NTSB · Safety Recommendation
Safety Recommendation A-11-039
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Require that role-playing or simulator-based exercises that teach first officers to assertively voice their concerns and that teach captains to develop a leadership style that supports first officer assertiveness be included as part of the already required crew resource management training for 14 Code of Federal Regulations Part 121, 135, and 91 subpart K pilots.
Safety Issue and Context
On January 27, 2009, about 0437 central standard time, an Avions de Transport Régional (ATR) Aerospatiale Alenia ATR 42-320 (ATR 42), N902FX, operating as Empire Airlines flight 8284, was on an instrument approach when it crashed short of the runway at Lubbock Preston Smith International Airport (LBB), Lubbock, Texas.2 The captain sustained serious injuries, and the first officer sustained minor injuries. The airplane was substantially damaged. The airplane was registered to FedEx Corporation and operated by Empire Airlines, Inc., as a 14 Code of Federal Regulations (CFR) Part 121 supplemental cargo flight. The flight departed from Fort Worth Alliance Airport, Fort Worth, Texas, about 0313.
Instrument meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan was filed. The National Transportation Safety Board (NTSB) determined that the probable cause of this accident was the flight crew’s failure to monitor and maintain a minimum safe airspeed while executing an instrument approach in icing conditions, which resulted in an aerodynamic stall at low altitude.
Contributing to the accident were (1) the flight crew’s failure to follow published standard operating procedures (SOP) in response to a flap anomaly, (2) the captain’s decision to continue with the unstabilized approach, (3) the flight crew’s poor crew resource management (CRM), and (4) fatigue due to the time of day in which the accident occurred and a cumulative sleep debt, which likely impaired the captain’s performance.
Response History
April 3, 2024 · NTSB Correspondence · FAA
We previously told the FAA that including example scenarios of the recommended role-playing exercises in Advisory Circulars (ACs) 120-51E, “Crew Resource Management Training,” and 120-35D, “Flightcrew Member Line Operational Simulations: Line-Oriented Flight Training, Special Purpose Operational Training, Line Operational Evaluation” would be an acceptable alternative to requiring these exercises in CRM training for pilots. We note, however, that the FAA no longer intends to revise these ACs because it believes operators should develop the example scenarios.
We point out that AC 120-51E, which was available at the time of this accident, suggests that assertiveness exercises should be included in CRM training programs; however, the accident first officer’s CRM training did not include any role-playing activities in which pilots could practice developing assertiveness skills, and it was limited to two presentation slides that encouraged pilots to speak up with “appropriate persistence until there is a clear resolution.”
In addition, although AC 121-42, “Leadership and Command Training for Pilots in Command,” and AC 121 43, “Mentoring Training for Pilots in Command” encourage instructors to facilitate practical exercises that allow crewmembers to practice interacting under situations that might occur on the job, neither of the ACs includes example scenarios to teach first officers to assertively voice their concerns and captains to develop a leadership style that supports first officer assertiveness.
We continue to believe that incorporating the recommended role-playing or simulator-based exercises into pilot CRM training would allow pilots to bridge the gap between their knowledge of assertiveness and the actions needed in the cockpit to be effectively assertive. However, because the FAA does not intend to require this training or include example scenarios in your training guidance, Safety Recommendation A-11-39 is classified CLOSED-- UNACCEPTABLE ACTION.