TO THE FEDERAL AVIATION ADMINISTRATION: Require all 14 Code of Federal Regulations Part 135 operators to establish safety management system programs.
Safety Issue and Context
On November 10, 2015, about 1453 eastern standard time, Execuflight flight 1526, a British Aerospace HS 125-700A (Hawker 700A), N237WR, departed controlled flight while on a nonprecision localizer approach to runway 25 at Akron Fulton International Airport (AKR) and impacted a four-unit apartment building in Akron, Ohio. The captain, first officer, and seven passengers died; no one on the ground was injured. The airplane was destroyed by impact forces and postcrash fire. The airplane was registered to Rais Group International NC LLC and operated by Execuflight under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as an on-demand charter flight.
Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed. The flight departed from Dayton-Wright Brothers Airport, Dayton, Ohio, about 1413 and was destined for AKR.
Response History
August 9, 2024 · NTSB Correspondence · FAA
From the Special Investigation Report (AIR-24-03) Safety and Industry Data Improvements for Part 135 Operations: 4.1 Safety Management System
The NTSB has long advocated that the FAA require various Part 135 operations to implement an SMS, having issued the first associated safety recommendation, which applied to HAA operators, in 2009.59 Subsequently, as a result of our investigation into the 2015 crash of a Part 135 on-demand charter flight in which all nine persons on board sustained fatal injuries, we recommended that the FAA expand the applicability of SMS requirements, as follows:
Require all 14 Code of Federal Regulations Part 135 operators to establish safety management system programs. (A-16-36)[60]
In the 7 years since we issued this recommendation, we reiterated it in the final reports of seven fatal accidents involving Part 135 operators that resulted in 39 fatalities and 9 serious injuries.61 Most of these accidents were also on the FAA’s list of 35 serious- and fatal-injury accidents involving Part 135 operators from 2015 to 2019 that the FAA determined could have been mitigated through the implementation of SMS (FAA 2023a, 1936).62
In addition to engaging in ongoing discussions with the FAA regarding the importance of an SMS requirement for Part 135
October 2, 2023 · NTSB Correspondence · FAA
On March 10, 2023, we submitted comments regarding the notice of proposed rulemaking (NPRM) titled, “Safety Management Systems,” which was published on January 11, 2023, and proposed expanding the applicability of Part 5 SMSs to include Part 135 operators, air tour operators under 91.147, and certain certificate holders under Part 21. We expressed our support of the proposed expansion of SMS requirements to include Part 135 operations and without exceptions for the size of the operator. We also said that publishing a final rule requiring SMS for all Part 135 operations would likely satisfy the intent of Safety Recommendation A 16 36.
We continue to find in our investigations that an effective SMS could have helped Part 135 operators identify and mitigate risks. Since this recommendation was issued, it has been reiterated 7 times. We believe the published NPRM is a positive step toward addressing this safety recommendation, and we encourage you to not delay publishing a final rule. In the meantime, pending our review of the published final rule, Safety Recommendation A-16-36 is classified OPEN-- ACCEPTABLE RESPONSE.
September 6, 2023 · NTSB Correspondence · FAA
On August 4, 2023, the Federal Aviation Administration (FAA) announced the publication of draft Advisory Circular (AC) 136-B048, Supplemental Information for the Creation of Operating Procedures and Pilot Training Subjects Related to OpSpec [operations specification]/LOA [letter of authorization] B048, and invited public comment on the document. The NTSB has a longstanding interest in air tour safety in the state of Hawaii, having investigated numerous Hawaii air tour accidents and issued many related safety recommendations and we offer our comments below.
We note that, based on the contents of the draft AC, it appears that the FAA’s intent is that it will replace FAA document AWP13-136, the Hawaii Air Tour Common Procedures Manual (HATCPM), which the FAA issued in 2008 for use by operators that obtained authorization (through OpSpec B048 or LOA B548) to deviate from the minimum altitude specified in 14 Code of Federal Regulations (CFR) Part 136, Appendix A. For those operators that obtained authorization through OpSpec B048/LOA B548, compliance with the provisions of the HATCPM was mandatory.
In our 2022 report on our investigation of the December 26, 2019, fatal air tour helicopter accident in Kekaha, Hawaii, we noted that the HATCPM had not been revised since it was issued and that the FAA informed us that it had been working on a replacement for about 7 years.
During our investigation, an air tour subject matter expert from the FAA’s Air Transportation Division, [14 CFR] Part 135 Air Carrier Operations Branch, informed us that the FAA’s vision for the new document was for it to be up to date; incorporate NTSB safety recommendations, congressional input, and National Park Service input; and be simpler, safer, and easier to manage. They also said that the document would likely address the use of Hawaii weather camera systems and operator implementation of safety management systems (SMSs).
We have examined the draft AC and are providing comments related to these issues and open NTSB recommendations related to air tour safety in Hawaii. We note that, although ACs, generally, are not regulatory documents, we presume that operators that obtain authorization through OpSpec/LOA B048 will be required to comply with the AC’s provisions (similar to the mandatory compliance with the HATCPM for those operators that held deviation authority).
April 11, 2023 · Recipient Response · FAA
-From Billy Nolen, Acting Administrator: The Federal Aviation Administration (FAA) published the Safety Management Systems (SMS) Notice of Proposed Rulemaking on January 11, 2023 (88 FR 1932). The FAA is proposing to update and expand the requirements for SMS and require certain certificate holders and commercial air tour operators to develop and implement an SMS.
This proposed rule would extend the requirement for an SMS to all certificate holders operating under the rules for commuter and on-demand operations, commercial air tour operators, production certificate holders that are holders or licensees of a type certificate (TC) for the same product, and holders of a TC who license out that TC for production.
This rulemaking effort and subsequent supporting guidance and FAA oversight will satisfy the intent of these safety recommendations.
I anticipate providing an update to Safety Recommendations A-16-36, A-19-28, A-19-30, A-19-31, A-21-48, and A-22-15 by March 31, 2024.
March 10, 2023 · NTSB Correspondence · FAA
The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA’s) notice of proposed rulemaking (NPRM) titled, “Safety Management Systems,” which was published at 88 Federal Register 1932 on January 11, 2023.
The NPRM proposes to expand the applicability of Title 14 Code of Federal Regulations (CFR) Part 5 Safety Management Systems (SMSs) beyond 14 CFR Part 121 operators to include 14 CFR Part 135 operators, air tour operators under 14 CFR 91.147, and certain certificate holders under 14 CFR Part 21.
The FAA states that the successful use of SMSs by Part 121 operators suggests that expanding SMS requirements can benefit other sectors of the aviation system. According to the NPRM, the proposed action addresses a congressional mandate and NTSB safety recommendations and moves the United States closer to harmonizing with International Civil Aviation Organization Annex 19 on SMSs for aviation service providers. The FAA analyzed our accident investigations to support this rulemaking project and demonstrate the benefits of SMSs.
Open NTSB Safety Recommendations on SMS
Six of our safety recommendations on SMSs issued to the FAA remain open. The oldest, Safety Recommendation A 16 36, asked the FAA to require that all Part 135
November 22, 2022 · NTSB Correspondence · FAA
You reported plans to publish a notice of proposed rulemaking (NPRM) by the end of September 2022 that would propose requiring SMSs for certain designers and producers of aircraft, engines, and propellers; certificate holders that conduct common carriage operations under Part 135; those who maintain Part 121 aircraft under Part 145; and specific types of air tour operators under Part 91.
We believe the NPRM you described has the potential to address this recommendation; however, to our knowledge, the NPRM has not been published.
We are concerned because this recommendation is 6 years old and, after the NPRM has been published, you will need additional time to complete the rulemaking process before a final rule can be published. Pending our review of the published NPRM and completion of the recommended actions, Safety Recommendation A-16-36 remains classified OPEN--UNACCEPTABLE RESPONSE.
July 21, 2022 · Recipient Response · FAA
-From Billy Nolen, Acting Administrator: The Federal Aviation Administration (FAA) reaffirms its continued efforts to review the Safety Management System (SMS) requirements in 14 CFR Part 5 to apply to 14 CFR Parts 21, 91, 135, and 145 operators to address the aforementioned safety recommendations. In the fall of 2020, the FAA initiated a notice of proposed rulemaking (NPRM) that would require certain entities to develop and implement an SMS that complies with the requirements in part 5.
The NPRM may propose to require certain persons engaged in the design and production of aircraft, engines, or propellers; certificate holders that conduct common carriage operations under part 135; persons engaged in maintaining part 121 aircraft under part 145; and persons conducting specific types of air tour operations under 91.147 to implement an SMS. The NPRM is anticipated to be published by September 30, 2022. We believe this rulemaking effort and subsequent FAA oversight will satisfy the intent of these safety recommendations. I anticipate providing an update to Safety Recommendations A-16-36, A-19-28, A-21-13, and A-21-14 by April 30, 2023.
May 26, 2022 · NTSB Correspondence · FAA
From Aviation Investigation Report AIR-22-05 “Collision into Terrain Safari Aviation Inc. Airbus AS350 B2, N985SA Kekaha, Hawaii, December 26, 2019” published on May 26, 2022: 2.5.2 Benefits of a Safety Management System
SMS is the formal, top-down, organization-wide approach to managing safety risk and assuring the effectiveness of safety risk controls. Its four main components are
• safety policy (which establishes senior management’s commitment to continually improve safety),
• safety risk management (which determines the need for new or revised risk controls),
• safety assurance (which evaluates the effectiveness of implemented risk control strategies), and
• safety promotion (which includes training, communications, and other actions to create a positive safety culture).
Safari did not have, and was not required to have, an SMS. The NTSB has long advocated that the FAA require SMS for various Part 135 operations, having issued the first associated safety recommendation, which applied to helicopter air ambulances, in 2009.60 Although the FAA published a final rule in 2014 that required helicopter air ambulance operators to implement tools and procedures that the FAA believed contained elements of an effective SMS, the rule did not require the complete SMS that we recommended.61
On November 3, 2016, we recommended that the FAA to do the following:
Require all 14 Code of Federal Regulations Part 135 operators to establish safety management system programs. (A-16-36)
Due to the importance of this safety recommendation, we included it on our current Most Wanted List of Transportation Safety Improvements under the issue area, “Require and Verify the Effectiveness of Safety Management Systems in all Revenue Passenger-Carrying Aviation Operations.”
April 1, 2022 · NTSB Correspondence · FAA
We note that, in 2020, you initiated the rulemaking project, “SMS for Part 21, 91, 135, and 145,” and that you intend to apply the requirements contained in Part 5, SMS, to this rulemaking.
We continue to find in our investigations that an effective SMS could have helped Part 135 operators identify and mitigate risks. Although we are encouraged that you plan to require SMS for these operations, we are concerned that, since Safety Recommendation A-16-36 was issued, it has been reiterated 6 times. Pending timely publication of a notice of proposed rulemaking and completion of the recommended action, Safety Recommendation A-16-36 remains classified OPEN-- UNACCEPTABLE RESPONSE.
October 7, 2021 · Recipient Response · FAA
-From Steve Dickson, Administrator: In our previous response to the Board, dated April 13, 2020, the Federal Aviation Administration (FAA) noted our continued efforts to conduct a review to determine the feasibility of expanding the Safety Management System (SMS) Final Rule to encompass part 135 operators to address Safety Recommendation A-16-36. The FAA initiated a rulemaking project in the fall of 2020 entitled, Safety Management System (SMS) for Part 21, 91, 135, and 145. The rulemaking project applies the existing regulatory requirements of 14 CFR, Part 5, Safety Management Systems into the new rulemaking.
In addition, it requires that all persons engaged in the design and production of aircraft, engines, or propellers; certificate holders that conduct common carriage operations under part 135; persons engaged in maintaining part 121 aircraft under part 145; and persons conducting specific types of air tour operations under part 91, to implement an SMS program into their operations.
We believe that this rulemaking effort will satisfy the intent of this safety recommendation.
I anticipate providing an update to this safety recommendation by September 30, 2022.
May 21, 2021 · NTSB Correspondence · FAA
Reiterated in the Aircraft Accident Report “Midair Collision over George Inlet de Havilland DHC-2, N952DB, and de Havilland DHC-3, N959PA Ketchikan, Alaska May 13, 2019” AAR-21-04 published on May 21, 2021: 2.9 Safety Management Systems The NTSB has long advocated for the implementation of SMS in Part 135 operations, having issued our first safety recommendation (which applied to helicopter air ambulance operations) in 2009.75 On February 21, 2014, the FAA published a final rule titled “Helicopter Air Ambulance, Commercial Helicopter, and Part 91 Helicopter Operations.”
Although the final rule required helicopter air ambulance operators to implement additional tools and procedures that the FAA believed contained elements of an effective SMS program, the rule did not require the complete SMS program that the NTSB recommended. Consequently, Safety Recommendation A-09-89 was classified “Closed—Unacceptable Action.” In 2016, the NTSB issued Safety Recommendation A-16-36 to the FAA to require all Part 135 operators to implement an SMS (NTSB 2016).
This recommendation is on the NTSB’s current Most Wanted List of Transportation Safety Improvements under the issue area, “Require and Verify the Effectiveness of Safety Management Systems in all Revenue Passenger-Carrying Aviation Operations.” In a response dated January 9, 2017, the FAA noted that Part 135 operators could participate in its voluntary SMS program. The FAA also stated its intention to conduct a review and hold meetings to determine if further action was needed on SMS for
February 25, 2021 · NTSB Correspondence · FAA
Reiterated 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.
2.4.2 Benefits of a Mandatory Safety Management System
The SMS internal evaluation and proactive hazard analysis functions associated with the flight risk analysis form were just a few of several provisions outlined in Island Express’ SMS Manual that the company did not use and was not required to use because its SMS was not required by the FAA.
The NTSB has long advocated that the FAA require SMS for various Part 135 operations, having issued our first associated recommendation (Safety Recommendation A-09-89, which applied to helicopter air ambulance operations) in 2009.61 Although the FAA published a final rule in 2014 that required helicopter air ambulance operators to implement tools and procedures that the FAA believed contained elements of an effective SMS, the rule did not require the complete SMS that we recommended.62 In our September 11, 2014, response to the FAA, we noted that “elements of an SMS…are not an acceptable substitute for the complete program,” and we classified Safety Recommendation A-09-89 “Closed—Unacceptable Action.”
On November 3, 2016, we issued Safety Recommendation A-16-36 to the FAA to require all Part 135 operators to implement an SMS.63 Due to our ongoing interest in this area and the importance of this recommendation, we included it 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 the FAA’s January 9, 2017, response, it stated that it had a formal SMS Voluntary Program in which
September 29, 2020 · NTSB Correspondence · FAA
We are concerned because, in the 3 years since you last responded to this recommendation, you are still evaluating the feasibility of requiring SMS programs for Part 135 operators. We point out that, in the same 3 years, Safety Recommendation A-16-36 has been reiterated four times as a result of our investigations of other fatal Part 135 operator accidents (NTSB 2017, 2018, 2019). In addition, on June 8, 2020, Safety Recommendation A-16-36 was classified “Open—Unacceptable Response” in our accident report, Helicopter Air Ambulance Collision with Terrain, Survival Flight Inc., Bell 407 Helicopter, N191SF, near Zaleski, Ohio, January 29, 2019.
As we indicated in our last response, satisfying this recommendation without a requirement means you will need to provide information on how many Part 135 operators have implemented it voluntarily. Pending completion of the recommended action, Safety Recommendation A-16-36 remains classified OPEN--UNACCEPTABLE RESPONSE.
June 8, 2020 · NTSB Correspondence · FAA
Reiterated and reclassified in Aviation Accident Report AAR-20-01, PB2020-101001, Notation 64859, Adopted on May 19, 2020 and published on June 8, 2020 “Helicopter Air Ambulance Collision with Terrain Survival Flight Inc. Bell 407 Helicopter N191SF near Zaleski, Ohio January 29, 2019
From the report:
2.2.3 Safety Management Systems
Although the DO stated Survival Flight had an SMS program, no documentation existed to corroborate this statement.88 Additionally, Survival Flight’s operation was not consistent with defined and industry-recognized components of an SMS.
For example, while a healthy safety policy establishes senior management’s commitment to continually improving safety, Survival Flight’s management’s behavior toward safety decisions elevated and reinforced operational performance over safety. Although the company had a defined structure for safety personnel and designated safety representatives at each base, safety initiatives were driven from the bottom up and not reinforced from above. The tenuous reporting culture at the company was symptomatic of this dichotomy.
In addition, the safety risk management component of SMS is dependent upon an established process for risk management and is also closely coupled with strong safety assurance methods in its ability to help support the overall management of safety. Survival Flight had neither an established process for risk management nor reliable methods to assess the effectiveness of mitigations. For example, without an FDM program that could provide management with data about how its aircraft were being operated, Survival Flight was dependent on its personnel to provide this information and help to identify both emergent risks as well as information about the effectiveness of mitigations.
However, without a healthy reporting culture, the ability of Survival Flight to actively manage safety consistent with an SMS was compromised. Safety reporting was undermined by punitive repercussions and the company did not have a transparent process for handling safety concerns. Some employees stated they chose not to report safety concerns either because they feared reprisal or because they felt their concerns would not be addressed.
Finally, a company’s safety promotion efforts to share safety-related information with its employees helps to reinforce and strengthen its safety culture.
For many Survival Flight employees, insight into the company’s position on safety came in the form of negative consequences for speaking up, questioning of flight declines by upper management, and lack of acknowledgement of certain safety concerns that were reported. This contradicted, rather than reinforced, any official company safety communications and policy statements. Therefore, the evidence shows that Survival Flight did not have an established safety management system aligned with the guidance in
June 8, 2020 · NTSB Correspondence · FAA
Reiterated and reclassified in Aviation Accident Report AAR-20-01, PB2020-101001, Notation 64859, Adopted on May 19, 2020 and published on June 8, 2020 “Helicopter Air Ambulance Collision with Terrain Survival Flight Inc. Bell 407 Helicopter N191SF near Zaleski, Ohio January 29, 2019
April 13, 2020 · Recipient Response · FAA
-From Steve Dickson, Administrator: In our initial response to the Board, dated January 9, 2017, we noted our plans to conduct a review to determine the feasibility of expanding the Safety Management System (SMS) Final Rule to encompass part 135 operators to address Safety Recommendation A-16-36.
We are still evaluating the feasibility of rulemaking to take the recommended actions. In addition, rulemaking schedules are subject to revision and evaluation in accordance with Executive Order 13771, Reducing Regulation and Controlling Regulatory Costs (82 FR 9339), and Executive Order 13777, Enforcing the Regulatory Reform Agenda (82 FR 12285). In light of the delays experienced by several rulemaking projects discussed in this response, as well as the impact of Executive Orders 13771 and 13777, we are weighing all potential alternate courses of action to address the safety issues identified by this recommendation.
I will keep the Board informed of the FAA’s progress on these safety recommendations, and anticipate providing an update by March 2021.
March 28, 2019 · NTSB Correspondence · FAA
From the Aircraft Accident Report: “Departure from Controlled Flight Trans-Pacific Air Charter, LLC, Learjet 35A, N452DA, Teterboro, New Jersey, May 15, 2017.” Report Number AAR-19-02, Notation 58039, adopted March 12, 2019 and published March 28, 2019, PB2019-100271: Section 2.5 Operational Safety Programs 2.5.1 Safety Management System
Despite having a dedicated safety officer position within the organization, Trans-Pacific did not have any formal safety programs in place, such as an anonymous hazard reporting program. The director of operations (who was acting as safety officer) said that he was available to pilots if a safety concern developed and that he had an “open door” policy.
The director of operations also provided anecdotal evidence that the company had addressed concerns that pilots reported but did not describe any means for identifying hazards beyond informal reports. The managing director stated that, at the time of the accident, the company had begun, but had not completed, the process of implementing an SMS. After the accident, the company planned to expedite the implementation of an SMS.54 However, Trans-Pacific provided no indication, as of February 2019, that the company’s SMS had been implemented.
The NTSB recognizes the value of SMS for all operators and has recommended broadening requirements for SMS.55 In the Akron accident report, the NTSB stated that the company’s “casual attitude” toward compliance with standards “illustrates a disregard for operational safety, an attitude that likely led its pilots to believe that strict adherence to standard operating procedures was not required” (NTSB 2016). (That accident report also referenced three other accidents involving Part 135 operators that could have benefitted from an SMS.)
56 As a result, the NTSB concluded that all Part 135 operators could benefit from an SMS because formal system safety methods would be incorporated into internal oversight programs and recommended that the FAA “require all 14 Code of Federal Regulations
April 26, 2018 · NTSB Correspondence · FAA
The following is from the NTSB Aviation Accident Report “Collision with Terrain Hageland Aviation Services, Inc. dba Ravn Connect Flight 3153 Cessna 208B, N208SD, Togiak, Alaska October 2, 2016.” Report number AAR-18-02. Adopted on April 17, 2018 and published on April 26, 2018.
During its investigation of the November 10, 2015, fatal accident in Akron, Ohio, involving a British Aerospace HS 125-700A operated under Part 135, the NTSB identified problems with the operator’s safety culture and a lack of compliance with SOPs (NTSB 2016).
In the report, the NTSB cited several additional Part 135 accidents (including the two 2013 Hageland accidents) that highlighted operational safety issues that could have been mitigated with SMS. As a result of its investigation, on November 7, 2016, the NTSB issued Safety Recommendation A-16-36, which recommended that the FAA require all Part 135 operators to establish an SMS (NTSB 2016).
On January 9, 2017, the FAA responded that while SMS is not currently required of Part 135 operators, the FAA had a formal SMS voluntary program for Part 135 operators. The FAA planned to review this voluntary program to determine if further action was needed to satisfy the recommendation.
On April 6, 2017, the NTSB replied that a review of major NTSB investigations of accidents from 2000 through 2015 found that seven accidents involving only Part 135
May 9, 2017 · NTSB Correspondence · FAA
From the NTSB Accident Report “Collision with Terrain, Promech Air, Inc., de Havilland DHC-3, N270PA, Ketchikan, Alaska, June 25, 2015” AAR-17-02, PB2017-102178, Notation 56539, adopted on April 25, 2017: Promech’s safety programs when the company had provided service under Part 121. However, interviews with Promech pilots revealed that they did not know who in the company was responsible for managing safety; several provided different names when asked about the subject.
The DO stated that Promech performed flight-risk assessment informally but that he believed the informal process accomplished the same objective as the use of formal risk assessment forms (which he had used at other jobs).
Promech had an anonymous safety-reporting system for use in submitting written reports of operational hazards and general unsafe conditions; however, neither the company president/CEO nor the DO could recall any safety report forms having been submitted. The company president/CEO said that, typically, pilots verbally told the managers if they had a concern.
Although company managers seemed confident that pilots would use either verbal or anonymous reporting if they had concerns, company management was unaware of serious incidents that had occurred, including a flight in which the accident pilot struck trees with an airplane during takeoff and later told some of his colleagues (and noted in his pilot logbook) that he “nearly died.” In addition, company managers stated that they were unaware that the accident pilot had turned around due to poor weather conditions during his first tour on the day of the accident and that two other Promech pilots reversed course multiple times to find their way out of Ella Lake on the morning of the accident.43
43 NTSB investigators discovered this through an interview with one of the pilots and by reviewing ADS-B data from the morning of the accident.
As a Part 135 operator, Promech was not required by the FAA to have a formal SMS; however, SMS has been recognized in all aspects of aviation operations as an effective way to establish and reinforce a positive safety culture and identify and correct deviations from SOPs. The DO indicated that the company did not have enough staff to manage a formal SMS program and that the company’s safety culture accomplished the same objective as a formal SMS program.
April 6, 2017 · NTSB Correspondence · FAA
We note that you recently published a final rule requiring that Part 121 operators have an SMS program, and that, in the notice of proposed rulemaking for this rule, you indicated that you would consider a similar requirement for Part 135 operators. We further note that Part 135 operators may currently participate in your formal voluntary program for establishing an SMS program. Finally, we note that, to satisfy this recommendation, you plan to “determine the feasibility of recommending” SMS for Part 135 operators and decide what further action is needed.
As discussed above with regard to Safety Recommendation A-16-34, we completed seven major accident investigations involving Part 135 on demand operators, in which 53 people died and another 4 were seriously injured. We believe this is evidence of a safety problem for which an SMS may be an effective mitigation. We are encouraged that you currently have a voluntary program to assist Part 135 operators in establishing an SMS; however, we also believe that to be consistent with fundamental SMS principles, it is necessary to measure how effective a mitigation is in addressing a safety risk.
To satisfy this recommendation, your planned determination regarding SMS for
January 9, 2017 · Recipient Response · FAA
-From Michael P. Huerta, Administrator: The FAA recently required part 121 certificate holders to have a Safety Management System (SMS) when it published the final rule. Safety Management Systems on January 8. 2015. In the notice of proposed rulemaking, the FAA considered that SMS could be applied to part 135 certificate holders at some point in the future. We would like to highlight that while SMS is not currently required of part 135 operators the FAA has a formal SMS voluntary program in which part 135 operators may participate.
We will conduct a review and hold meetings to determine the feasibility of recommending MS for part 135 certificate holders and determine if further action is needed.
operators to discuss improving the safety of the industry, and panel participants shared their perspectives on SMS.63 On May 11, 2023, we hosted a webinar that included a roundtable discussion with several small and midsized operators to explore how they implemented an SMS, the challenges they overcame, and the safety and economic benefits they were seeing (NTSB 2023b).
On January 11, 2023, the FAA issued an NPRM proposing to require an SMS for all Part 135 certificate holders (FAA 2023a, 1932). In our March 10, 2023, comments on the NPRM, we stated that we strongly supported the proposed expansion of SMS requirements to include Part 135 operations and noted that our investigations have consistently shown the need for aviation service providers to implement an SMS to ensure its benefits to the industry and the public are realized (NTSB 2023a, 3–4).
On April 26, 2024, the FAA issued its final rule to require all Part 135 operators to have an SMS, which is responsive to our recommendation. Thus, the NTSB concludes that the FAA’s SMS final rule, which requires all Part 135 operators to incorporate formal system safety methods into their internal oversight programs, will help these operators proactively identify and mitigate risks to prevent accidents. Therefore, the NTSB classifies Safety Recommendation A-16-36 CLOSED-- ACCEPTABLE ACTION in this report.
The FAA has noted that, by design, SMS is scalable to allow the integration of safety management practices into a unique business model for operators of any size (FAA 2015b, 21–46). However, during our investigation of the 2019 accident involving the air tour helicopter that encountered IMC and crashed in Kekaha, Hawaii, fatally injuring seven people, we found that the operator’s president (who was also the director of operations) mistakenly believed that the operation was too small to maintain an SMS (NTSB 2022a, 73). As a result of our investigation and to help ensure that small operators can successfully implement SMS, we recommended that the FAA do the following:
Develop guidance for small operators for scaling a safety management system that includes methods and techniques for implementation and specific examples applicable to several operational sectors, including air tours. (A-22-15)
In its 2023 NPRM, the FAA acknowledged that smaller operators (because they have fewer people) have fewer opportunities for checks and balances on decisions that can affect safety and that SMS can help mitigate this by creating a structure for proactively monitoring decision-making processes and addressing deficiencies.65 The FAA stated that, with SMS, “a one-person operator would have a system for documenting their own hazard information, actions, mitigations, safety performance, etc., for future reference” (FAA 2023a, 1940).
The FAA has also acknowledged that implementing an SMS could help single-pilot and single-PIC operators identify and mitigate such issues as operational control deficiencies (FAA 2023a, 1953–4; FAA 2016b, 3). We believe this is an important observation because, as described in section 1, nearly one-third of Part 135 certificate holders are single-pilot or single-PIC operators. Further, as discussed in section 2.2, although we believe that a certificated dispatcher could enhance the safety of all Part 135 operations, we are aware that hiring additional personnel may not be practical for single-pilot and single-PIC operators due to their limited size and scope.
Thus, the NTSB concludes that, for Part 135 operators of limited size and scope for which the hiring of a certificated dispatcher may not be practical (such as single-pilot and single-PIC operators), implementation of an appropriately scaled SMS that includes planning tools to analyze and assess the inherent risks in operations can help in the development of effective operational control strategies, including methods for ensuring adequate preflight weather, route, and fuel planning.
In the NPRM, the FAA stated that it was revising AC 120-92, “Safety Management Systems for Aviation Service Providers,” to include guidance and numerous examples for small operators on how to scale an SMS (FAA 2015b; FAA 2023a, 1953-4). However, in our comments on the NPRM, we noted that the FAA’s proposed revisions in the draft AC were too general.
In the SMS final rule, the FAA excepted “certain single-pilot operators” from requirements that would be impractical for their operations, such as certain recordkeeping, communication, and disciplinary action requirements that would not be applicable in organizations of their size (FAA 2024c, 33076).
The FAA’s final rule stated that guidance (including ACs) to help single-pilot organizations navigate the exceptions would be available about 30 days after publication of the final rule in the Federal Register (FAA 2024c, 33075).
We note that, in section 308 of the FAA Reauthorization Act of 2024, which was signed into law on May 16, 2024, Congress directed the FAA to consider the scalability of SMS in any regulation requiring SMS implementation, regardless of the size or complexity of the operation. On May 21, 2024, the FAA issued revised AC 120-92D, which included an appendix that provided potential methods that smaller aviation organizations, including single-pilot and single-PIC operators, could use when developing an SMS scaled to the size and complexity of their organization.
The appendix included a table that discussed various SMS implementation strategies and provided examples of how practices such as performance monitoring and documenting and managing hazards can be scaled and applied by smaller operators (FAA 2024d). The NTSB believes that the inventory of methods and techniques contained in this guidance will help operators of all sizes implement an effective SMS. Therefore, the NTSB classifies Safety Recommendation A-22-15 Closed—Acceptable Action in this report.
Safety Management Systems and Other Safety Assurance Processes
In 2016, we issued Safety Recommendation A-16-36, which urged the FAA to require all Part 135 operators to establish SMS.4 We were pleased to learn that on January 11, 2023, the FAA published a notice of proposed rulemaking (NPRM) announcing its intent to require such systems for Part 135 operators and air tour operators operating under 14 CFR 91.147. We strongly support the FAA’s proposed expansion of SMS requirements, which would include all Hawaii air tour operators.
We note that the draft AC states that a certificate holder “should present to the Administrator the method they will utilize to analyze, mitigate, and manage risks while conducting commercial air tour operations under the authorization” and that the FAA will review each certificate holder’s application as a whole and may recommend changes before approval. This appears to lay the groundwork for FAA verification of future SMS requirements.
Therefore, although the draft AC is not directly responsive to Safety Recommendation A-16-36, its reporting provision would allow the FAA to evaluate operators’ risk management strategies, including the applicable components of SMS, once the proposed new rule is implemented.
Our 2022 investigation report on the Kekaha accident also highlighted the importance of the safety assurance aspect of SMS for preventing a drift toward risky weather-related operating practices among Hawaii air tour pilots.
In that report, we issued Safety Recommendation A-22-16, which urged the FAA to issue a safety alert for operators (SAFO) to encourage air tour operators to establish safety assurance processes to routinely review recorded onboard videos and ADS-B flight tracking data, ideally as part of an SMS with an integrated flight data monitoring program, for the purpose of identifying and addressing risky trends in weather-related operating practices, such as encounters or near encounters with instrument meteorological conditions (IMC)-related hazards.
In August 2022, the FAA replied that it disagreed that issuing a SAFO to establish a safety assurance process is in the best interest of promoting aviation safety. The FAA pointed out that a formal safety assurance procedure currently exists in OpSpec B048, which requires that certificate holders conduct one formal commercial air tour safety meeting each year to discuss safety trends and Part 136, Appendix A issues.
However, we do not believe that OpSpec B048 is responsive to this recommendation, as the intent of this recommendation is to encourage air tour operators to review recorded ADS-B data to identify and track occurrences, such as a flight’s descent below a required minimum altitude, and review the circumstances of the event with the pilot in a nonpunitive fashion to explore what happened and learn about the integrity and effectiveness of existing risk controls. This recommendation is currently classified Open—Unacceptable Response.
We note that the draft AC lists FAA AC 120-92, Safety Management Systems for Aviation Service Providers, under a section titled “Related Reading Material” and that AC 120-92 includes information on all the major components of SMS. We also note that the draft AC encourages Hawaii air tour operators to engage in risk management. The draft AC states that the FAA may recommend that operators include additional safety risk analysis (a component of SMS), but it does not contain specific provisions that address the development of safety assurance processes like those described in Safety Recommendation A-22-16. Therefore, the draft AC is not responsive to Safety Recommendation A-22-16.
Safety Recommendation A-22-15, which was also issued as a result of the Kekaha investigation, urged the FAA to develop guidance for small operators for scaling an SMS that includes methods and techniques for implementation and specific examples applicable to several operational sectors, including air tours. Although the draft AC does not specifically discuss scaling an SMS for Hawaii air tour operators, we noted that the FAA has informed us that its ongoing SMS rulemaking effort will address this recommendation. Thus, Safety Recommendation A-22-15 is classified Open—Acceptable Response.
Safety Recommendation A-22-18 (also from our report on the Kekaha accident) urged the FAA to issue and periodically update a special airworthiness information bulletin (SAIB) that lists newly manufactured helicopters that are equipped with features likely to reduce accidents resulting from inadvertent encounters with IMC, describes retrofit options for helicopters that do not have such equipment, and encourages the voluntary integration of these safety features. This recommendation is classified Open—Await Response. Although this recommendation specifically called for the publication of an SAIB, we note that the draft AC does not encourage voluntary integration of such safety features.
It does, however, state that an operator should include in its application a description of any supplemental type certificates related to aircraft instrumentation and equipment. Therefore, although the draft AC is not responsive to Safety Recommendation A-22-18, we are pleased that it may increase the FAA’s awareness of any such equipment that may be installed.
operators establish SMSs. We issued this safety recommendation from the investigation into the 2015 crash of a
on demand charter flight in which all nine persons onboard the airplane died. Footnote: We issued Safety Recommendation A 16 36 on November 3, 2016, as part of the final report of the investigation into a November 10, 2015, accident in Akron, Ohio.
The Hawker 700A airplane operating as an on demand charter flight under 14 CFR Part 135 departed controlled flight while on approach to the airport and impacted an apartment building. For more information, see NTSB. 2016. Crash During Nonprecision Instrument Approach to Landing, Execuflight Flight 1526, British Aerospace HS 125 700A, N237WR, Akron, Ohio, November 10, 2015. AAR-16-03. Washington, DC: NTSB. In the years since, we reiterated this safety recommendation in the final reports of seven Part 135 accidents resulting in 39 fatalities and nine serious injuries, and it is currently classified Open—Unacceptable Response.
Footnote: These accidents involved HEMS, air tours, and on demand charter operations. See NTSB accident reports AAR-17-02, AAR-18-02, AAR-19-02, AAR-20-01, AAR-21-01, AAR-21-04, and AIR-22-05. For a history of reiterations and correspondence with the FAA about this safety recommendation, see Safety Recommendation A 16 36. In 2019, Safety Recommendation A 19 28 asked the FAA to require all commercial air tour operators, regardless of their operating rule, to implement an SMS. This safety recommendation resulted from the investigation of an air tour accident conducted under 14 CFR 91.147 in New York, New York, in which the five passengers on board died.
Footnote: For more information on this March 11, 2018, accident involving an Airbus Helicopters AS350 which lost engine power during cruise flight, see NTSB. 2019. Inadvertent Activation of the Fuel Shutoff Lever and Subsequent Ditching, Liberty Helicopters Inc., Operating a FlyNYON Doors Off Flight, Airbus Helicopters AS350 B2, N350LH, New York, New York, March 11, 2018. AAR-19-04. Washington, DC: NTSB.
In March 2021, we reiterated Safety Recommendation A 19 28 in our investigation report on the safety of revenue passenger-carrying operations conducted under Part 91; the safety recommendation is currently classified Open—Acceptable Response. We also issued two new safety recommendations in that report: Safety Recommendations A 21 13 and -14 expanded our call for SMSs to include all Part 91 revenue passenger carrying operations such as sightseeing flights conducted in hot air balloons, intentional parachute jump flights, living history flight experience and other vintage aircraft flights, among others. Both recommendations are currently classified Open—Acceptable Response.
Footnote: Safety Recommendation A 21 13 asked the FAA require SMSs for the revenue passenger-carrying operations conducted under Part 91 or 14 CFR 119.1(e) exceptions, and Safety Recommendation A 21 14 asked that the FAA provide ongoing oversight of each operator’s SMS once established. For more information, see NTSB. 2021. Enhance Safety of Revenue Passenger Carrying Operations Conducted Under 14 Code of Federal Regulations Part 91. AAR-21-03. Washington, DC: NTSB.
In November 2021, following an accident involving the cross-wiring of the airplane’s antiskid brake systems that resulted in one fatality, we issued Safety Recommendation A 21 48 asking the FAA to require organizations that design, manufacture, and maintain aircraft to establish an SMS. Safety Recommendation A 21 48 is currently classified Open—Await Response. Footnote: For more information, see NTSB. 2021. Runway Overrun During Landing, Peninsula Aviation Services Inc., d.b.a. PenAir flight 3296, Saab 2000, N686PA, Unalaska, Alaska, October 17, 2019. AAR 21-05. Washington, DC: NTSB.
Most recently, in May 2022, we issued Safety Recommendation A 22 15 asking the FAA to develop guidance for small operators for scaling an SMS that includes methods and techniques for implementation and specific examples applicable to several operational sectors, including air tours. Footnote: Safety Recommendation A 22 15 is currently classified Open—Initial Response Received. For more information, see NTSB. 2022. Collision into Terrain, Safari Aviation Inc., Airbus AS350 B2, N985SA, Kekaha, Hawaii, December 26, 2019. AIR-22-05. Washington, DC: NTSB.
In the 15 years since our first aviation safety recommendation for SMSs in 2007, our investigations have consistently shown the need for aviation safety providers to implement SMSs to ensure its benefits to industry and the public are realized.
Our specific comments on areas of the NPRM relevant to these open safety recommendations follow.
We strongly support the proposed expansion of SMS requirements to include Part 135 operations without exceptions for the size of the operator. Safety Recommendation A-16-36 applies to all Part 135 operators because our investigations demonstrated that catastrophic accidents in Part 135 operations occur across a wide range of operator sizes. We believe that the safety of all Part 135 operations can be improved through implementation of SMSs. If the FAA issues a final rule requiring SMS for all Part 135 operations, it will likely satisfy the intent of Safety Recommendation A 16 36.
We appreciate that the FAA has recognized the need for SMS for HEMS operations, as we have previously recommended.
We also strongly support the proposed expansion of SMS requirements to include all operators conducting air tours under 14 CFR 91.147. As with our discussion on Part 135, we note that Safety Recommendation A-19-28 applied to all operators conducting air tour operations under 14 CFR 91.147 regardless of size. If this aspect of the NPRM were adopted as presented, it would likely satisfy the intent of Safety Recommendation A 19 28.
We appreciate that the diversity of Part 135 operators requires the FAA to consider how the rule can be effectively interpreted and heeded by operators spanning a wide range of characteristics, including their size and type of operations and available resources; this also applies to air tour operators under 14 CFR 91.147. In the NPRM, the FAA sought feedback (Question 2) from industry on whether the requirement for SMS should be limited to a certain subset of 14 CFR Part 135 and 91.147 operators, and what alternatives would achieve the same safety objectives as SMSs for operators not included under an SMS rule.
However, the value of an SMS to an operator comes from proactive management of safety through implementation of its four clearly defined and interdependent
In the FAA’s January 9, 2017, response about this recommendation, it stated that it had established a formal SMS Voluntary Program in which
operator could apply for FAA recognition of its SMS and receive FAA assistance with implementing and validating it. An SMS developed within this program would be subject to ongoing FAA oversight and compliance monitoring to ensure it conformed with the safety policy, safety risk management, safety assurance, and safety promotion functions, which operators were expected to fully implement (FAA 2019b).
The FAA also said it would conduct a review and hold meetings to determine whether further action, such as an SMS requirement for Part 135 operators, was needed. In an April 13, 2020, update, the FAA stated that it was still evaluating the feasibility of rulemaking to take the recommended actions.
In the years since we issued Safety Recommendation A-16-36, we have reiterated it six times based on findings from investigations of other fatal accidents involving Part 135 operators that did not have a fully implemented SMS subject to FAA oversight (NTSB 2017b, 2018, 2019, 2020a, 2021a, and 2021b). On June 8, 2020, as a result of the FAA’s lack of responsive action, we classified Safety Recommendation A-16-36 “Open—Unacceptable Response.”
On October 27, 2020, the FAA administrator said during a speech at the FAA’s Rotorcraft Safety Conference that the FAA was hoping to publish a proposed SMS rule in 2022 that will apply to “air taxis,”“air tour operators,” and others (FAA 2020). On October 27, 2021, the FAA informed us that, in the fall of 2020, it had initiated a rulemaking project, “Safety Management System (SMS) for Parts 21, 91, 135, and 145,” which would apply SMS requirements to Part 135 certificate holders (among others).
Although the FAA has promoted Part 135 operators’ participation in its SMS Voluntary Program in advance of any potential rulemaking, we note that the participation level has been low. A review of FAA data showed that, as of February 2, 2022, 1,940 certificate holders were authorized to conduct Part 135 operations, but only 30 have an FAA-accepted SMS and 165 others (whose SMSs are in various stages of development) have applied for FAA acceptance.
Thus, although we are encouraged by the FAA’s initiation of a rulemaking project, pending timely publication of a notice of proposed rulemaking and completion of the recommended action, Safety Recommendation A-16-36 remains classified “Open—Unacceptable Response.”
Many of the safety issues identified in this accident could be mitigated through the implementation of SMS, not only for Safari but also for other air tour operators. For example, as discussed in section 2.5, although Safari had a company policy that defined expectations for pilot adherence to minimum weather requirements, it had no safety assurance feedback mechanism to reliably assess whether company strategies for ensuring that pilots avoid below-minimum weather conditions were working as intended.
Further, risk assessment of specific hazards could help Safari and other operators identify methods for improving pilot decision-making to reduce the likelihood of IMC encounters. This could involve, for example, providing pilots with more detailed, route-specific guidance that specifies certain decision points, such as which landmarks must be visible before they can proceed further along the tour route.
Thus, the NTSB concludes that the safety of all air tour operations, regardless of size, would be enhanced by the implementation of an SMS. Therefore, the NTSB reiterates Safety Recommendation A-16-36. Information that the FAA has disseminated on the framework of SMS notes that, by design, SMS is scalable to allow the integration of safety management practices into any size operator’s unique business model (FAA 2015). However, Safari’s president/DO was under the mistaken belief that Safari’s operations were too small to maintain an SMS.
Therefore, the NTSB also recommends that the FAA develop guidance for small operators for scaling an SMS that includes methods and techniques for implementation and specific examples applicable to several operational sectors, including air tours.
The FAA’s SMS Voluntary Program included provisions by which a Part 135 operator could apply for FAA recognition of its SMS and receive FAA assistance with implementing and validating it. An SMS developed within the FAA’s SMS Voluntary Program would also be subject to ongoing FAA oversight and compliance monitoring to ensure conformance with safety policy, safety risk management, safety assurance, and safety promotion functions, which operators were expected to fully implement.
The FAA did not respond again for 3 years until April 13, 2020, when it said it was still evaluating the feasibility of rulemaking to require SMS for Part 135 operators.
Given the delays experienced by this and several other rulemaking projects addressing NTSB recommendations, as well as the impact of Executive Orders 13771 and 13777 (requiring the removal of two regulations for every new regulation implemented), the FAA stated that it was considering potential alternate courses of action to address this recommendation (both executive orders were revoked on January 20, 2021, by Executive Order 13992).76 Because the FAA had not taken any further action to satisfy it, the NTSB classified Safety Recommendation A-16-36 as “Open—Unacceptable Response” on June 8, 2020.
In the 4 years since the FAA’s initial response, we have reiterated Safety Recommendation A-16-36 five times based on our findings from investigations of other fatal Part 135 operator accidents (NTSB 2017, 2018, 2019, 2020, and 2021). On October 27, 2020, during a speech at the FAA’s Rotorcraft Safety Conference, the FAA administrator said the FAA was hoping to publish a proposed SMS rule in 2022 that will apply to “air taxis,”“air tour operators,” and other types of operators (FAA 2020).
We are also aware that the Office of Management and Budget’s Fall 2020 Unified Agenda of Regulatory and Deregulatory Actions (published December 9, 2020) listed the NTSB Aircraft Accident Report FAA’s “Safety Management System (SMS)for Parts 21, 91, 135, and 145,” as a “long-term action” item (OMB 2020).77
We note that, although the FAA has promoted Part 135 operators’ participation in its SMS Voluntary Program in advance of any potential rulemaking, the participation level has been low.
A review of FAA data showed that, ofthe1,940 certificate holders currently authorized to conductPart135 operations, only 20have an FAA-accepted SMS;149others, whose SMS programs are in various stages of development, have applied for FAA acceptance.78The NTSB is encouraged
by the FAA’s reported intent for rulemaking, but until the FAA requires SMS for Part 135operators, Safety RecommendationA-16-36 remains classified “Open—Unacceptable Response.”
One of the components of SMS is safety risk management. According to AC120-92B, part of safety risk management includes performing a system analysis when a new system, system change, or new operational procedure is introduced. The system analysis is designed to identify hazards and implement control measures to mitigate those hazards. According to the director of operations at Taquan Air, he was not aware that the Chelton EFIS traffic alerting capability was lost when the equipment was upgraded to a RANGR 978 transceiver as part of the post-Capstone upgrade program.
However, a review of the flight manual supplement for the RANGR 978 transceiver indicated that it did not support traffic alerting.
Although Taquan Air implemented an SMS after the accident, it did not have one at the time. If it did, it is possible that a system analysis of the new equipment would have identified the loss of the traffic alerting capability in the flight manual supplement. If this change had been identified, the company could have evaluated the potential increase in risk associated with the removal of this safety protection and considered strategies for mitigating the increased risk of a midair collision introduced by this change.
Additionally, a system analysis could have identified the potential for broadcasting incomplete ADS-B information with the GSL71turnedoff. This realization could have prompted the implementation of design, training, or procedural safeguards (such as a checklist item) to protect against broadcasting incomplete location information before an accident occurred.
Thus, the NTSB concludes that if Taquan Air had been required to have an SMS at the time of the accident, the activities required by the safety risk management element would have provided better opportunities for Taquan Air to discover and mitigate the increased risk of airborne collision posed by changes to the Capstone-affiliated avionics installed in its aircraft, which provides another example of the value of SMS for all Part 135 operators. Therefore, the NTSB reiterates Safety Recommendation A-16-36.
The FAA’s SMS Voluntary Program included provisions by which a Part 135 operator could apply for FAA recognition of its SMS and receive FAA assistance with implementing and validating it. An SMS developed within the FAA’s SMS Voluntary Program would also be subject to ongoing FAA oversight and compliance monitoring to ensure conformance with safety policy, safety risk management, safety assurance, and safety promotion functions, which operators were expected to fully implement (FAA 2019d, 17-3-1-1 through -13).
The FAA also said it would conduct a review and hold meetings to determine whether further action was needed, such as whether the recently implemented final rule that required 14 CFR Part 121 operators to implement an SMS should be expanded to also cover Part 135 operators.
For 3 years, we received no further response from the FAA, but on April 13, 2020, the FAA informed us that it was still evaluating the feasibility of rulemaking to take the recommended actions. The FAA said that, in light of the delays experienced by this and several other rulemaking projects addressing NTSB recommendations, as well as the impact of Executive Orders 13771 and
61 Safety Recommendation A-09-89, issued September 24, 2009, recommended that the FAA require SMS for helicopter air ambulance operations. See appendix C for more information.
62 The final rule, “Helicopter Air Ambulance, Commercial Helicopter, and Part 91 Helicopter Operations,” was published on February 21, 2014.
63 See appendix C for more information.
13777 (requiring the removal of two regulations for every new regulation implemented), it was considering potential alternate courses of action to address Safety Recommendation A-16-36.
In the 4 years since the FAA’s initial response, we have reiterated this recommendation four times based on our findings from investigations of other fatal accidents involving Part 135 operators that did not have a fully implemented SMS subject to FAA oversight (NTSB 2017b, 2018, 2019, and 2020a). As a result of the FAA’s lack of responsive action, we classified Safety Recommendation A-16-36, “Open—Unacceptable Response.”
On October 27, 2020, the FAA administrator said during a speech at the FAA’s Rotorcraft Safety Conference that the FAA was hoping to publish a proposed SMS rule in 2022 that will apply to “air taxis,”“air tour operators,” and others (FAA 2020). We are also aware that the Office of Management and Budget’s Fall 2020 Unified Agenda of Regulatory and Deregulatory Actions (published December 9, 2020) listed the FAA’s “Safety Management System (SMS) for Parts 21, 91, 135, and 145,” as a “long-term action” item (OMB 2020).64
We note that, although the FAA has promoted Part 135 operators’ participation in its SMS Voluntary Program in advance of any potential rulemaking, the participation level has been low. A review of FAA data showed that, currently, of 1,940 certificate holders authorized to conduct Part 135 operations, only 17 have an FAA-accepted SMS and 158 others, whose SMSs are in various stages of development, have applied for FAA acceptance. Thus, although we are encouraged by the FAA’s reported intent for rulemaking, until the FAA requires SMS for Part 135 operators, Safety Recommendation A-16-36 remains classified “Open—Unacceptable Response.”
As the circumstances of this accident show, Island Express had the SMS tools and guidance available that outlined the safety assurance functions that could have helped the company ensure the effectiveness of its flight risk analysis forms. Had the SMS been required by the FAA, it would have been subject to FAA oversight to inspect the SMS for alignment with FAA objectives and to provide feedback to help the company implement its program. Thus, the NTSB concludes that a fully implemented, mandatory SMS could enhance Island Express’ ability to manage risks. Therefore, the NTSB reiterates Safety Recommendation A-16-36.
Additionally, the NTSB believes that Island Express should not wait for the FAA to take action on requiring SMS for Part 135 operators before fully implementing its SMS. Therefore, the NTSB recommends that Island Express participate in the FAA’s SMS Voluntary Program.
An effective SMS program establishes senior management’s commitment to continually improve safety and defines the processes and structure needed to meet safety goals. Concerning management structure, an effective SMS program advocates for a safety manager to report directly to top-level management, illustrating the safety department’s access to independent reporting and direct lines of communication and ultimately demonstrating the company’s prioritization of safety. Similarly, AC 120-92B instructs that a key element of creating a successful safety culture is the designation of the “accountable executive” who has the ultimate responsibility for safety management within the organization.
Often, safety initiatives can impact operations; therefore, a safety manager’s safety concerns should be considered independently of the DO’s operational concerns.
The NTSB has previously advocated for the implementation of SMS programs in commercial operations. As a result of an increase in fatal HAA accidents in 2008, the NTSB recommended that the FAA require all “[HAA] operators to implement [SMS] programs that include sound risk management practices” (A-09-89; NTSB 2009).
On February 21, 2014, the FAA issued a final rule, “Helicopter Air Ambulance, Commercial Helicopter, and Part 91 Helicopter Operations,” requiring HAA operators to incorporate additional tools and procedures to increase the overall safety of their operations. (FAA 2014)
On September 11, 2014, the NTSB replied to the FAA that although some of the tools and procedures required by the final rule included some of the elements of an effective SMS program, they were not a substitute for a complete program. Consequently, NTSB classified Safety Recommendation A-09-89 “Closed—Unacceptable Action.”
On September 24, 2014, the FAA replied that its goal was to require SMS for all Part 135 operators, including HAA operators. However, due to staffing limitations, an HAA-specific SMS rule could not be addressed at that time. The FAA also stated that it was developing requirements for participation in its SMS Voluntary Program and that the 21 HAA operators in the program operated 82% of HAA aircraft. In a December 5, 2014, response, the NTSB stated that although the FAA planned to eventually require SMS for all Part 135 operators, including HAA operators, Safety Recommendation A-09-89 remained classified “Closed—Unacceptable Action.”
In 2016, the NTSB recommended that the FAA “require all [Part 135] operators to establish [SMS] programs” as a result of the investigation of the November 10, 2015, fatal Part 135 airplane accident involving Execuflight flight 1526, a British Aerospace HS 125-700A (Hawker 700A) (A-16-36; NTSB 2016). In a response dated January 9, 2017, the FAA noted that Part 135 operators could participate in a voluntary SMS program. The FAA also stated its intention to conduct a review and hold meetings to determine if further action was needed on SMS for Part 135 operators.
On April 6, 2017, the NTSB replied that to be consistent with fundamental SMS principles, it is necessary to measure how effective a mitigation is in addressing a safety risk. To satisfy this recommendation, the FAA’s planned determination regarding SMS for Part 135 operators and necessary further action would require information on how many Part 135 operators had voluntarily implemented an SMS program compliant with the FAA’s SMS standards. Safety Recommendation A-16-36, was classified “Open—Acceptable Response” pending:
(1) Determination of whether the FAA’s formal voluntary SMS program is being widely implemented by Part 135 operators;
(2) Further effective action if it is determined that the data needed to make this determination are not available; or,
(3) If data are available, additional actions needed to ensure that SMS is widely implemented by Part 135 operators.
On April 13, 2020, the FAA sent a letter to the NTSB referencing current FAA actions surrounding several previously issued NTSB safety recommendations, including safety recommendation A-16-36. The FAA stated that it is continuing to evaluate the feasibility of rulemaking to require SMS for Part 135 operators.
In addition, rulemaking schedules are subject to revision and evaluation in accordance with Executive Order 13771, Reducing Regulation and Controlling Regulatory Costs, and Executive Order 13777, Enforcing the Regulatory Reform Agenda.90
In the 3 years since the FAA responded to this recommendation and in the 5 1/2 years since the last FAA response to Safety Recommendation A-09-89, the FAA has not taken any action or reported any plans to require an SMS program for all Part 135 operators.
The NTSB has since reiterated Safety Recommendation A-16-36 three times as a result of our investigations of other fatal Part 135 operator accidents (NTSB 2017, 2018, 2019).91 That recommendation is also listed on the NTSB’s 2019-2020 Most Wanted List of Transportation Safety Improvements under the issue area of “Improv
operators to establish safety management system programs” (Safety Recommendation A-16-36).
In a January 9, 2017, response concerning Safety Recommendation A-16-36, the FAA noted that
operators could participate in a formal voluntary SMS. The FAA also stated its intention to conduct a review and hold meetings to determine if further action was needed on SMS for
Our April 6, 2017, response to the FAA concerning Safety Recommendation A-16-36 again cited the results of our review of major accident investigations involving Part 135 on-demand operators (see the discussion of Safety Recommendation A-16-34). We stated that these accidents involved a safety problem that an SMS could have mitigated. Given the FAA’s stated intention of reviewing Part 135 operations regarding voluntary SMS, we classified Safety Recommendation A-16-36 “Open—Acceptable Response.”
The NTSB again recognized the benefits of SMS for Part 135 operators as a result of our investigation of the June 25, 2015, accident involving a de Havilland DHC-3 operated by Promech Air, which struck mountainous terrain northeast of Ketchikan, Alaska, in near-zero visibility conditions (NTSB 2017). The NTSB’s investigation found that Promech had an anonymous safety reporting system that company managers believed was effective. Promech’s director of operations stated his belief that the company’s informal flight risk assessment process accomplished the same objective as formal risk assessment forms (which he had used at other jobs).
The company president said that, typically, pilots verbally reported concerns to managers.
Despite their confidence in the company’s existing safety programs, Promech managers were unaware of serious incidents that had occurred. For example, the accident pilot had struck trees during a different takeoff; this event was known to other company pilots but had never been reported to management.
The NTSB concluded that, “although Promech had a hazard reporting system, the system was underused by the pilots, and the company’s informal safety processes were not effective for identifying major risks in the company’s flight operations and did not facilitate organizational learning about major areas of risk.” Similar to the Akron accident investigation, the NTSB concluded that an SMS could benefit all Part 135 operators because SMS requires the operators to incorporate formal system safety methods into their internal oversight programs. As a result, the NTSB reiterated Safety Recommendation A-16-36.
The recommendation was again reiterated as a result of the Togiak, Alaska, accident investigation. The NTSB noted that Hageland Aviation Services had three accidents in 3 years involving continued visual flight rules flight into instrument meteorological conditions.57 The NTSB believed that the similar circumstances of these three accidents indicated the potential for underlying safety issues that an SMS might have identified.
Trans-Pacific’s management (as with Promech’s and Hageland’s) likely believed its existing safety programs effectively identified and mitigated hazards. However, the company’s programs did not identify or mitigate the hazards that contributed to this accident.
For example, Trans-Pacific’s safety program did not identify or mitigate the hazard of unapproved (and likely inexperienced) SICs acting as PF. Similarly, Trans-Pacific did not identify the hazard associated with pairing two pilots who had both exhibited difficulties in training.
Under an SMS, Trans-Pacific’s progressive qualification policy could be considered part of the risk management component of SMS. In theory, the policy provided a structured way for SICs to develop experience (first under the supervision of management pilots or check airmen and then with company PICs).
However, Trans-Pacific lacked the safety assurance component of SMS that would have triggered a review of the progressive qualification policy. Such a review would have likely identified that SICs could not gain experience or advance according to the policy because no Learjet-qualified management pilots or check airmen were employed by the company during the time that the accident SIC was employed by the company.
As previously discussed, an FDM program would have provided the company information about how flights were being conducted during normal operations. SMS complements FDM because SMS ensures formal review of strategies developed to mitigate risks identified through FDM.
Thus, the NTSB concludes that an SMS would have improved Trans-Pacific’s ability to identify and mitigate risks because an SMS requires operators to incorporate formal system safety methods into their internal oversight programs. Therefore, the NTSB reiterates Safety Recommendation A-16-36. In addition, the NTSB notes that Safety Recommendations A-16-36 was associated with the “Improve the Safety of Part 135 Aircraft Flight Operations” issue area on the agency’s 2019-2020 Most Wanted List of Transportation Safety Improvements.
operators) killed 53 people and seriously injured 4. The NTSB believed that this was evidence of a safety problem for which an SMS may be an effective mitigation. The NTSB was encouraged by the FAA’s response that it has a voluntary program to assist
operators in establishing an SMS; however, pending further responsive action from the FAA, the NTSB classified Safety Recommendation A-16-36 “Open—Acceptable Response.”
On May 9, 2017, the NTSB reiterated the safety recommendation after its investigation of the previously referenced fatal CFIT accident in Ketchikan involving Promech (NTSB 2017a). Thus, the NTSB concludes that an SMS, which requires operators to incorporate formal system safety methods into their internal oversight programs, could help Hageland and other Part 135 operators identify and mitigate the types of risks identified in this accident investigation. Therefore, due to its relevance to the circumstances of this accident, the NTSB reiterates Safety Recommendation A-16-36.
The NTSB concludes that, although Promech had a hazard reporting system, the system was underused by the pilots, and the company’s informal safety processes were not effective for identifying major risks in the company’s flight operations and did not facilitate organizational learning about major areas of risk.
A more proactive safety program, like an SMS, could identify safety risks, seek to mitigate them, and foster a culture in which safety-related incidents are reported without embarrassment or fear of reprisal and in which the company focuses its efforts on the risks that pose the greatest potential threat to life and equipment.
SMS could help Promech learn from incidents (like the accident pilot’s tree collision and pilots’ turnarounds because of weather) and establish policies to reduce the risks of recurrence.
The FAA issued its final rule in January 2015 requiring SMS for Part 121 air carriers and included the key requirements for an SMS in newly created 14 CFR Part 5, “Safety Management Systems.” In its final rule, the FAA stated that its intent in developing Part 5 was to establish a uniform standard that could be extended to apply to other operating parts, including Part 135 (80 Federal Register 1308) (NARA 2015).
However, in the 2 years since Part 5 was established, the FAA has not initiated rulemaking to address SMS for Part 135 operators.
The NTSB also discovered operational safety issues during its investigation of the November 10, 2015, fatal accident involving a British Aerospace HS 125-700A airplane that departed controlled flight while on approach to an airport in Akron, Ohio (NTSB 2016). The airplane was operated under Part 135 by Execuflight, which did not have an SMS. Although not required, an SMS likely could have helped Execuflight and the FAA identify and correct the operational safety issues that contributed to the accident.
(The Execuflight accident report also referenced three other accidents involving Part 135 operators that could have benefitted from an SMS program.)44 As a result, on November 7, 2016, the NTSB issued Safety Recommendation A-16-36, which asked the FAA to “[r]equire all 14 [CFR] Part 135 operators to establish [SMS] programs.” As of the date of this report, Safety Recommendation A-16-36 is classified “Open—Initial Response Received.”
The safety benefits of SMS have been demonstrated by Part 121 carriers and Part 135 helicopter EMS operators who have voluntarily implemented SMS (Bergin 2013; Buckner 2013).
The FAA has a formal voluntary program that Part 135 operators can use to establish an SMS and has produced a video presentation, SMS for Small Operators, that shows how an SMS can be effectively scaled for a smaller operator, such as Promech.45 Because Part 135 operations often involve carrying passengers for hire, the FAA is responsible for ensuring that Part 135 operators have adequate safety protections in place for the flying public. The NTSB concludes that an SMS can benefit all Part 135 operators because they require the operators to incorporate formal system safety methods into their internal oversight programs.
Therefore, because of the relevance of Safety Recommendation A-16-36 to Promech’s accident, the NTSB reiterates the recommendation in this report.
operators have implemented Safety Recommendation A-16 36, which is classified OPEN--ACCEPTABLE RESPONSE pending:
(1) your determination whether your formal voluntary SMS program is being widely implemented by Part 135 operators;
(2) further effective action if it is determined that the data needed to make this determination are not available; or,
(3) if data are available, additional actions needed to ensure that SMS is widely implemented by Part 135 operators.