New Recommendations

As a result of this investigation, the National Transportation Safety Board makes the following new safety recommendations:

To the Federal Aviation Administration:

Require principal operations inspectors to ensure that operators with flight crews performing 14 Code of Federal Regulations Part 121, 135, and 91 subpart K overnight operations brief the threat of fatigue before each departure, particularly those occurring during the window of circadian low. (A-14-72)

Require operators to develop an annual recurrent dispatcher resource management module for dispatchers that includes participation of pilots to reinforce the need for open communication. (A-14-73)

Require principal operations inspectors to work with operators to ensure that their operating procedures explicitly state that any changes to an approach after the completion of the approach briefing should be rebriefed by the flight crewmembers so that they have a common expectation of the approach to be conducted. (A-14-74)

Require principal operations inspectors to ensure consistency among their operators’ training documents, their operators’ Federal Aviation Administration -approved and -accepted documents, such as the aircraft operating manual, and manufacturers’ guidance related to terrain awareness and warning system caution and warning alert responses, and ensure that responses are used during night and/or instrument meteorological conditions that maximize safety. (A-14-75)

Require principal operations inspectors of 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to ensure that Federal Aviation Administration-approved nonprecision instrument approach landing procedures prohibit “dive and drive” as defined in Advisory Circular 120-108. (A-14-76) (Supersedes Safety Recommendation A-06-8)

Require that the remarks section of meteorological aerodrome reports be provided to all dispatchers and pilots in flight dispatcher papers and through the aircraft communication addressing and reporting system. (A-14-77)

Expand the current guidance available in Federal Aviation Administration Order 7110.65, “Air Traffic Control,” to further define meteorological aerodrome report pertinent remarks. (A-14-78)

Issue a safety advisory bulletin to air traffic controllers providing examples of the types of meteorological aerodrome report remarks information considered pertinent and reminding them of the requirement to add such pertinent remarks to automatic terminal information service broadcasts. (A-14-79)

Issue a special airworthiness information bulletin to notify operators about the circumstances of this accident and the potential safety improvements related to the Honeywell enhanced ground proximity warning system part number 965 0976-003-218-218 or later software update. (A-14-80)

Advise operators of aircraft equipped with terrain awareness and warning systems (TAWS) of the circumstances of this accident, including that, in certain situations, an escalating series of TAWS warnings may not occur before impact with terrain or obstacles. Encourage operators to review their procedures for responding to alerts on final approach to ensure that these procedures are sufficient to enable pilots to avoid impact with terrain or obstacles in such situations. (A-14-81)

Revise the minimum operational performance standards to improve the effectiveness of terrain awareness and warning systems when an airplane is configured for landing and near the airport, including when the airplane is descending at a high rate and there is rising terrain near the airport. (A-14-82)

Require all operators of airplanes equipped with the automated “minimums” alert to activate it. (A-14-83)

For those airplanes not equipped with an automated “minimums” alert, require all operators of airplanes equipped with terrain awareness and warning systems (TAWS) to activate the TAWS 500-ft voice callout or similar alert. (A-14-84)

Require principal operations inspectors of 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to verify that procedures critical to approach setup, like configuring an approach in the flight management computer for those approaches dependent on that step, are included in Federal Aviation Administration-approved or -accepted manuals. (A-14-85)

Work with industry, for all applicable aircraft, to develop and implement means of providing pilots with a direct and conspicuous cue when they program the flight management computer flight plan incorrectly such that it contains such elements as improper waypoints or discontinuities that would allow the vertical deviation indicator to present misleading information for an approach. (A-14-86)

To UPS:

Work with the Independent Pilots Association to conduct an independent review of the fatigue event reporting system to determine the program’s effectiveness as a nonpunitive mechanism to identify and effectively address the reported fatigue issues. Based on the findings, implement changes to enhance the safety effectiveness of the program. (A-14-87)

Work with the Independent Pilots Association to counsel pilots who call in fatigued and whose sick bank is debited to understand why the fatigue call was made and how to prevent it from recurring. (A-14-88)

To the Independent Pilots Association:

Work with UPS to conduct an independent review of the fatigue event reporting system to determine the program’s effectiveness as a nonpunitive mechanism to identify and effectively address the reported fatigue issues. Based on the findings, implement changes to enhance the safety effectiveness of the program. (A-14-89)

Work with UPS to counsel pilots who call in fatigued and whose sick bank is debited to understand why the fatigue call was made and how to prevent it from recurring. (A-14-90)

To Airbus:

Develop and implement, for applicable Airbus models, means of providing pilots with a direct and conspicuous cue when they program the flight management computer flight plan incorrectly such that it contains such elements as improper waypoints or discontinuities that would allow the vertical deviation indicator to present misleading information for an approach. (A-14-91)

Previous Recommendations Reclassified in This Report

One recommendation to the Federal Aviation Administration is reclassified “Closed—Unacceptable Action/Superseded.”

Require all 14 CFR Part 121 and 135 operators to incorporate the constant-angle-of-descent technique into nonprecision approach procedures and to emphasize the preference for that technique where practicable. (A-06-8)

To read the complete NTSB final investigation report (170 pages), click HERE