NTSB · Safety Recommendation
Safety Recommendation A-10-029
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to (1) routinely download and analyze all available sources of safety information, as part of their flight operational quality assurance program, to identify deviations from established norms and procedures; (2) provide appropriate protections to ensure the confidentiality of the deidentified aggregate data; and (3) ensure that this information is used for safety-related and not punitive purposes.
Safety Issue and Context
On February 12, 2009, about 2217 eastern standard time,1 a Colgan Air, Inc., Bombardier DHC-8-400 (Q400),2 N200WQ, operating as Continental Connection flight 3407, was on an instrument approach to Buffalo-Niagara International Airport, Buffalo, New York, when it crashed into a residence in Clarence Center, New York, about 5 nautical miles northeast of the airport. The 2 pilots, 2 flight attendants, and 45 passengers aboard the airplane were killed, one person on the ground was killed, and the airplane was destroyed by impact forces and a postcrash fire.
The flight, which originated from Liberty International Airport (EWR), Newark, New Jersey, was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121. Night visual meteorological conditions prevailed at the time of the accident.
Response History
January 31, 2024 · NTSB Correspondence · FAA
The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) notice of proposed rulemaking (NPRM) titled “25 Hour Cockpit Voice Recorder (CVR) Requirement, New Aircraft Production,” published at 88 Federal Register 84090 on December 4, 2023. The NTSB notes the FAA is proposing to require the installation of 25-hour duration CVRs on only newly manufactured aircraft that require a CVR operating under Title 14 Code of Federal Regulations Parts 91, 121, 125, and 135.
For the reasons provided in this response, we do not fully support the NPRM because it does not propose a similar requirement to retrofit existing airplanes required to carry a CVR and a flight data recorder (FDR).
In 2018, the NTSB issued the following two recommendations to the FAA: Require all newly manufactured airplanes that must have a cockpit voice recorder (CVR) be fitted with a CVR capable of recording the last 25 hours of audio. (A-18-30)
By January 1, 2024, require retrofit of all cockpit voice recorders (CVR) on all airplanes required to carry both a CVR and a flight data recorder with a CVR capable of recording the last 25 hours of audio. (A-18-31)
As noted in the NPRM, these recommendations were issued after an incident in 2017 when an Air Canada Airbus A320 lined up to land on a taxiway occupied by several aircraft. The flight crew of the Airbus A320 descended below 100 feet above ground level before starting to climb. The CVR data were overwritten before Air Canada officials learned of the severity of the incident.
Although this incident prompted Safety Recommendations A-18-30 and A-18-31, the NTSB also identified 33 other events where the CVR data were overwritten because there was a delay between an event and the flight crew recognizing that event to be a serious incident or accident or the flight continued to operate for more than 2 hours after the event took place.
Since Safety Recommendations A-18-30 and A-18-31 were issued, at least 14 additional investigations have been hampered by the lack of CVR data that were overwritten, including 7 serious runway incursions that occurred in 2023 and a rapid decompression that occurred on an Alaska Airlines 737-9 MAX flight on January 5, 2024 (see table). In our 2018 report, the NTSB noted that CVRs are among the most valuable tools for accident investigation because they provide contemporaneous information on flight crew intentions and coordination as well other factors, such as procedural compliance, workload, fatigue, and situational awareness.