Safety Recommendation A-10-145

We note that you no longer intend to issue a safety alert for operators or a notice on this topic, or revise FAA Order 8900.1, “Flight Standards Information Management System,” to recommend that operators include the recommended training. You believe this recommendation is addressed in the FAA’s guidance, policies, and industry procedures that are related to safety management system (SMS) risk-based decision-making protocols.

Although we have long recognized the value of SMSs for a variety of aviation operations, we do not believe having an SMS is enough to ensure that operators provide pilots of dual-engine helicopters with the recommended training. In addition, most dual-engine helicopter operations are conducted under Part 133, 135, or 91, and, therefore, would not be required to have an SMS, which is currently only required for Part 121 operators.

We continue to believe that, because simultaneous dual-engine power loss scenarios exhibit different characteristics and require different response techniques, it is critical that pilots of these helicopters receive the recommended training so they can recognize and react appropriately to these scenarios. However, because you have not taken any action to address this 13-year-old recommendation, Safety Recommendation A-10-145 is classified CLOSED-- UNACCEPTABLE ACTION.

-From Polly Trottenberg, Acting Administrator: The FAA previously stated we were developing a safety alert for operators (SAFO), an FAA notice, and revisions to Order 8900.1, Flight Standards Information Management System, to address this safety recommendation. However, based upon further review of our Safety Management System risk-based decision-making protocols, it has been determined that current FAA guidance, policies, and industry procedures adequately address this safety recommendation. The FAA will no longer pursue the SAFO, notice, and Order 8900.1 revisions.

I believe the FAA has effectively addressed Safety Recommendation A-10-145 and consider our actions complete.

We note that you have reviewed the current Part 60 helicopter flight simulation training device (FSTD) standards, as well as the superseded standards that many FSTDs were originally qualified under, and determined that the maneuvers associated with a simultaneous dual-engine power loss can only be performed in levels C and D FSTDs. We also note that, in addition to revising FAA Order 8900.1, “Flight Standards Information Management System,” to encourage operators to include the recommended training, you plan to issue a safety alert for operators and a notice on this topic.

We continue to believe that your plan to revise FAA Order 8900.1 is responsive to this recommendation. However, we point out that, to fully satisfy the intent of this recommendation, the revised order should not only address simulator training, but also initial and recurrent ground training. Pending our review of the revisions to FAA Order 8900.1, Safety Recommendation A 10 145 remains classified OPEN-- ACCEPTABLE RESPONSE.

Please update us at ExecutiveSecretariat@ntsb.gov on your progress toward addressing this recommendation, and do not submit both an electronic and a hard copy of the same response.

-From Steve Dickson, Administrator: The FAA has communicated with several simulator operators and reviewed the applicable flight simulation training device (FSTD) standards to determine if simulators that would be used to conduct such dual-engine power loss scenarios are indeed capable of providing the fidelity necessary to conduct this training. After review of the current part 60 helicopter simulator standards as well as the superseded simulator standard that many grandfathered FSTDs were originally qualified under, we believe such training can be conducted in FSTDs qualified at level C or level D.

This is due to several required subjective and objective testing requirements in part 60 that cover the aerodynamics and flight control modeling involved in dual engine failure scenarios and related maneuvers. Flight test validation is required for levels C and D simulators for maneuvers such as autorotation entry, autorotation performance and trim, and autorotational landing that are all related to a dual-engine failure scenario.

The FAA is finalizing a safety alert for operators, an FAA notice, and revisions to FAA Order 8900.1, Flight Standards Information Management System, to recommend operators revise their training programs to include dual-engine failure scenarios. We anticipate the publication of these documents in Fiscal Year 2021 and will provide an update by September 30, 2021.

Thank you for reconsidering your previous position regarding this recommendation. We are encouraged that you now plan to revise FAA Order 8900.1 to require the recommended training, in light of information we provided in our November 14, 2012, letter regarding similar helicopter accidents we investigated between 1982 and 2010 that resulted in a total of 14 fatalities. Pending completion of the revision, Safety Recommendation A-10-145 is classified OPEN—ACCEPTABLE RESPONSE.

-From Michael P. Huerta, Administrator: As a result of the Board's November 14, 20 12, letter, the FAA reconsidered requiring scenario-based pilot training in a helicopter simulator for a simultaneous dual-engine power loss event. In addition, the FAA published an airworthiness directive (AD) that will reduce the chance of similar accidents.

Based on additional information provided by the Board, and the FAA's latest review, of this issue, the FAA believes operators must require simultaneous dual-engine power loss scenarios in both initial and recurrent ground and simulator flight training for pilots of dual-engine helicopters in their training programs. Pilots need to be able to recognize dual-engine failure by referencing instrument indications, and then apply proper recovery procedures. The FAA plans to update FAA Order 8900.1 to include this training.

The FAA has learned that FlightSafety International, one of the largest FAA-approved part 142 training centers located in West Palm Beach, Florida, has already incorporated pilot training program scenarios with dual-engine fa ilures into their training. FlightSafety trains 2,900 dual-engine helicopter pilots per year.

In our letter dated August 2, 2012, we mentioned AD FAA-2012-0340, which was subsequently published on November 15,2012. The AD is available at the following Web address: http:/ /go. usa.gov/ZBVh.

This AD applies to Sikorsky S-76C++ overhead engine control levers and incorporates a damper and a positive detent for the fly position. We believe thi s will decrease the likelihood of an accident, like the one that triggered this recommendation, of occurring again.

I will keep the Board informed of the FAA's progress on this safety recommendation and provide an update by January 31 , 2015.

The NTSB remains concerned that pilots of dual-engine helicopters are not required to receive initial and recurrent ground and simulator training on how to recognize and react appropriately to simultaneous dual-engine power loss scenarios. We point out that, during training and operations, dual-engine helicopter pilots are accustomed to one engine failing at a time. However, a simultaneous dual-engine loss of power exhibits different characteristics, such as the sound of engines slowing and a different feeling of vibrations in the cockpit, and will require different techniques for taking corrective action.

Between 1982 and 2010, we investigated 52 accidents of dual-engine helicopters, of which 24 experienced loss of power in both engines, resulting in a total of 14 fatalities. We recognize that simultaneous dual-engine loss of power does not occur frequently; however, if it does occur, immediate corrective action is necessary to prevent serious injury to the flight crew and passengers, and damage to the helicopter.

We further point out that, on May 22, 2012, the NTSB submitted comments to the FAA in response to the notice of proposed rulemaking (NPRM) titled “Airworthiness Directives; Sikorsky Aircraft Corporation Helicopters.” We continue to support the proposed AD, which, if implemented, would satisfy the intent of Safety Recommendation A-10-136. However, we do not believe that this AD will satisfy Safety Recommendation A-10-145. Accordingly, pending a requirement for simultaneous dual-engine power loss scenarios in both initial and recurrent ground and simulator training for pilots of dual-engine helicopters, Safety Recommendation A-10-145 is classified OPEN—UNACCEPTABLE RESPONSE.

-From Michael P. Huerta, Acting Administrator: The FAA reviewed the feasibility of requiring scenario-based pilot training in a helicopter simulator for a simultaneous dual-engine power loss event. We also evaluated the need for both initial and recurrent ground simulator training for helicopter pilots on simultaneous dual-engine power loss.

The FAA believes that there is a very small likelihood that an accident scenario leading to dual-engine power loss will occur again. Therefore, we do not plan on requiring this training. We are taking other actions in response to this accident, including issuing an airworthiness directive for the Sikorsky S-76C++ overhead engine control levers that incorporates a damper and a positive detent for the fly position. We believe that this will prevent the specific accident sequence that triggered this recommendation from occurring again. On March 29, 2012, the FAA published an Airworthiness Directive Notice of Proposed Rulemaking (FAA Docket No.

F AA-20 12-0340) to mandate this design change on S-76C++ rotorcraft. The comment period closed on May 29, 2012.

I will keep the Board informed of the FAA's progress on this safety recommendation and provide an update by March 2013.

The FAA indicated that it plans to review the feasibility of the recommended requirement and will determine an appropriate course of action based on this information. Pending our receipt and review of the FAA’s findings, Safety Recommendation A-10-145 is classified OPEN—ACCEPTABLE RESPONSE.

CC# 201100057: - From J. Randolph Babbitt, Administrator: The FAA will review the feasibility of requiring scenario-based pilot training in a helicopter simulator for a simultaneous dual-engine power loss event. The FAA will also evaluate the need for both initial and recurrent ground simulator training for helicopter pilots on simultaneous dual-engine power loss. Based on the review the FAA will determine an appropriate course of action. I will keep the Board informed of the FAA's progress and provide an updated response to this recommendation by January 2012.