NATA Safety 1st Flitebag – Issue 27 – 1st Quarter 2012 Page 1

Welcome to Issue 27 of NATA’s Safety 1st Flitebag, our quarterly online safety newsletter, supporting the NATA Safety 1st Management System (SMS) for Air Operators.

This quarterly newsletter highlights known and emerging trends, environmental and geographical matters, as well as advances in operational efficiency and safety. Flight and ground safety have been enhanced and many accidents prevented because of shared experiences.

DANGEROUS MEDICINE IN THE AIR By: Lindsey McFarren, President McFarren Aviation Consulting (MAC) lindsey@mcfarrenaviation.com The aviation community preaches almost constantly about the negative impacts of drinking alcohol and flying. Some pilots are so afraid of a positive drug test they avoid rock concerts so they don’t get a contact buzz. Before taking a prescription medication pilots check to be sure it’s approved by the FAA and read all of the possible side effects. But in some cases, the most dangerous substances a pilot can consume before flying are available over the counter at your corner drug store. Have you taken any of these medications before flying? You’d be surprised how long these drugs stay in your system and could affect your performance! Diphenhydramine Doesn’t sound familiar? How about Benadryl, Tylenol PM, or Unisom? Diphenhydramine is an antihistamine used in the treatment of the common cold and hay fever, but it’s also an active ingredient in many over-the-counter sleep aids. Published warnings about diphenhydramine state, “…may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery).” We can assume an aircraft would count as “heavy machinery.” The instructions on one box of Benadryl say to take one to two tablets every four

to six hours. The FAA recommends multiplying the dosing interval by a factor of five to determine when it might be safe to fly. So if a pilot takes a medication with diphenhydramine as an active ingredient before bed to treat a common cold, that pilot is likely still to have some diphenhydramine in his or her system upon waking. If he or she has got a flight that morning, the medication could still have an impact on reaction time in the aircraft. Based on the FAA’s factor-of-five guidance, the pilot should wait thirty hours prior to flying an aircraft.

Issue 27 1st Quarter 2012

In This Issue: • Dangerous Medicine In The Air ......................................................1

• ACSF News – Register Now For 2012 ACSF Symposium, ACSF And FltPlan.com Working Together, New Board Of Governor Members ...............................................................................................4

• Industry News – BARR Program Reinstated, Positive Changes Proposed To Takeoff Minimum Rule, Ground-Breaking FBO Audit Standard Launched And More .............................................................7

• NTSB News – NTSB Cites ATC Error As Probable Cause Of Near-Mid-Air Collision, Hersman Comments On Fatigue , NTSB Issues Landing Distance Recommendations To FAA ...................................14

• Information For Operators (InFOs) ...............................................21

• Safety Alert For Operators (SAFOs) ..............................................22

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In August 2010, a Cessna A185 departed a paved runway for a flight, intending to perform a water landing on a lake later. The pilot did not raise the landing gear after takeoff and crashed when the landing gear impacted the water during landing, killing the pilot. The National Transportation Safety Board (NTSB) mentioned in accident reports that the pilot was anticipating surgery for the removal of stomach cancer and might have been having difficulty sleeping, but could not determine that fatigue was a factor in the accident. However, the forensic toxicology examination indicated recent use of diphenhydramine. The NTSB determined the probable cause(s) of this accident to be the pilot's failure to retract the landing gear prior to a water landing. Contributing to the accident was the pilot's impairment due to medication.

In February 2010, a Cessna 310 crashed, killing three people. The NTSB reported the forensic toxicology examination showed positive results for diphenhydramine. Diphenhydramine was detected in the pilot’s blood and urine. The NTSB could not definitively say the drugs were causal to the accident, but the results were notable enough to emphasize in the report.

Dextromethorphan Dextromethorphan is found in Coricidin®HBP Cough and Cold, Robitussin®, Vicks® products, and several other cough medications to suppress coughing. Dextromethorphan is also a popular recreational drug, whereby an individual purposely overdoses to produce the desired effect. Even standard dosing can have a sedative effect and cause dizziness. Robitussin® Peak Cold Cough and Cold includes dosing instructions of two teaspoons every four hours. Following the FAA’s rule of thumb of multiplying the dosing interval by five, a pilot should wait twenty hours after taking that product before flying.

In November 2009, an experimental Kennedy Lancair impacted terrain just off of the runway at Lenhardt Airport, Hubbard, Oregon. The pilot was ATP-rated. The forensic toxicology examination of the pilot found Dextromethorphan and other over-the-counter medications in the pilot’s blood and urine. The National Transportation Safety Board determined the probable cause(s) of this accident to be the loss of control during takeoff for undetermined reasons. Contributing to the accident was the pilot's impairment from an over-the-counter sedating medication.

In September 2009, a Piper PA-11 crashed in Florida, killing one individual and seriously injuring another. The NTSB report stated, “Post-mortem toxicological testing did reveal elevated levels of an over-the-counter sedating antihistamine, strongly suggesting impairment due to the use of that substance.” The probable cause of the accident was determined to be the pilot’s improper use of flight controls following a partial loss of engine power for undetermined reasons. Contributing to the accident was the pilot’s impairment from the use of an over-the-counter sedating antihistamine.

Loperamide So you ate the sushi on your over-night in Wichita last night and now you’re suffering the consequences. Loperamide is found in antidiarrheals such as Imodium® and Kaopectate®. Loperamide can cause drowsiness and dizziness. The dosing instructions on Imodium are two caplets when you first realize sushi in Wichita is a bad idea and one caplet after every “reminder,” so it is more difficult to determine the period of time required from last dose to safe flying. However, it is likely the illness itself would keep you from flying that day.

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Ibuprofen What could be safer than Advil® or Motrin®? Ibuprofen, the active ingredient in both medications used as an analgesic to treat minor pain, can cause dizziness and nausea. The instructions on Motrin recommend one tablet every four to six hours. That means a pilot should wait 30 hours after taking Ibuprofen prior to flying. Medications and NTSB Reports Although not uncommon for the forensic toxicology examination to show some signs of over-the-counter medication use (try searching the NTSB database for “diphenhydramine” – you will be surprised), it is relatively uncommon for the NTSB to list a medication as a probable cause or contributing factor in an accident. If the NTSB lists medication usage as a probable cause or contributing factor, you can be sure the medication was found in high levels or in kidneys, liver or blood, often indicating recent dosage.

The NTSB is appropriately relatively conservative in determining probable cause and contributing factors. Not all medications are found to be directly causal in aviation accidents because the board would have to infer too many conditions to make that determination. Consequently, some accidents report levels of over-the-counter medications in the body without determining the drugs to be causal. This accounts for the discrepancy between the number of accident reports that mention over-the-counter medications but do not list the drugs as a probable cause or contributing factor.

Additional Tips Don’t forget to consider the condition that prompted you to take the medication in the first place. If you have a cold that is distracting you from flying duties or you haven’t slept well in several days, you might not be fit to fly even if the medication is out of your system. The first time you take an over-the-counter medication, you should use the FAA’s rule of thumb to determine a safe period of time between dosing and flying, multiplying the maximum dosing interval by a factor of five. Once you are familiar with your own reactions to a medication and determine that a particular drug does not cause you negative side effects, you might be able to shorten that time period and still fly safely. Don’t assume an over-the-counter medication is safe just because you don’t need a doctor to prescribe it. Read the drug label carefully and take any warnings about drowsiness, dizziness, blurred vision, or nausea seriously. It’s better to find out you have a reaction to an over-the-counter medication when you’re still on the ground, not at 10,000 feet! Lindsey McFarren is the president of McFarren Aviation Consulting, which specializes in general aviation safety and operations consulting. lindsey@mcfarrenaviation.com

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REGISTER NOW FOR THE 2012 AIR CHARTER SAFETY SYMPOSIUM: FEBRUARY 28-29

The Air Charter Safety Foundation’s 2012 Air Charter Safety Symposium will be held on February 28-29 at the NTSB Training Center in Dulles, Virginia. The theme for the 2012 Symposium is “Safety is Everyone’s Responsibility” and the conference features Dr. Tony Kern, CEO of Convergent Performance.

Registration is available online at www.acsf.aero/symposium. Registration includes admittance to the ACSF Symposium both days and all scheduled group meals, breaks, and social functions. Transportation to and from the SpringHill Suites Ashburn Dulles North is also included.

The ACSF Symposium is a fantastic event for suppliers, consultants and other industry participates to showcase their business as a sponsor. Contact Diane Gleason at dgleason@nata.aero or call 888-723-3135 for more information.

Conference logistics, including hotel information and local airports, is available at www.acsf.aero/symposium.

ACSF is also hosting an Auditor Workshop for the ACSF Industry Audit Standard (IAS) for:

• individuals interested in becoming IAS accredited auditors,

• current auditors who wish to renew their accreditation status, and

• operators interested in learning about the IAS audit standards and process.

Details about the Auditor Workshop can be found at www.acsf.aero/en/cev/41.

Register today!

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FLTPLAN.COM AND ACSF WORKING TOGETHER FOR SAFETY

FltPlan.com, in conjunction with the Air Charter Safety Foundation (ACSF), will be adding new functionality to be compatible with the ACSF Industry Audit Standard (IAS).

The ACSF's Industry Audit Standard is a program built to set the standard for independent evaluation of a Part 135 air charter operator's or Part 91K shared ownership company's safety and regulatory compliance.

Why the ACSF Industry Audit Standard?

ACSF members and the charter community have expressed concern that their companies are currently subject to numerous audits by third-party aviation auditing companies on behalf of consumers. The preparation for these audits has resulted in a significant increase in both staff time and resources.

The aviation community has evolved to the point that change in the standards and audit processes is required if the industry is to keep pace with the demands of the marketplace. One of the more significant demands is the release and eventual mandatory implementation of a Safety Management Systems (SMS) standard by both FAA and ICAO.

ACSF has worked closely with the FAA and international interests to ensure that its audit standard will accomplish two key functions -- first, to verify compliance with regulatory requirements, and secondly, to evaluate the level of compliance with recognized SMS standards.

All documents, including the Pre-Audit Self-Assessment Checklist, are available at no charge at http://www.acsf.aero/audit. For more information about the Industry Audit Standard, or to schedule your audit please contact Russ Lawton at audit@acsf.aero or call ACSF toll-free at 1-888-SAFE-135.

FltPlan.com's SMS system is already being used by hundreds of companies to help meet SMS requirements for Large and Turbojet aircraft and obtain IS-BAO registration. The FltPlan.com program is also recognized by safety auditors as one of the easiest and best means for operators to comply with SMS requirements.

For more info, please see: http://www.fltsafety.com/SMSinfo.htm.

ACSF ANNOUNCES THREE NEWLY APPOINTED BOARD OF GOVERNORS MEMBERS The Air Charter Safety Foundation (ACSF) is pleased to announce three newly appointed members to the ACSF Board of Governors. Ronald Brower, corporate secretary and associate general counsel for NetJets Inc. and its subsidiaries — Brower has worked more than 15 years in the aviation industry, serving both as a business executive and legal advisor. Brower handles corporate organization and governance matters for the NetJets family of companies, promotes the development

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of NetJets’ international business (principally in Asia), and oversees and coordinates all legal services performed for NetJets’ subsidiary Executive Jet Management. Brower also serves as NetJets’ principal advisor and advocate on regulatory matters and international government affairs, and he serves as chairman of NetJets’ Policy Working Group. Throughout his career, Brower has held positions as associate general counsel and director of government affairs for Northwest Airlines (now merged into Delta Air Lines). Before working for Northwest Airlines, he worked at the Washington, DC law firms of Verner, Liipfert, Bernhard, McPherson & Hand (now part of DLA Piper) and Hogan & Hartson (now part of Hogan Lovells). At those firms, his law practice focused principally on regulatory and transactional matters involving the aviation and aerospace industries. His clients included NetJets, Northwest Airlines, other domestic and foreign air carriers, private aircraft owners and operators, transportation trade associations, tour operators, foreign civil aviation authorities, and parties involved in space tourism. Douglas Carr, vice president of safety, security and regulation for the National Business Aviation Association (NBAA), Washington DC — Carr is responsible for leading the association’s efforts on business aviation safety and oversight of NBAA’s regulatory activity involving business aviation aircraft equipment mandates, operations and security. He has distinguished himself at NBAA by leading the association’s effort on the Fractional Ownership Aviation Rulemaking Committee to develop recommendations for the FAA and as the chair of the Federal Aviation Administration’s (FAA) Part 125/135 ARC Flight and Rest Subcommittee. Additionally, he chaired the FAA’s Takeoff and Landing Performance Assessment Aviation Rulemaking Committee and coordinated the association’s response to the TSA’s Large Aircraft Security Program proposal. Internationally, Carr has represented business aviation interests at the International Civil Aviation Organization and as part of several rulemaking efforts at the European Aviation Safety Agency. Prior to joining NBAA, Carr was employed by the National Air Transportation Association as a specialist in government and industry affairs. There, he was responsible for issues affecting FAR Part 135 on-demand air carriers and flight training providers. He is a graduate of Southern Illinois University at Carbondale, where he received a Bachelor of Science degree in aviation management and an Associate of Science degree in aviation flight. Carr is a commercial, multi-engine, instrument-rated pilot and a certificated flight instructor. Dave Hewitt, president of Hewitt and Company LLC, a business and aviation consulting firm formed in 2011 — Hewitt has more than 30 years of aviation experience, including 28 years of involvement in Part 135 operations in operational, technical, and executive positions. Prior to the formation of Hewitt and Company, he held various positions within NetJets, spanning a 13-year career. These positions included senior vice president, safety and compliance for NetJets North America, senior vice president for NetJets International, and vice president, operations for Executive Jet Management. Hewitt has also been an FAA aviation safety inspector at the Cincinnati Flight Standards District Office and a chief pilot/check airman/instructor for a Part 135 certificate holder located in the Midwest.

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Hewitt has served on many industry association, safety, and regulatory groups over his career. He is currently a member of the NATA Air Charter Committee and NBAA Domestic Operations Committee. He was the founding industry co-chairman of the FAA Turbine Aircraft Operations Subgroup (part of the General Aviation Joint Steering Committee) that studied turbine aircraft safety and made recommendations to the FAA to improve turbine aircraft safety. He also served on the FAA Section 206 Aviation Rulemaking Committee, was the Operations Working Group chairman for the FAA Part 125/135 Aviation Rulemaking Committee, a member of the FAA Operations Specifications Working Group, and a participant on the FAA Weight and Balance Aviation Rulemaking Committee and the FAA Part 91, Subpart K Guidance Development Team. Hewitt is a graduate of Embry-Riddle Aeronautical University and has over 7200 hours of flight time. He holds an Airline Transport Pilot license with type ratings in the Cessna Citation, Lear Jet, and Douglas DC-3 and is also a Certificated Flight Instructor in airplanes and gliders. “We are pleased to have these distinguished gentlemen joining the ACSF Board of Governors,” said Air Charter Safety Foundation Chairman James C. Christiansen. “Having three individuals with such extensive knowledge and varied experience within the industry can only bring great attributes to the foundation, and we look forward to working with them to continue the foundation’s mission of promoting and increasing the benchmark of safety in the charter industry.”

INDUSTRY NEWS BARR PROGRAM REINSTATED: NEW PROCEDURES FOR BLOCKING YOUR TAIL NUMBER

The BARR Program has been reinstated, but blocking requests are now handled by the FAA. You no longer need a 'Security Concern' to block your aircraft from Public viewing.

At this time, previously blocked aircraft under the old BARR program will not be automatically re-instated. Under the new process operators who wish to have their aircraft blocked must submit their request to the FAA.

You can submit the required information to FAA by email at: CertifiedSecurityConcern@faa.gov

OR

by mail to: FAA Certified Security Concern ATO System Operations Services Room 1002 800 Independence Avenue, SW Washington, DC 20591

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In your email to the FAA Include: 1. Aircraft owner, Operator name & address 2. Email address FAA can utilize to communicate with aircraft owner/operator about the blocking request 3. Call sign (Tail Number) to be blocked 4. Blocking level desired: ASDI Vendor Level

Blocked by ASDI Vendors

The FAA coordinates with all ASDI vendors to have your aircraft registration number blocked from their respective programs. Blocking the aircraft registration with the ASDI vendors removes the aircraft registration from the aircraft flight data. FltPlan.com Note: Block at this level if you need to track your aircraft. Blocked at FAA Source For an additional level of security operators may choose to block their aircraft flight data at the FAA Source, which will remove all aircraft flight data before it is transmitted to the ASDI vendors. This means the information never reaches any ASDI vendor and therefore is not incorporated into their system. FltPlan.com Note: Blocking at this level will prevent you from tracking your blocked tail number. So you got your tail number blocked, but you still want to track it? If you want to track your tail number once it's blocked, FltPlan.com can help. FltPlan.com can save your company thousands of dollars. FltPlan.com lets you track your blocked tail numbers as part of our Premium Flight Tracking program. Premium Flight Tracking costs $14.95 a month and allows you to track up to 10 of your blocked tail numbers at no extra cost. Be aware that some flight tracking vendors charge over $700.00 for one plane. For more information on blocking your tail number or tracking your blocked tail number contact FltPlan.com at 1-203-262-8900 or Click here. If you're already a Premium Flight Tracker Once you've submitted your paperwork to the FAA to block your tail number, please contact our office so that we can update our paperwork and reinstate your Premium Flight Tracking for those blocked tail numbers. Reprinted with permission from FltPlan.com FAA MAKES POSITIVE CHANGE TO TAKEOFF MINIMUM RULE What’s at Issue The Federal Aviation Administration (FAA) published a direct final rule that will allow qualified Part 135 operators to conduct lower-than-standard takeoffs at military and foreign airports if they have received the proper Operations Specification (OpSpec).

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Why It’s Important This change would provide increased operational flexibility to Part 135 operators. Major Provisions Current Lower Than Standard Authority Limited to U.S. Many operators have received lower than standard authority via OpSpec C079. However, that authority is limited to airports within the United States. The language currently at § 135.225 (f) limits operations to standard takeoff minimums at military airports and airports outside the United States. The authority of OpSpec C079 does not supersede the regulatory restriction of § 135.225 (f). By making the change to § 135.225 (f), the FAA will be able to allow Part 135 operators who have obtained OpSpec C079 to use that authority at military and foreign airports. The direct final rule recognizes that changing § 135.225 (f) to allow the FAA to grant authority for lower than standard minimum takeoffs outside the United States would align Part 135 regulations with Parts 91 and 121, as both of those operating rules permit the activity when authorized by the agency. The specific change to § 135.225 (f) is the inclusion of the phrase, “unless authorized by the certificate holder’s operations specifications.” About a “Direct Final Rule” Previously, the FAA granted an exemption that permitted operators holding OpSpec C079 to use that authority internationally. Because that exemption received no negative comment and because the FAA feels that there is no compromise in safety by making this change, they have issued the regulatory change as a direct final rule. If the FAA receives negative comments on this change, it would require the FAA then to conduct the traditional rulemaking with a notice and comment period prior to a final rule. NATA Position NATA applauds the FAA’s action on this matter and encourages members to submit comments supporting the change to the FAA. Such comments should be submitted on or before February 10, 2012. Status Assuming no negative comments to the rule are received, the revised rule will take effect on February 27, 2012. Download the direct final rule as published in the Federal Register on January 11, 2012. NATA LAUNCHES GROUND-BREAKING FBO AUDIT STANDARD The National Air Transportation Association (NATA) is pleased to present a ground-breaking audit standard specifically for FBOs. NATA established the NATA Safety 1st Ground Audit Standard to promote industry best practices and Safety Management Systems (SMS) development among ground handling providers in response to member requests for a safety

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standard and rating for FBOs. This audit standard is the first published audit for FBOs and other ground-handling service providers. "NATA members expressed concern that their companies are subject to numerous audits by charter operators, fractional ownership program managers and many other consumers," said NATA Safety 1st Program Manager Elizabeth Nicholson. "The preparation and hosting of these audits drains both staff time and resources to accommodate the various audits, which range in complexity from completing and returning an electronic self-audit form to a multi-day on-site audit. The requirements of the auditing companies vary greatly, making preparation for the audits a year-round necessity." NATA's Safety & Security Committee, which includes representatives from large and small FBOs, on-demand charter operators, fractional program managers, insurance brokers, fuel companies, and more, was instrumental in drafting this important new audit standard. Objectives of the NATA Safety 1st Ground Audit Standard:

• Achieve a standardized and consistent audit product acceptable to on-demand air charter operators, business aircraft operators, and other ground handling facility users

• Develop a program similar in concept to that currently utilized by airline ground handling facilities • Follow an ISO-compliant format • Create one audit standard to satisfy operators, customers, and others by including:

• Best practices • Safety Management Systems (FAA and ICAO standards • Regulatory compliance (TSA, EPA, and OSHA)

• Eliminate the need for multiple audits from numerous aircraft operators by providing consistent audits • Maintain online registry to confirm successful completion

"NATA Safety 1st is the industry-known leader in FBO safety and training programs. It became clear to us that a single standard for FBOs could eliminate the burden of multiple audits and raise the standard of safety throughout the FBO industry," said NATA President and CEO James K. Coyne. Find out more about NATA's Safety 1st Ground Audit by visiting www.nata.aero/groundaudit.

NATA LAUNCHES STATE ADVOCACY PROGRAM

The National Air Transportation Association (NATA) has launched a new State Advocacy Network (SAN) consisting of association members in every state who will serve as liaisons between member businesses, state legislatures, and the association. "General aviation businesses are confronted with issues that require prompt attention, including airport and land use, security, taxation, aircraft noise and emissions," stated NATA President and CEO James K. Coyne. "Identifying pertinent

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legislation and regulations ahead of their implementation in every state throughout this county is one of the greatest challenges we face as an industry." NATA’s SAN comprises volunteers who act as representatives to keep each other and the association informed of pressing issues in their states. "NATA members are active participants in their states and local communities and as SAN volunteers their expertise and knowledge of issues affecting the industry are invaluable," concluded Coyne. "Staying informed of issues effecting aviation businesses throughout the country is vital to promoting the interests of our members as well as to defeating unwarranted policies." For more information on the State Advocacy Network and how you can get involved, please visit www.nata.aero/SAN.

FAA PUBLISHES FINAL RULE ON PILOT FATIGUE

NATA Note: This rule applies to Part 121 operations only. However, the FAA has suggested an upcoming Part 135 rule could closely mirror this one.

U.S. Transportation Secretary Ray LaHood and Federal Aviation Administration (FAA) Acting Administrator Michael Huerta recently announced a sweeping final rule that overhauls commercial passenger airline pilot scheduling to ensure pilots have a longer opportunity for rest before they enter the cockpit.

“This is a major safety achievement,” said Secretary LaHood. “We made a promise to the traveling public that we would do everything possible to make sure pilots are rested when they get in the cockpit. This new rule raises the safety bar to prevent fatigue.”

“Every pilot has a personal responsibility to arrive at work fit for duty. This new rule gives pilots enough time to get the rest they really need to safely get passengers to their destinations,” said FAA Acting Administrator Huerta.

The Department of Transportation identified the issue of pilot fatigue as a top priority during a 2009 airline Safety Call to Action following the crash of Colgan Air flight 3407. The FAA launched an aggressive effort to take advantage of the latest research on fatigue to create a new pilot flight, duty and rest proposal, which the agency issued on September 10, 2010.

Key components of this final rule for commercial passenger flights include:

Varying flight and duty requirements based on what time the pilot’s day begins. The new rule incorporates the latest fatigue science to set different requirements for pilot flight time, duty period and rest based on the time of day pilots begin their first flight, the number of scheduled flight segments and the number of time zones they cross. The previous rules included different rest requirements for domestic, international and unscheduled flights. Those differences were

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not necessarily consistent across different types of passenger flights, and did not take into account factors such as start time and time zone crossings.

Flight duty period. The allowable length of a flight duty period depends on when the pilot’s day begins and the number of flight segments he or she is expected to fly, and ranges from 9-14 hours for single crew operations. The flight duty period begins when a flight crew member is required to report for duty, with the intention of conducting a flight and ends when the aircraft is parked after the last flight. It includes the period of time before a flight or between flights that a pilot is working without an intervening rest period. Flight duty includes deadhead transportation, training in an aircraft or flight simulator, and airport standby or reserve duty if these tasks occur before a flight or between flights without an intervening required rest period.

Flight time limits of eight or nine hours. The FAA limits flight time – when the plane is moving under its own power before, during or after flight – to eight or nine hours depending on the start time of the pilot’s entire flight duty period.

10-hour minimum rest period. The rule sets a 10-hour minimum rest period prior to the flight duty period, a two-hour increase over the old rules. The new rule also mandates that a pilot must have an opportunity for eight hours of uninterrupted sleep within the 10-hour rest period.

New cumulative flight duty and flight time limits. The new rule addresses potential cumulative fatigue by placing weekly and 28-day limits on the amount of time a pilot may be assigned any type of flight duty. The rule also places 28-day and annual limits on actual flight time. It also requires that pilots have at least 30 consecutive hours free from duty on a weekly basis, a 25 percent increase over the old rules.

Fitness for duty. The FAA expects pilots and airlines to take joint responsibility when considering if a pilot is fit for duty, including fatigue resulting from pre-duty activities such as commuting. At the beginning of each flight segment, a pilot is required to affirmatively state his or her fitness for duty. If a pilot reports he or she is fatigued and unfit for duty, the airline must remove that pilot from duty immediately.

Fatigue Risk Management System. An airline may develop an alternative way of mitigating fatigue based on science and using data that must be validated by the FAA and continuously monitored.

In 2010, Congress mandated a Fatigue Risk Management Plan (FRMP) for all airlines and they have developed these plans based on FAA guidance materials. An FRMP provides education for pilots and airlines to help address the effects of fatigue which can be caused by overwork, commuting, or other activities. Airlines will be required to train pilots about the potential effects of commuting.

Required training updates every two years will include fatigue mitigation measures, sleep fundamentals and the impact to a pilot’s performance. The training will also address how fatigue is influenced by lifestyle – including nutrition, exercise, and family life – as well as by sleep disorders and the impact of commuting.

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The estimated cost of this rule to the aviation industry is $297 million but the benefits are estimated between $247- $470 million. Covering cargo operators under the new rule would be too costly compared to the benefits generated in this portion of the industry. Some cargo airlines already have improved rest facilities for pilots to use while cargo is loaded and unloaded during night time operations. The FAA encourages cargo operators to opt into the new rule voluntarily, which would require them to comply with all of its provisions.

The final rule has been sent to the Federal Register for display and publication. It is currently available at: http://www.faa.gov/regulations_policies/rulemaking/recently_published/media/2120-AJ58-FinalRule.pdf, and will take effect in two years to allow commercial passenger airline operators time to transition.

A fact sheet with additional information is at http://www.faa.gov/news/fact_sheets/.

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NTSB CITES ATC ERROR AS PROBABLE CAUSE OF NEAR MID-AIR COLLISION OVER GULFPORT-BILOXI

INTERNATIONAL AIRPORT

Today the NTSB cited an operational error by a tower air traffic controller as the probable cause of a near mid-air collision involving a commercial jetliner and a small private plane over the Gulfport-Biloxi airport. On Sunday, June 19, 2011, at 12:35 p.m. CDT at Gulfport-Biloxi International Airport, a Cessna 172 was cleared for takeoff on runway 18 by the tower air traffic controller. Sixteen seconds later, the same air traffic controller cleared an Embraer 145, a commercial passenger flight, for takeoff on runway 14, the flight path of which intersects the flight path of runway 18. While both airplanes were about 300 feet above the airfield, the Embraer passed in front of the Cessna. The closest proximity between the two planes was estimated to be 0 feet vertically and 300 feet laterally. The Embraer 145, operated as ExpressJet flight 2555 (dba Continental/United Express) was carrying 50 passengers and 3 crewmembers, and was bound for Houston Bush Intercontinental Airport (IAH) where it landed uneventfully. No one in either airplane was injured in the incident. In May 2010, the NTSB held a forum to highlight the importance of developing and reinforcing the highest standards of professionalism in aviation (http://go.usa.gov/RmM). The issue area of pilot and air traffic controller professionalism was added to the NTSB's Most Wanted List of Safety Improvements in May 2011: http://go.usa.gov/Rmn. The complete incident report is available at http://go.usa.gov/REE. The accident docket, which contains statements from the pilots, the airport diagram, and other investigation related documents, is available at http://go.usa.gov/RHv.

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STATEMENT FROM NTSB CHAIRMAN DEBORAH A.P. HERSMAN ON NEW FAA FLIGHT AND DUTY TIME

RULE

Fatigue has been on the NTSB's Most Wanted List of transportation safety improvements since 1990. Over the first century of powered flight, countless accidents trace pilot fatigue as a contributing factor. This is why the NTSB is so pleased that the FAA today issued a long-awaited science-based rule for flight and duty time. Secretary LaHood and former FAA Administrator Babbitt have worked for years to shepherd this contentious rule through the process. We applaud the leadership of DOT and FAA for bringing it across the finish line. While this is not a perfect rule, it is a huge improvement over the status quo for large passenger-carrying operations. Yet, we are extremely disappointed that the new rule is limited to Part 121 carriers. A tired pilot is a tired pilot, whether there are 10 paying customers on board or 100, whether the payload is passengers or pallets. As the FAA said in its draft, "Fatigue threatens aviation safety because it increases the risk of pilot error that could lead to an accident." This is particularly a concern for crews that fly "on the back side of the clock." We look forward to working with the FAA and the aviation community to support the rule's essential education and training components and to identify areas where additional measures are needed.

NTSB ISSUES LANDING DISTANCE RECOMMENDATIONS TO FAA AFTER AMERICAN AIRLINES RUNWAY

OVERRUN On December 22, 2009, about 22:22 eastern standard time, American Airlines flight 331, a Boeing 737-800, N977AN, ran off the departure end of runway 12 after landing at Norman Manley International Airport (KIN) Kingston, Jamaica. The aircraft landed approximately 4,000 feet down the 8,911-foot-long, wet runway with a 14-knot tailwind component and was unable to stop on the remaining runway length. After running off the runway end, it went through a fence, across a road, and came to a stop on the sand dunes and rocks above the waterline of the Caribbean Sea adjacent to the road. No fatalities or post crash fire occurred. Eighty-five of the 154 occupants (148 passengers, 4 flight attendants, and 2 pilots) received injuries ranging from minor to serious. The airplane was substantially damaged. Instrument meteorological conditions and heavy rains prevailed at the time of the accident flight, which originated at Miami, Florida, on an instrument flight rules flight plan.

During flight 331’s approach to KIN, air traffic control (ATC) advised the flight crew that it may be necessary to circle to land on runway 30 and indicated a wind from 320º at 10 knots. The flight crewmembers acknowledged the wind information and informed ATC of their intent to do a straight-in approach to runway 12. The KIN tower then indicated a wind direction of 320º at 14 knots and asked if the flight crew still wanted to land on runway 12. The flight crew confirmed runway 12, and the tower then advised that the runway was wet. The flight crew configured the airplane to

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land with a flap setting of 30º rather than the full flap setting of 40º. Both flight crewmembers later reported that they felt the airplane float prior to touchdown. Neither pilot called for a go-around at any point during the approach and landing.

Available information indicated that, at the time of departure from Miami, flight 331 was properly dispatched (according to the requirements of 14 CFR 121.195) to runway 12 at KIN based on “wet/good” runway conditions at an estimated landing weight of 143,900 pounds and assuming no tailwind. However, weather conditions upon arrival at KIN had deteriorated since the flight’s departure. Both crewmembers stated during post-accident interviews that they had landed at KIN many times and did not perform an arrival landing distance assessment to runway 12, even after ATC provided wind information that indicated tailwind conditions were present for that runway. The American Airlines 737 Operating Manual directs that an arrival landing distance assessment be performed if landing conditions change after departure, taking into consideration meteorological and runway surface conditions, among other factors.

In the last 10 years, many aviation safety organizations have studied runway overruns involving transport-category airplanes to identify high risk factors that lead to overruns and strategies to mitigate risks. A common finding is that the risk of an overrun is greatly increased when landings are conducted on contaminated runways in tailwind conditions. Any tailwind increases the approach and touchdown groundspeed of an aircraft, requiring more runway length to decelerate. This factor can be critical where poor runway conditions exist or where the required runway length for landing is close to the available runway length. Accordingly, the NTSB’s investigations of several runway overrun accidents and resultant recommendations have focused on runway surface conditions and a lack of required arrival landing distance assessments; however, the accident involving American Airlines flight 331 highlights deficiencies in operational procedures and flight crew training and guidance concerning landing in tailwind conditions that should be addressed.

Training and Guidance in Mitigating the Risk of Runway Overruns

The 2009 Flight Safety Foundation publication Reducing the Risk of Runway Excursions provides prevention strategies for flight operations departments to implement as a means of addressing risk factors associated with runway overruns, including ensuring flight crews understand “that landing with a tailwind on a contaminated runway is not recommended.” This publication also recommends that operators “define and train procedures for…[g]o-around, including during flare and after touchdown.” At the time of the accident, American Airlines had a no-fault go-around policy in place that was documented in the American Airlines Flight Manual. The policy states, in part, that it exists in recognition that “a successful approach can end in a missed approach” and that “if in the pilot’s judgment a safe landing cannot be accomplished within the touchdown zone, or the aircraft cannot be stopped within the confines of the runway, a go-around is…required.”

Advisory Circular (AC) 91-79, “Runway Overrun Prevention,” also provides a means for pilots and operators of turbine-powered airplanes to identify, understand, and mitigate risks associated with runway overruns during the landing phase of flight, including detailed information that may be used to develop company standard operating procedures to mitigate those risks. As a risk mitigation, the AC indicates that operators’ standard operating procedures should address when to

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execute a go-around, but the AC does not discuss the increased risk of runway overrun during a landing in tailwind conditions or the associated mitigation strategies to prevent runway overruns while landing with a tailwind, such as fully extending flaps or being prepared to go around.

To ensure sufficient runway length is available to stop, pilots must land their aircraft within the touchdown zone, which is a task made more challenging in tailwind conditions. Federal regulations concerning airline flight training requirements do not require that pilots receive training in conducting landings with a tailwind. The 737-800 fleet training manager for American Airlines indicated during an interview that the company does not provide training for tailwind landings but does provide training for landings at higher elevations because “there was no difference between a high altitude landing versus a tailwind landing as there was a higher speed” associated with both. He also stated that he could not identify a benefit for training in tailwind landings.

The flight crew of flight 331 stated during post-accident interviews that they had landed with a tailwind before but had not received any training on conducting landings in tailwind conditions. American Airlines line pilots also reported that they do not receive training on tailwind landings during simulator or flight training nor do they receive guidance (including mitigation strategies) about the runway overrun risks associated with tailwind landings. The American Airlines Boeing 737 Operating Manual contains no restriction (beyond the airplane limitation) for a tailwind landing on a wet or contaminated runway, and landing with full flaps is only recommended. Several line pilots stated that the first time they had ever conducted a tailwind landing was during line operations. The NTSB believes pilots should be knowledgeable about the effects of a tailwind on the landing performance of their aircraft and should be trained on specific procedures and techniques associated with conducting tailwind landings, with the aim of reducing the risk of a runway overrun. While it may not be possible to train flight crews on tailwind landings in an actual airplane due to the variable dynamics of weather and ATC restrictions, an airline may train flight crews on tailwind landings in a full-motion flight simulator. With the availability of advanced simulation and technology, most flight training for airline pilots is accomplished in flight simulation training devices as allowed by 14 CFR Parts 121 and 135.

The NTSB concludes that providing pilots training in tailwind landings would improve pilots’ preparation in mitigating the risk of runway overruns while landing in tailwind conditions. Therefore, the NTSB recommends that the Federal Aviation Administration (FAA) require principal operations inspectors (POI) to review flight crew training programs and manuals to ensure training in tailwind landings is (1) provided during initial and recurrent simulator training; (2) to the extent possible, conducted at the maximum tailwind component certified for the aircraft on which pilots are being trained; and (3) conducted with an emphasis on the importance of landing within the touchdown zone, being prepared to execute a go-around, with either pilot calling for it if at any point landing within the touchdown zone becomes unfeasible, and the related benefits of using maximum flap extension in tailwind conditions.

The NTSB also concludes that because the dynamics of a tailwind approach and landing, particularly on wet or contaminated runways, expose flight crews to additional risks and challenges, they should be provided current and comprehensive guidance regarding the risks associated with tailwind landings and made aware of the reduced margins of safety during tailwind landing operations. Therefore, the NTSB recommends that the FAA revise AC 91-79 “Runway

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Overrun Prevention” to include a discussion of the risks associated with tailwind landings, including tailwind landings on wet or contaminated runways as related to runway overrun prevention. Once AC 91-79 has been revised, the NTSB recommends that the FAA require POIs to review airline training programs and manuals to ensure they incorporate the revised guidelines concerning tailwind landings. Landing Distance Assessments

Although flight 331 was properly dispatched under the provisions of section 121.195(b) at the time of departure, the weather conditions upon arrival at KIN (heavy rains and tailwind) had deteriorated, and the flight crew did not perform an arrival landing distance assessment for runway 12 as provided in the American Airlines 737 Operating Manual. As noted in Flight Safety Foundation Approach and Landing Accident Reduction (ALAR) Briefing Note 8.1, a factor in runway overruns is worse-than-anticipated runway conditions. Had the flight crew performed an arrival landing distance assessment, the pilots would have determined, based on American Airlines landing distance charts, that the airplane was capable of landing within the available runway length with a 30º flap setting and 14-knot tailwind; however, the arrival landing distance assessment also would have alerted the pilots that the stopping margin under these conditions was reduced, which may have prompted them to consider overrun risk mitigation strategies, such as using full flaps and maximum manual braking, selecting a different runway, considering a go-around, or choosing to divert.

Because the performance effects of a tailwind on landing distance are not taken into account for dispatch purposes, flight crews would be better prepared to employ runway overrun risk mitigation strategies if they had a full understanding of the performance issues associated with a tailwind landing on a particular runway. A reliable way for flight crews to assess aircraft performance in actual wind conditions before landing is the required performance of a landing distance assessment before every arrival.

Following its investigation of the runway overrun accident involving Southwest Airlines flight 1248, the NTSB issued Safety Recommendation A-07-61 on October 2, 2007, which asked the FAA to do the following:

Require all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to accomplish arrival landing distance assessments before every landing based on a standardized methodology involving approved performance data, actual arrival conditions, a means of correlating the airplane’s braking ability with runway surface conditions using the most conservative interpretation available, and including a minimum safety margin of 15 percent.

In its most recent response (dated August 23, 2010) concerning this recommendation, the FAA stated that it was evaluating recommendations provided by the Take Off and Landing Performance Assessment (TALPA) Aviation Rulemaking Committee (ARC) and intended to initiate rulemaking in 2011. The FAA also stated that, in the interim, it was validating the accuracy and usability of the ARC-developed runway surface condition reporting matrix, which forms the foundation for many of the TALPA recommendations, and continuing to encourage operators to incorporate the safety elements contained in Safety Alert for Operators 0601216 pending the completion of the rulemaking process. The

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FAA stated that it would provide an updated response by January 2011. Safety Recommendation A-07-61 is classified “Open—Acceptable Response.”

Although the FAA published SAFO 06012 with the intent of pursuing rulemaking that addresses landing distance assessments, in the interim, operators are still not required to comply with its recommendations and currently many operators do not.17 During post-accident interviews, the American Airlines 737-800 aircrew program manager stated that he was not familiar with the operational aspects of SAFO 06012, and an American Airlines ground instructor stated that the airline did not provide instructors and check airmen with SAFO information that would benefit pilots' decision-making when considering overrun prevention.

The NTSB is concerned that, because of operational and conditional variations that may include a tailwind landing upon arrival at the destination, it is possible for an airplane to use more of the landing runway than predicted during preflight (dispatch) calculations and for pilots to continue to overrun runways while landing. As the FAA concluded in SAFO 06012, operator compliance with preflight landing distance planning requirements alone “does not ensure that the airplane can safely land within the distance available on the runway in the conditions that exist at the time of arrival, particularly if the runway, runway surface condition, meteorological conditions, airplane configuration, airplane weight, or use of airplane ground deceleration devices is different than that used in the preflight calculation.” The FAA continues to rely on operators’ voluntary compliance with SAFO 06012 but, as demonstrated by statements provided by American Airlines personnel, the SAFO is not being consistently disseminated or implemented. The NTSB concludes that, until rulemaking requiring the performance of arrival landing distance assessments is complete, the FAA needs to ensure that operators distribute the information in SAFO 06012 to the necessary personnel. Therefore, the NTSB recommends that the FAA require POIs to ensure that the information contained in SAFO 06012 is disseminated to Part 121, 135, and 91 subpart K instructors, check airmen, and aircrew program designees and they make pilots aware of this guidance during recurrent training.

The NTSB did not receive an update in January 2011 on the status of the rulemaking as stated in the FAA’s August 2010 response concerning Safety Recommendation A-07-61. If implemented as recommended, this rulemaking would require Part 121, 135, and 91 subpart K flight crews to perform arrival landing distance assessments for the specific runway of intended landing, including operations conducted in tailwind conditions. More than 4 years after this recommendation was issued, the continued lack of this requirement greatly reduces the likelihood that flight crews will make fully informed decisions about the performance capabilities of their aircraft prior to landing, particularly on wet or contaminated runways, and, under such circumstances, increases the risk of a runway overrun. Therefore, the NTSB reiterates Safety Recommendation A-07-61 and reclassifies it “Open—Unacceptable Response.”

Therefore, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration:

Require principal operations inspectors to review flight crew training programs and manuals to ensure training in tailwind landings is (1) provided during initial and recurrent simulator training; (2) to the

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extent possible, conducted at the maximum tailwind component certified for the aircraft on which pilots are being trained; and (3) conducted with an emphasis on the importance of landing within the touchdown zone, being prepared to execute a go-around, with either pilot calling for it if at any point landing within the touchdown zone becomes unfeasible, and the related benefits of using maximum flap extension in tailwind conditions. (A-11-92)

Revise Advisory Circular 91-79, “Runway Overrun Prevention,” to include a discussion of the risks associated with tailwind landings, including tailwind landings on wet or contaminated runways as related to runway overrun prevention. (A-11-93)

Once Advisory Circular 91-79, “Runway Overrun Prevention,” has been revised, require principal operations inspectors to review airline training programs and manuals to ensure they incorporate the revised guidelines concerning tailwind landings. (A-11-94)

Require principal operations inspectors to ensure that the information contained in Safety Alert for Operators 06012 is disseminated to 14 Code of Federal Regulations Part 121, 135, and 91 subpart K instructors, check airmen, and aircrew program designees and they make pilots aware of this guidance during recurrent training. (A-11-95)

The National Transportation Safety Board also reiterates the following recommendation to the Federal Aviation Administration and reclassifies it “Open—Unacceptable Response”:

Require all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to accomplish arrival landing distance assessments before every landing based on a standardized methodology involving approved performance data, actual arrival conditions, a means of correlating the airplane’s braking ability with runway surface conditions using the most conservative interpretation available, and including a minimum safety margin of 15 percent. (A-07-61)

In response to the recommendations in this letter, please refer to Safety Recommendations A-11-92 through -95 and A-07-61. If you would like to submit your response electronically rather than in hard copy, you may send it to the following e-mail address: correspondence@ntsb.gov. If your response includes attachments that exceed 5 megabytes, please e-mail us asking for instructions on how to use our secure mailbox. To avoid confusion, please use only one method of submission (that is, do not submit both an electronic copy and a hard copy of the same response letter). Chairman HERSMAN, Vice Chairman HART, and Members SUMWALT, ROSEKIND, and WEENER concurred in these recommendations.

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Information for Operators (InFO) Each issue of the NATA Safety 1st Flitebag includes a review of the latest InFOs. If you have not read previous issues, please review all InFOs by clicking here.

An InFO contains valuable information for operators that should help them meet certain administrative, regulator or operational requirements with relatively low urgency or impact on safety. InFOs contain information or a combination of information and recommended action to be taken by the respective operators identified in each individual InFO. Number Title

11019 (PDF) Air Carrier Safety and Pilot Training (ACSPT) Aviation Rulemaking Committee (ARC) Charter and Report

12001 (PDF) Flight Planning Responsibilities When Conducting Reduced Vertical Separation Minimum (RVSM) Operations

12002 (PDF) Category I (CAT I) 1800 Runway Visual Range (RVR), Special Authorization Category I (SA CAT I) and Special Authorization Category II (SA CAT II) Instrument Landing System (ILS) Approaches

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Safety Alert for Operators (SAFOs) Each issue of the NATA Safety 1st Flitebag includes a review of the latest SAFOs. If you have not read previous issues, please review all SAFOs by clicking here. What is a SAFO? A SAFO contains important safety information and may include recommended action. SAFO content should be especially valuable to air carriers in meeting their statutory duty to provide service with the highest possible degree of safety in the public interest. Number Title

11010 (PDF) TCAS II Guidance and Training for 14 CFR Part 135 & Part 125 Certificate Holders, Part 125 Letter of Deviation Authority (LODA) holders (125M), Part 91 Subpart K (91K) Program Managers, Part 91 Operators and Part 142 Training Centers

11011 (PDF) Runway Excursions at Jackson Hole Airport (JAC)

11011 SUP (PDF) SUP: Runway Excursions at Jackson Hole Airport (JAC)

12001 (PDF) Cessna CE-560XL Tailcone Stinger Drains

The National Air Transportation Association (NATA), The Voice of Aviation Business, is committed to raising the standard on air safety and implemented additional guidance through NATA’s Safety 1st Management System (SMS) for Air Operators. The Flitebag provides continuing education in support of the SMS program. Subscribe to the NATA Safety 1st Flitebag. If you are not currently a subscriber to NATA Safety 1st Flitebag and would like to receive it on a regular basis, please email Safety1st@nata.aero. The NATA Safety 1st Flitebag is distributed free of charge to NATA member companies and NATA Safety 1st participants.