk assessment forms (which he had used at other jobs). The company president said that, typically, pilots verbally reported concerns to managers. Despite their confidence in the company’s existing safety programs, Promech managers were unaware of serious incidents that had occurred. For example, the accident pilot had struck trees during a different takeoff; this event was known to other company pilots but had never been reported to management. The NTSB concluded that, “although Promech had a hazard reporting system, the system was underused by the pilots, and the company’s informal safety processes were not effective for identifying major risks in the company’s flight operations and did not facilitate organizational learning about major areas of risk.” Similar to the Akron accident investigation, the NTSB concluded that an SMS could benefit all Part 135 operators because SMS requires the operators to incorporate formal system safety methods into their internal oversight programs. As a result, the NTSB reiterated Safety Recommendation A-16-36. The recommendation was again reiterated as a result of the Togiak, Alaska, accident investigation. The NTSB noted that Hageland Aviation Services had three accidents in 3 years involving continued visual flight rules flight into instrument meteorological conditions.57 The NTSB believed that the similar circumstances of these three accidents indicated the potential for underlying safety issues that an SMS might have identified. Trans-Pacific’s management (as with Promech’s and Hageland’s) likely believed its existing safety programs effectively identified and mitigated hazards. However, the company’s programs did not identify or mitigate the hazards that contributed to this accident. For example, Trans-Pacific’s safety program did not identify or mitigate the hazard of unapproved (and likely inexperienced) SICs acting as PF. Similarly, Trans-Pacific did not identify the hazard associated with pairing two pilots who had both exhibited difficulties in training. Under an SMS, Trans-Pacific’s progressive qualification policy could be considered part of the risk management component of SMS. In theory, the policy provided a structured way for SICs to develop experience (first under the supervision of management pilots or check airmen and then with company PICs). However, Trans-Pacific lacked the safety assurance component of SMS that would have triggered a review of the progressive qualification policy. Such a review would have likely identified that SICs could not gain experience or advance according to the policy because no Learjet-qualified management pilots or check airmen were employed by the company during the time that the accident SIC was employed by the company. As previously discussed, an FDM program would have provided the company information about how flights were being conducted during normal operations. SMS complements FDM because SMS ensures formal review of strategies developed to mitigate risks identified through FDM. Thus, the NTSB concludes that an SMS would have improved Trans-Pacific’s ability to identify and mitigate risks because an SMS requires operators to incorporate formal system safety methods into their internal oversight programs. Therefore, the NTSB reiterates Safety Recommendation A-16-36. In addition, the NTSB notes that Safety Recommendations A-16-36 was associated with the “Improve the Safety of Part 135 Aircraft Flight Operations” issue area on the agency’s 2019-2020 Most Wanted List of Transportation Safety Improvements.
Response: The following is from the NTSB Aviation Accident Report “Collision with Terrain Hageland Aviation Services, Inc. dba Ravn Connect Flight 3153 Cessna 208B, N208SD, Togiak, Alaska October 2, 2016.” Report number AAR-18-02. Adopted on April 17, 2018 and published on April 26, 2018. During its investigation of the November 10, 2015, fatal accident in Akron, Ohio, involving a British Aerospace HS 125-700A operated under Part 135, the NTSB identified problems with the operator’s safety culture and a lack of compliance with SOPs (NTSB 2016). In the report, the NTSB cited several additional Part 135 accidents (including the two 2013 Hageland accidents) that highlighted operational safety issues that could have been mitigated with SMS. As a result of its investigation, on November 7, 2016, the NTSB issued Safety Recommendation A-16-36, which recommended that the FAA require all Part 135 operators to establish an SMS (NTSB 2016). On January 9, 2017, the FAA responded that while SMS is not currently required of Part 135 operators, the FAA had a formal SMS voluntary program for Part 135 operators. The FAA planned to review this voluntary program to determine if further action was needed to satisfy the recommendation. On April 6, 2017, the NTSB replied that a review of major NTSB investigations of accidents from 2000 through 2015 found that seven accidents involving only Part 135 on-demand operators (not all Part 135 operators) killed 53 people and seriously injured 4. The NTSB believed that this was evidence of a safety problem for which an SMS may be an effective mitigation. The NTSB was encouraged by the FAA’s response that it has a voluntary program to assist Part 135 operators in establishing an SMS; however, pending further responsive action from the FAA, the NTSB classified Safety Recommendation A-16-36 “Open—Acceptable Response.” On May 9, 2017, the NTSB reiterated the safety recommendation after its investigation of the previously referenced fatal CFIT accident in Ketchikan involving Promech (NTSB 2017a). Thus, the NTSB concludes that an SMS, which requires operators to incorporate formal system safety methods into their internal oversight programs, could help Hageland and other Part 135 operators identify and mitigate the types of risks identified in this accident investigation. Therefore, due to its relevance to the circumstances of this accident, the NTSB reiterates Safety Recommendation A-16-36.
Response: From the NTSB Accident Report “Collision with Terrain, Promech Air, Inc., de Havilland DHC-3, N270PA, Ketchikan, Alaska, June 25, 2015” AAR-17-01, PB2017-102178, Notation 56539, adopted on April 25, 2017: Promech’s safety programs when the company had provided service under Part 121. However, interviews with Promech pilots revealed that they did not know who in the company was responsible for managing safety; several provided different names when asked about the subject. The DO stated that Promech performed flight-risk assessment informally but that he believed the informal process accomplished the same objective as the use of formal risk assessment forms (which he had used at other jobs). Promech had an anonymous safety-reporting system for use in submitting written reports of operational hazards and general unsafe conditions; however, neither the company president/CEO nor the DO could recall any safety report forms having been submitted. The company president/CEO said that, typically, pilots verbally told the managers if they had a concern. Although company managers seemed confident that pilots would use either verbal or anonymous reporting if they had concerns, company management was unaware of serious incidents that had occurred, including a flight in which the accident pilot struck trees with an airplane during takeoff and later told some of his colleagues (and noted in his pilot logbook) that he “nearly died.” In addition, company managers stated that they were unaware that the accident pilot had turned around due to poor weather conditions during his first tour on the day of the accident and that two other Promech pilots reversed course multiple times to find their way out of Ella Lake on the morning of the accident.43 43 NTSB investigators discovered this through an interview with one of the pilots and by reviewing ADS-B data from the morning of the accident. As a Part 135 operator, Promech was not required by the FAA to have a formal SMS; however, SMS has been recognized in all aspects of aviation operations as an effective way to establish and reinforce a positive safety culture and identify and correct deviations from SOPs. The DO indicated that the company did not have enough staff to manage a formal SMS program and that the company’s safety culture accomplished the same objective as a formal SMS program. The NTSB concludes that, although Promech had a hazard reporting system, the system was underused by the pilots, and the company’s informal safety processes were not effective for identifying major risks in the company’s flight operations and did not facilitate organizational learning about major areas of risk. A more proactive safety program, like an SMS, could identify safety risks, seek to mitigate them, and foster a culture in which safety-related incidents are reported without embarrassment or fear of reprisal and in which the company focuses its efforts on the risks that pose the greatest potential threat to life and equipment. SMS could help Promech learn from incidents (like the accident pilot’s tree collision and pilots’ turnarounds because of weather) and establish policies to reduce the risks of recurrence. The FAA issued its final rule in January 2015 requiring SMS for Part 121 air carriers and included the key requirements for an SMS in newly created 14 CFR Part 5, “Safety Management Systems.” In its final rule, the FAA stated that its intent in developing Part 5 was to establish a uniform standard that could be extended to apply to other operating parts, including Part 135 (80 Federal Register 1308) (NARA 2015). However, in the 2 years since Part 5 was established, the FAA has not initiated rulemaking to address SMS for Part 135 operators. The NTSB also discovered operational safety issues during its investigation of the November 10, 2015, fatal accident involving a British Aerospace HS 125-700A airplane that departed controlled flight while on approach to an airport in Akron, Ohio (NTSB 2016). The airplane was operated under Part 135 by Execuflight, which did not have an SMS. Although not required, an SMS likely could have helped Execuflight and the FAA identify and correct the operational safety issues that contributed to the accident. (The Execuflight accident report also referenced three other accidents involving Part 135 operators that could have benefitted from an SMS program.)44 As a result, on November 7, 2016, the NTSB issued Safety Recommendation A-16-36, which asked the FAA to “[r]equire all 14 [CFR] Part 135 operators to establish [SMS] programs.” As of the date of this report, Safety Recommendation A-16-36 is classified “Open—Initial Response Received.” The safety benefits of SMS have been demonstrated by Part 121 carriers and Part 135 helicopter EMS operators who have voluntarily implemented SMS (Bergin 2013; Buckner 2013). The FAA has a formal voluntary program that Part 135 operators can use to establish an SMS and has produced a video presentation, SMS for Small Operators, that shows how an SMS can be effectively scaled for a smaller operator, such as Promech.45 Because Part 135 operations often involve carrying passengers for hire, the FAA is responsible for ensuring that Part 135 operators have adequate safety protections in place for the flying public. The NTSB concludes that an SMS can benefit all Part 135 operators because they require the operators to incorporate formal system safety methods into their internal oversight programs. Therefore, because of the relevance of Safety Recommendation A-16-36 to Promech’s accident, the NTSB reiterates the recommendation in this report.
Response: We note that you recently published a final rule requiring that Part 121 operators have an SMS program, and that, in the notice of proposed rulemaking for this rule, you indicated that you would consider a similar requirement for Part 135 operators. We further note that Part 135 operators may currently participate in your formal voluntary program for establishing an SMS program. Finally, we note that, to satisfy this recommendation, you plan to “determine the feasibility of recommending” SMS for Part 135 operators and decide what further action is needed. As discussed above with regard to Safety Recommendation A-16-34, we completed seven major accident investigations involving Part 135 on demand operators, in which 53 people died and another 4 were seriously injured. We believe this is evidence of a safety problem for which an SMS may be an effective mitigation. We are encouraged that you currently have a voluntary program to assist Part 135 operators in establishing an SMS; however, we also believe that to be consistent with fundamental SMS principles, it is necessary to measure how effective a mitigation is in addressing a safety risk. To satisfy this recommendation, your planned determination regarding SMS for Part 135 operators and necessary further action will require information on how many Part 135 operators have implemented Safety Recommendation A-16 36, which is classified OPEN--ACCEPTABLE RESPONSE pending: (1) your determination whether your formal voluntary SMS program is being widely implemented by Part 135 operators; (2) further effective action if it is determined that the data needed to make this determination are not available; or, (3) if data are available, additional actions needed to ensure that SMS is widely implemented by Part 135 operators.
Response: -From Michael P. Huerta, Administrator: The FAA recently required part 121 certificate holders to have a Safety Management System (SMS) when it published the final rule. Safety Management Systems on January 8. 2015. In the notice of proposed rulemaking, the FAA considered that SMS could be applied to part 135 certificate holders at some point in the future. We would like to highlight that while SMS is not currently required of part 135 operators the FAA has a formal SMS voluntary program in which part 135 operators may participate. We will conduct a review and hold meetings to determine the feasibility of recommending MS for part 135 certificate holders and determine if further action is needed.