Reiterated and reclassified in NTSB Aviation Accident Report AAR-21-01 “Rapid Descent Into Terrain Island Express Helicopters Inc. Sikorsky S-76B, N72EX Calabasas, California January 26, 2020.” Published on February 25, 2021.
2.6 Benefits of Flight Data Monitoring Program
Island Express did not have and was not required to have an FDM program, which involves the recording and analysis of flight-related information to help pilots, instructors, and operators improve performance and safety. An FDM program, which can be integrated into an SMS, has the potential to provide important information regarding pilot performance during flights, which may be particularly beneficial for operators like Island Express that conduct single-pilot operations and, thus, have little opportunity to directly observe their pilots in the operational environment.
FDM programs typically involve the use of an onboard device that is capable of recording various flight parameters or video installed on each aircraft in an operator’s fleet. Periodic review of the recorded data enables an operator to identify deviations from company procedures, established norms, and other potential safety issues. For example, data reviews from company flights may help a company identify deviations, gather information to better understand the context of those deviations, and take proactive measures to implement mitigations and corrective action before an accident occurs.
The NTSB has long recognized the value of an FDM program, starting with Safety Recommendation A-09-90, issued in 2009, which recommended that the FAA require helicopter air ambulance operators to establish a structured FDM program and install recording devices capable of supporting it. The FAA’s February 21, 2014, final rule, “Helicopter Air Ambulance, Commercial Helicopter, and Part 91 Helicopter Operations,” required helicopter air ambulance
67 A review of NTSB aircraft accident investigation data revealed that, during 2010 through 2019, we investigated 198 aircraft accidents—184 of which were fatal—in which spatial disorientation played a role or was cited in the investigative findings. Helicopters were involved in 24 of these accidents, 20 of which were fatal. (Note: These totals include only accidents that occurred in the United States and for which the investigations were completed as of January 14, 2021.)
operators to equip their fleet with recording devices but did not require them to establish an FDM program. In our September 11, 2014, letter to the FAA, we noted that a mandate for FDM programs was needed to identify deviations from established norms and procedures and to identify other potential safety issues, and we asked the FAA to provide details of its plans for addressing this part of the recommendation.
In its November 1, 2017, response, the FAA expressed concerns that, because the protections of Part 193, “Protection of Voluntarily Submitted Information,” are available only if the data are collected by operators as part of a voluntary FAA-approved program, it did not intend to mandate the programs. In our response to the FAA, we emphasized that the intent of our recommendation was for operators to establish internal FDM programs, which would not share collected data with the FAA, and, thus, the data would not need protections.
However, based on the FAA’s response that it would not mandate FDM programs as we recommended, we classified Safety Recommendation A-09-90 “Closed—Unacceptable Action.”68
68 In our January 25, 2018, reply to the FAA, we noted that Safety Recommendation A-09-90 did not intend for the FAA to require helicopter air ambulance operators to establish a safety program that shares data with the FAA and for which the Part 193 protections do not apply (such as the flight operations quality assurance program for Part 121 operators, which share de-identified aggregate information with the FAA). The intent of the recommendation was for helicopter air ambulance operators to establish an internal program by which they analyze their recorded FDM data and monitor trends within their operations.
We informed the FAA that, because the collected data would not need to be shared with the FAA, we did not see the need for protecting it. We classified Safety Recommendation A-09-90 “Closed—Unacceptable Action” on January 25, 2018. See appendix C for more information.
69 See appendix C for more information.
On November 3, 2016, we issued Safety Recommendation A-16-34, which recommended that the FAA require all Part 135 operators to install flight data recording devices capable of supporting an FDM program (NTSB 2016).
On the same date, we issued Safety Recommendation A-16-35, which recommended that the FAA, after the action in Safety Recommendation A-16-34 is completed, require all Part 135 operators to establish a structured FDM program that reviews all available data sources to identify deviations from established norms and procedures and other potential safety issues.69 Due to our ongoing interest in this area and the importance of these recommendations, we included them in the NTSB’s 2019-2020 Most Wanted List of Transportation Safety Improvements for the issue area, “Improve the Safety of Part 135 Aircraft Flight Operations.”
In response to Safety Recommendation A-16-34, on January 9, 2017, the FAA said it would conduct a review to determine the feasibility of requiring all Part 135 certificate holders to install FDM recording devices on their aircraft. The FAA noted that it had conducted a similar review when considering the development of the helicopter air ambulance final rule and determined that a requirement for such devices did not meet the cost-benefit requirements for safety.
However, Congress mandated the equipment requirement in Section 306(a) of the FAA Modernization and Reform Act of 2012, which stated that revised regulations should apply only to Part 135 certificate holders providing air ambulance services. As a result of the Congressional mandate, the February 21, 2014, helicopter air ambulance final rule contained the mandate for the FDM equipment on helicopter air ambulances. Regarding the FAA’s new review for Safety Recommendation A-16-34, the FAA noted that a key focus would be to determine the feasibility of achieving a favorable cost-benefit ratio.
On April 6, 2017, we replied that we reviewed the regulatory evaluation of the February 21, 2014, final rule. We noted that the regulatory evaluation showed costs of approximately $20.4 million over a 10-year period and that we were surprised to see that the benefits amounted to $0. We issued Safety Recommendation A-16-34 because an FDM program, which requires that aircraft be equipped with appropriate recording systems, offers a great opportunity for operators to improve the safety of their operations and avoid accidents.
A review of NTSB major aviation accident investigations involving Part 135 on-demand operators during the period of 2000 through 2015 found seven accident investigations with findings related to pilot performance. In these seven accidents, 53 people were fatally injured and another 4 were seriously injured. The NTSB believes that an effective FDM program can help an operator identify issues with pilot performance and, through an SMS, lead to mitigations that will prevent future accidents. As a result, the NTSB does not believe it is appropriate to indicate that there are no quantifiable benefits from a mandate for FDM equipment and programs.
In response to Safety Recommendation A-16-35, on January 9, 2017, the FAA replied that it previously considered mandating FDM programs as a part of the development of the February 21, 2014, helicopter air ambulance final rule and determined that its voluntary programs were successful for monitoring and evaluating operational practices and procedures. The FAA also said it believed that maintaining a vo