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NTSB · Safety Recommendation

Safety Recommendation A-07-035

Recommendation

TO THE FEDERAL AVIATION ADMINISTRATION: Require, for all aircraft required to have a traffic alert and collision avoidance system (TCAS) installed and for existing and future system designs, that the airborne loss of collision avoidance system functionality, for any reason, provide an enhanced aural and visual warning requiring pilot acknowledgment.

Safety Issue and Context

On September 29, 2006, about 1657 Brasilia standard time,1 a Boeing 737-800 (PR-GTD) operated by Gol Airlines of Brazil and an Embraer Legacy 600 business jet (N600XL) owned and operated by Excelaire of Long Island, New York, collided in flight over the Amazon jungle approximately 100 nautical miles (nm)2 southeast of Cachimbo Air Base, Brazil. The Boeing 737 was destroyed by in-flight breakup and impact forces; all 154 occupants were killed. The Embraer Legacy sustained damage to the left wing and left horizontal stabilizer, and the flight crew subsequently performed an emergency landing at Cachimbo Air Base.

The two crew members and five passengers were not injured, and there was no further damage to the airplane. The Boeing 737 was operating as a scheduled domestic air carrier flight on an instrument flight rules (IFR) flight plan; the Embraer Legacy was operating under 14 Code of Federal Regulations (CFR) Part 91 and was also on an IFR flight plan. Visual meteorological conditions prevailed in the area at the time of the accident.

Response History

February 17, 2026 · NTSB Correspondence · FAA

From the Aviation Investigation Report AIR-26-02, “Midair Collision over the Potomac River PSA Airlines Flight 5342, Mitsubishi Heavy Industries (MHI) RJ Aviation CL-600-2C10 (CRJ700), and US Army Priority Air Transport Flight 25, Sikorsky UH-60L Washington, DC January 29, 2025”

1.15.3 ADS-B The NTSB also has a long history of supporting the use of technologies, such as ADS-B, that provide identification and location information for aircraft due to the ability of these technologies to improve safety. Between 2006 and 2007, we recommended requirements for equipment that could provide increased aircraft identification, location, and communication capabilities for aircraft operations in the Gulf of America and remote areas of Hawaii and Alaska, with the intent of enhancing flight location, collision avoidance, and weather information services for these operations (see Safety Recommendations A-06-21 and -22, and A-07-025 and -26; NTSB, 2006; NTSB, 2007a).

Following the 2006 midair collision involving a business jet and a transport category airplane over Brazil that claimed 154 lives, we recommended requirements for equipment that could provide pilots with enhanced alerts regarding the status of transponder and traffic collision avoidance capabilities (Safety Recommendations A 07-35 through -37; NTSB, 2007b).

Following the 2007 fatal midair collision of two news-gathering helicopters over Phoenix, Arizona, the NTSB sought to enhance the traffic-avoidance logic for helicopters’ onboard equipment by recommending the development of standards and requirements for the incorporation of specific criteria for the types of maneuvers and environments unique to helicopters (Safety Recommendations A 09 4 and -5, superseded by Safety Recommendations A 10 127 and -128; NTSB 2009; NTSB, 2010).

In an October 2007 notice of proposed rulemaking to require ADS B Out, the FAA stated that it did not plan to also require ADS-B In capability because ADS-B In “has not been identified as a requirement for maintaining the safety and efficiency of NAS operations.” In a letter dated February 14, 2008, in response to this notice of proposed rulemaking, the NTSB expressed our belief that this assessment was incorrect and stated that equipping aircraft with ADS-B In capability would “provide an immediate and substantial contribution to safety,” especially near airports.

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Recommendation Facts

Status
Closed - Acceptable Alternate Action
Issued
May 2, 2007
Priority
CLASS II
Recipient
FAA
Adopted
April 25, 2007
Closed
September 18, 2018
Related Investigation
DCA06RA076AB
Related Report
None
The NTSB further stated in our response to the FAA’s proposed rule that “the FAA's failure to expedite the adoption of full ADS-B capability (both ADS-B In and ADS-B Out) would be unfortunate and would result in missing or unnecessarily delaying an opportunity to remedy a serious and notorious safety issue” (NTSB, 2008).

The FAA Modernization and Reform Act of 2012 required the FAA to identify the type of avionics required for all classes of airspace. It also specifically required the FAA to initiate rulemaking to require aircraft operating in capacity-constrained airspace, at capacity-constrained airports, or in “any other airspace deemed appropriate by the administrator” be equipped with ADS-B In technology by 2020. An aviation rulemaking committee chartered in April 2012 recommended that the FAA focus on the development of key ADS-B In applications, including airborne traffic awareness systems, that would provide benefits to operators.

In 2014, the FAA developed a rulemaking action plan to issue a notice of proposed rulemaking by 2018 and a final rule in 2022.

In 2014, an RTCA committee chartered by the FAA completed the development of standards for ADS-B-supported aircraft surveillance applications, DO-317B (RTCA, 2014). However, the FAA Reauthorization Act of 2018 repealed the requirement that the FAA initiate rulemaking to require ADS-B In technology and instead directed the FAA to ensure that any regulations resulting from that rulemaking had no effect. Because the FAA had not yet issued any regulations, no action was required to change any regulations.

In May 2021, the NTSB issued several safety recommendations (A-21-15 through -17) regarding ADS B following the investigation into a midair collision between two air tour airplanes in Ketchikan, Alaska, in 2019 (NTSB, 2021a). Safety Recommendation A 21-15 asked the FAA to identify areas with a high concentration of air tour traffic and to require that 14 CFR Parts 91 and 135 air tour operators who operate within those areas be equipped with an ADS-B Out- and In-supported traffic advisory system that includes visual and aural alerts.

Safety Recommendation A-21-16 asked that the FAA require that all non-air tour aircraft operating within the airspace identified as a high traffic tour area in Safety Recommendation A-21-15 be equipped with ADS-B Out. Safety Recommendation A-21-17 asked that the FAA require the installation of ADS-B Out and In supported airborne traffic advisory systems that include aural alerting functions in all aircraft conducting operations under 14 CFR Part 135.

In a July 2021 response, the FAA requested a meeting with NTSB staff to further clarify the intent of the recommendations. However, as noted in NTSB correspondence dated February 4, 2022, when the NTSB attempted to schedule this meeting, FAA staff stated that a meeting was no longer necessary. In May 2022, the NTSB reiterated Safety Recommendation A-21-15 in our report on the fatal helicopter air tour accident that occurred in Kekaha, Hawaii, in December 2019 (NTSB, 2022).

In correspondence dated June 26, 2023, the FAA stated that its Air Traffic and Aviation Safety Organizations met to discuss the NTSB recommendations and determined that the agency’s current ADS-B requirements adequately addressed the needs of aviation safety and it would not pursue additional requirements. The FAA stated that its current guidance and requirements were sufficient to meet the intent of the recommendations. In addition, the FAA stated that the previously requested meeting with NTSB staff was no longer needed.

In an October 24, 2023, follow-up letter regarding Safety Recommendation A 21-17, the NTSB emphasized that the absence of an ADS-B In requirement for Part 135 passenger-carrying operations fails to take advantage of the demonstrated safety benefit of ADS-B In traffic awareness and alerting and is inconsistent with the “appropriate level of public safety” the FAA itself expects for operations in which passengers bear no responsibility for the aircraft’s operation (NTSB, 2023).

In its most recent response to Recommendation A-21-15, on November 6, 2024, the FAA repeated that current ADS-B requirements continue to adequately address the needs of aviation safety and that it would not pursue additional ADS B operator requirements at this time (FAA, 2024f). During the investigative hearing for the DCA midair collision, however, the FAA ATO’s acting deputy COO stated that the agency supported requiring newly manufactured aircraft in the United States be equipped with ADS-B In. He also stated that the agency supported requiring the installation and operation of ADS-B In for aircraft operating in airspace where they are required to transmit ADS B Out.

February 25, 2020 · NTSB Correspondence · FAA

The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) notice of proposed rulemaking (NPRM) titled, “Remote Identification of Unmanned Aircraft Systems,” which was published at 84 Federal Register 72438 on December 31, 2019. We welcome the opportunity to provide comments on this NPRM, which the FAA has identified as an important step in safely integrating unmanned aircraft (or drones, as defined in the NPRM) into the national airspace system (NAS).

The FAA stated that remote identification (remote ID) for unmanned aircraft systems (UAS), which includes location information for both the unmanned aircraft and the ground control station, is a necessary milestone for supporting expanded operations, such as those involving cargo delivery, flights over people, and flights beyond visual line of sight. The NTSB has a long history (dating back to 1969) of supporting the use of technologies that provide certain identification and location information for manned aircraft, based on the ability of these technologies to improve aviation safety.

Over the past few decades, we have issued numerous safety recommendations for the use of technologies to enable pilots, air traffic controllers, and other personnel (such as operators’ flight-followers) to maintain awareness of aircraft location, both in the NAS and in proximity to other aircraft. Thus, in the context of aviation safety, we support the general concept of remote ID for UAS. We offer our comments on the NPRM as a general concurrence with the concept as a milestone for enabling the safe integration of a wide variety of UAS operations into the NAS by supporting enhanced aeronautical services, such as collision avoidance and air traffic management.

For example, between 2006 and 2007, we recommended requirements for equipment that could provide increased aircraft identification, location, and communication capabilities for manned aircraft operations in the Gulf of Mexico and remote areas of Hawaii and Alaska, with the intent of enhancing flight location, collision avoidance, and weather information services for these operations (Safety Recommendations A-06-21 and -22 and A-07-25 and 26).

In addition, following the 2006 midair collision involving a business jet and a transport-category airplane over Brazil that claimed 154 lives, we recommended requirements for equipment that could provide pilots with enhanced alerts regarding the status of transponder and traffic collision-avoidance capabilities (Safety Recommendations A-07-35 through -37).

Following the 2007 fatal midair collision of two news-gathering helicopters over Phoenix, Arizona, the NTSB sought to enhance the traffic-avoidance logic for helicopters’ onboard equipment by recommending the development of standards and requirements for the incorporation of specific criteria for the types of maneuvers and environments unique to helicopters (Safety Recommendations A-09-4 and -5, superseded by A 10-127 and 128).

We have also gone on record as supporting the importance of aircraft identification and location equipment on unmanned aircraft following the crash of a Predator B in Nogales, Arizona, in 2006 (more information about this accident, NTSB case number CHI06MA121, is available at https://ntsb.gov/_layouts/ntsb.aviation/index.aspx).

For example, between 2006 and 2007, we recommended requirements for equipment that could provide increased aircraft identification, location, and communication capabilities for manned aircraft operations in the Gulf of Mexico and remote areas of Hawaii and Alaska, with the intent of enhancing flight location, collision avoidance, and weather information services for these operations (Safety Recommendations A-06-21 and -22 and A-07-25 and 26).

In addition, following the 2006 midair collision involving a business jet and a transport-category airplane over Brazil that claimed 154 lives, we recommended requirements for equipment that could provide pilots with enhanced alerts regarding the status of transponder and traffic collision-avoidance capabilities (Safety Recommendations A-07-35 through -37).

Following the 2007 fatal midair collision of two news-gathering helicopters over Phoenix, Arizona, the NTSB sought to enhance the traffic-avoidance logic for helicopters’ onboard equipment by recommending the development of standards and requirements for the incorporation of specific criteria for the types of maneuvers and environments unique to helicopters (Safety Recommendations A-09-4 and -5, superseded by A 10-127 and 128).

We have also gone on record as supporting the importance of aircraft identification and location equipment on unmanned aircraft following the crash of a Predator B in Nogales, Arizona, in 2006 (more information about this accident, NTSB case number CHI06MA121, is available at https://ntsb.gov/_layouts/ntsb.aviation/index.aspx).

September 18, 2018 · NTSB Correspondence · FAA

We previously said that your November 2, 2010, final rule revising Title 14 Code of Federal Regulations Part 25.1322, “Flightcrew Alerting,” satisfied this recommendation, but only for newly type certificated designs. Because this recommendation applies to both new and existing designs, we asked that you describe how you would address installations on existing designs of TCASs. We note that, based on a risk assessment you conducted, you concluded that mandating a retrofit for all existing TCAS and transponder systems as recommended is not warranted, and you do not plan to take this action.

Among the reasons that you reached this conclusion is that, on January 1, 2020, all operators will need to have installed new TCAS equipment in all of their airplanes to use Automatic Dependent Surveillance Broadcast (ADS-B).

We note that, on July 21, 2017, you issued Advisory Circular (AC) 20-151C, “Airworthiness Approval of Traffic Alert and Collision Avoidance Systems (TCAS II), Versions 7.0 & 7.1 and Associated Mode S Transponders.” This AC describes requirements that satisfy Safety Recommendation A-07-35. The January 1, 2020, implementation of ADS-B requires operators to adopt new and upgraded TCAS systems that meet the current guidance and to modify the installed TCAS equipment. This upgraded equipment will need to be compliant with the provisions of Part 25.1322 or with AC 20-151C.

We agree that the requirements associated with the ADS-B mandate, together with the requirements in Part 25.1322 and AC 20-151C, are an alternative that satisfies Safety Recommendation A-07-35, which is classified CLOSED--ACCEPTABLE ALTERNATE ACTION.

May 31, 2018 · Recipient Response · FAA

-From Daniel K. Elwell, Acting Administrator: In its letter dated March 6. 201 4, the Board noted that the revised § 25 .1 322. Flight crew Alerting, satisfied this recommendation for newly type certificated designs.

However. the Board asked the Federal Aviation Administration (FAA) to describe how we would address existing Traffic Alert and Collision Avoidance System (TCA ) installations. We conducted a risk assessment (enclosed) to determine whether extending the requirements for § 25.1322 to existing TCJ\S and transponder install at ions is justified. Such an action to raise the level of safety across the existing fleet would require rulemaking. This risk assessment considered the development and implementation of several improvements and technology advancements that reduce the risk associated with disabled or non functioning TCAS and transponder systems.

Based on this risk assessment, we concluded that mandating a retro fit for all existing TCAS and transponder systems to include an enhanced aural and visual warning requiring pilot acknowledgement is not warranted by the risk. Nor is this action necessary given the mitigations explored in the risk assessment. such as improvements to certification guidance and operational procedures. Of these mitigations, the FAA updated operator procedures ensuring transponders remain on during flight, and issued Advisory Circular (J\C) 20-1 51 C. Airworthiness Approval of Traffic Alert and Collision Avoidance Systems (TCAS 11), Versions 7.0 & 7. l and Associated Mode S Transponders on July 21. 20 17.

This AC provides additional flight crew alerting guidance for a transponder failure, a transponder in the standby mode. a TCAS failure, or TCAS in the standby mode. The AC requires annunciating these failures in yellow/amber in a pilot's primary field of view. and recommends an interface with the aircraft's master caution and warning system. This AC is available at the following Web site: http://www.faa.gov/documentLibrary/media/Advisory_Circular/AC_20-151 C.pdf.

Other mitigations will be fully realized with the January I, 2020, implementation of Automatic Dependent Surveillance Broadcast, operator adoption of new and upgraded TCAS systems meeting the current guidance, and modification of TCAS equipment as part of the FAA·s Next Generation Air Transportation System. These improvements will ultimately satisfy the safety issues identified by this recommendation with regard to the existing fleet, and continue to reduce the overall fleet exposure to this type of hazard without the need for a mandated change.

I believe that the FAA has effectively addressed this safety recommendation and consider our actions complete.

January 24, 2018 · NTSB Correspondence · FAA

The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) notice of proposed rulemaking (NPRM) titled, “Normal and Transport Category Rotorcraft Certification,” which was published at 82 Federal Register 50583 on November 1, 2017. The NPRM proposes to amend the certification standards of normal- and transport category helicopters. The proposed changes would reduce or eliminate the need for certain special conditions currently required to obtain certification of modern rotorcraft and would also incorporate the requirements of equivalent level of safety findings that the FAA has imposed as conditions for approving certain design features.

The FAA is proposing the changes to address modern designs currently used in the rotorcraft industry and to reduce the burden on applicants for certification of new rotorcraft designs. We have reviewed the NPRM and provide comments below regarding specific sections of this NPRM. Sections 27.1309 and 29.1309, “Equipment, systems, and installations.”

The NPRM proposes revisions to sections 27.1309 and 29.1309, which indicate design and installation criteria for equipment, systems, and installations to ensure that they perform their intended functions under any foreseeable operating condition. Regarding proposed subsection (c), which discusses a means to alert the crew in the event of a failure, we suggest including language to indicate that the alert should occur in a timely manner. In addition, we suggest adding language to indicate that an appropriate alert, including assessment of the need for multiple sensory modality warnings, must be provided if immediate pilot awareness and immediate or subsequent corrective action is required.

We note that we have previously issued recommendations to the FAA regarding the need for multiple sensory modality warnings (visual and aural) in both airplanes and helicopters. (For more information, see Safety Recommendations A-07-35, A-07-52, A-09-117, A-10-142, and A-10-143, which can be accessed from the Safety Recommendations page on our website (www.ntsb.gov).) For example, after a January 4, 2009, accident involving a dual-engine Sikorsky S-76C++ helicopter that departed controlled flight and crashed about 7 minutes after takeoff from Lake Palourde Base Heliport, Amelia, Louisiana, we issued Safety Recommendation A-10-144, which asked the FAA to do the following:

Revise [Title] 14 Code of Federal Regulations 27.33 and 29.33 to require an audible low rotor revolutions per minute alarm system and master warning light for all dual engine helicopters, even those that are equipped with a device that automatically increases power on the operating engine when the other engine fails.

On February 16, 2017, we classified this recommendation “Closed—Unacceptable Action” after the FAA indicated (in 2015) that it was anticipating restructuring airworthiness standards but did not take timely action to address this recommendation. Although this recommendation is closed, we believe the subject is still relevant, and, in its review of sections 27.1309 and 29.1309, the FAA should consider requiring applicants to address alerting through multiple sensory modalities (visual and aural or visual and tactile) to help ensure the timely capture and direction of a pilot’s attention to the condition triggering the alert.

March 6, 2014 · NTSB Correspondence · FAA

The FAA’s November 2, 2010, final rule revising 14 Code of Federal Regulations, Part 25.1322, “Flightcrew Alerting,” satisfies this recommendation, but only for newly type certificated designs. Because this recommendation applies to both new and existing designs, we request that you describe how you will address existing design TCAS installations. Pending our receipt of your reply, Safety Recommendation A-07-35 remains classified OPEN—ACCEPTABLE RESPONSE.

September 10, 2009 · NTSB Correspondence · FAA

Notation 8143: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) Notice of Proposed Rulemaking (NPRM) titled “Flightcrew Alerting,” which was published in 74 Federal Register 130 on July 9, 2009. The notice proposes to amend 14 Code of Federal Regulations (CFR) Part 25.1322, which addresses flight crew alerting for transport-category airplanes. According to the NPRM, the proposed revisions address regulations regarding definitions, prioritization, color requirements, and performance for flight crew alerting. The revisions would update the current regulations regarding the latest technology and functionality for flight crew alerting.

The revisions are necessary to add alerting functions and consolidate and standardize definitions and regulations for flight crew warning, caution, and advisory alerting systems. The revisions would also conform to European Aviation Safety Agency standards for flight crew warning, caution, and advisory alerting systems. The NTSB supports the proposed revisions to 14 CFR Part 25.1322. These revisions acknowledge the significant advances in technology and alerting capabilities of aircraft that have occurred since February 1977, when the rule was enacted.

The revisions are based on sound human factors principles and should help to ensure that alerting systems in newly certificated aircraft facilitate flight crew performance. A notable requirement among the proposed revisions is that redundant sensory cuing (such as aural and visual) be incorporated into alerts for conditions requiring immediate flight crew awareness. The NTSB recognizes the importance of providing salient cues through at least two different sensory systems and has issued safety recommendations as a result of accidents involving delayed flight crew awareness.

The NTSB notes that an important component to rulemaking for flight crew alerting will be the availability of comprehensive guidance to provide manufacturers and the FAA a means to ensure that the standards in the proposed revisions to 14 CFR Part 25.1322 are consistently applied. Such guidance should provide clear examples on how to comply with the new and revised requirements, especially for the requirement that all flight crew alerts, including warnings, cautions, and advisories, must conform with an alert prioritization hierarchy, which would inform flight crews of the urgency of each type of alert so that the crews could take actions on the most important ones first.

As stated in the NPRM, the FAA is preparing an advisory circular to provide guidance in this area, and the NTSB looks forward to commenting on a draft of the guidance. The FAA specifically requested comments on whether there was justification for applying the proposed rule differently for intrastate operations in Alaska because of Section 1205 of the FAA Reauthorization Act of 1996 (110 Stat. 3213). The NTSB believes that nothing contained in the proposed rulemaking justifies applying it differently for intrastate operations in Alaska. The NTSB appreciates the opportunity to comment on this proposed rule.

December 21, 2007 · NTSB Correspondence · FAA

The FAA stated that, other than the accident aircraft, it had no evidence of problems with TCAS’s being inadvertently turned off or to standby. The TCAS control panel used in EMB-135/-145 aircraft is installed in various locations in other aircraft and the FAA believes that, in these other locations, the design of the panel provides adequate protection against someone’s inadvertently switching the system to off or standby. The FAA also believes that the problem of inadvertently switching the TCAS to off or standby is unique to the EMB-135/-145 installation.

The FAA noted that the pilot footrest in the Legacy 600 is located adjacent to the control panel such that the aircraft transponder could be inadvertently set to standby while the pilot is utilizing the footrest. Doing so would disable the TCAS. As a result, the FAA believes that the proper course of action is to investigate fully the installation on the Legacy 600 aircraft and require corrective action as appropriate. The FAA will also review installations in other aircraft that use the same type of control panel to determine whether corrective action is needed.

The FAA indicated that, at this time, the FAA does not see the need to raise the level of alerting on all TCAS-equipped aircraft.

Additionally, the FAA plans to evaluate the general flight-deck-alerting philosophy concerning TCAS equipment to ensure that pilots have adequate notification of abnormal or unanticipated TCAS functionality. The FAA also plans to update its guidance material for the airworthiness of transponder and TCAS installations to provide more emphasis on the associated human factor considerations in particular, the design and placement of the controls and the possibility of inadvertent operation.

The FAA’s focus on what caused the TCAS to be in standby mode in the accident aircraft rather than the failure of the crew to notice for 55 minutes that the TCAS was not functional is not responsive to this recommendation. The Safety Board believes that the location of the footrest causing the system to inadvertently be placed into standby mode is one possible explanation, but is not the only method by which the system can inadvertently be placed into an unsafe mode (either off or standby).

During the investigation of the Brazilian accident, the FAA notified the Board of an incident that occurred in March 2007 in which a commercial flight entered U.S. airspace from Mexico with no transponder return or TCAS functionality enabled. Because this aircraft showed only a primary radar return without identification, the U.S. Air Force dispatched two F-16s to intercept the flight. According to the FAA, while in Mexican airspace, the flight had been given a new air traffic code. The flightcrew put the transponder into standby mode while changing the code and then forgot to return the transponder to operation.

The crew did not notice any warnings or cautions from their system indicating that it was in standby. After entering U.S. airspace, the flightcrew contacted air traffic control and only then became aware that their transponder was in standby mode.

The March 2007 incident provides an example of a situation in which a transponder was placed into standby mode, and the crew flew for some time unaware of this problem. This incident was not caused by careless placement of a flightcrew member’s foot inadvertently switching the system off or into standby mode. Although the FAA stated in its letter that, other than the aircraft involved in the accident in Brazil, it had no evidence of problems with TCAS’s being inadvertently turned off or to standby, the March 2007 incident is another instance of this problem.

The Safety Board respectfully points out that the FAA notified the Board about this incident, demonstrating that the FAA does in fact have evidence of at least one other problem in addition to r than the accident in Brazil.

When a pilot inadvertently fails to activate the transponder and the controller recognizes and notifies the pilot of this problem, in most instances, the pilot corrects the problem when notified; however, failure of a controller to provide a timely backup warning, or the failure of a foreign controller to provide a similar service, can have catastrophic results in the current airspace system. Although loss of a transponder can be detected by air traffic control in many circumstances, this is not a reliable method to ensure the integrity of the collision avoidance system because of normal limitations in radar or communication coverage.

For example, radar coverage is typically limited in remote areas, below certain altitudes, in oceanic airspace, and especially near nontowered fields. In addition, verbal warnings may not be timely because they depend on a controller’s noting and properly assessing the situation before making a two-way radio transmission, which is subject to coverage limitations, blocking, or misunderstanding.

While the Board recognizes the benefit of avoiding possible inadvertent placement of the transponder or TCAS into standby or off mode due to the location of the footrest, Safety Recommendation A-07-35 asks for enhanced aural and visual warnings requiring pilot acknowledgment when there is an airborne loss of collision avoidance system functionality for any reason. Therefore, FAA activities examining other aircraft installations in which placement of the control panel may cause inadvertent placement of the TCAS into standby or off modes are not relevant to this recommendation.

The FAA’s plans to evaluate the flight deck alerting philosophy associated with TCAS equipment is responsive to this recommendation, provided that it focuses on capturing the crew’s attention in-flight when the TCAS is not functional, rather than just installations in which placement of controls may increase the potential to inadvertently set the system to off or standby. Pending a requirement for all TCAS-equipped aircraft to provide appropriate visual and aural warnings to alert pilots when the TCAS system is not functioning for any reason in-flight, Safety Recommendation A-07-35 is classified OPEN -- ACCEPTABLE RESPONSE.

August 6, 2007 · Recipient Response · FAA

MC# 2070406: - From Marion C. Blakey, Administrator: Aside from the accident involving the Legacy 600 (EMB-L35bj), the Federal Aviation Administration has no objective evidence of problems associated with transponder/traffic alert and collision avoidance systems (TCAS) being inadvertently turned OFF (or to Standby). This type of control panel, which incorporates line select push-buttons, is installed in various locations in other aircraft types. In these other installation locations, we believe that the design of the panel provides adequate protection against inadvertent operation of the line select button that controls the transponder’s ON/Standby mode.

The problem of inadvertent operation of this button appears unique to the EMB-135/145 installation. During the conduct of the investigation, it was noted the Legacy 600 pilot footrest is located adjacent to the control panel such that it is possible to inadvertently operate the line select button, while utilizing the footrest, and set the transponder to standby. Setting the transponder to standby effectively disables the TCAS function.

While the Brazilian authorities conducting the investigation have not announced any conclusions related to this observation, the FAA believes the proper course of action is to investigate fully the installation on the Legacy 600 aircraft and require corrective action as appropriate. The FAA will also review installations in other aircraft that use this particular control panel to determine the need for corrective action. If our review uncovers an installation where the transponder/TCAS controls have the potential for inadvertent operation, we will consider the need for enhanced alerting.

At this time, based on the interim findings of this accident, the FAA does not see the need to raise the level of alerting on all TCAS-equipped aircraft. In addition, the FAA will evaluate general flight deck alerting philosophy of planes required to carry TCAS equipment and assess if it needs to be adjusted to ensure pilots have adequate notification of abnormal or unanticipated TCAS functionality. As part of this evaluation, we will evaluate the need for fleet-wide retrofit of enhanced annunciation of TCAS failures.

The FAA will also update Advisory Circular guidance material for the airworthiness of transponder and TCAS installations to provide more emphasis on the human factors evaluation of the installation, specifically controls and their possibility of inadvertent operation. I will keep the Board informed of the FAA’s progress on this safety recommendation.