Safety Recommendation A-20-013

You reported that aviation safety inspectors (ASIs) and POIs with any rotorcraft experience are difficult to hire, and those with HAA experience are even harder to find. We note that requiring HAA experience to become an HAA POI would reduce the current number of ASIs and, without replacements, could limit overall safety. We also note that you currently offer recurrent and specialized training in specific areas, using subject matter experts from within the FAA who serve as course mentors.

The POI that was assigned to the accident operator had limited helicopter experience, did not hold a rotorcraft rating on his commercial pilot certificate, and had no experience with HAA operations. We believe developing specialized training for POIs assigned to HAA operations that addresses these areas and is led by other POIs with HAA experience could be an acceptable alternative solution to this recommendation. We request that you consider this or other alternative solutions. In the meantime, pending our review of a plan for addressing this important safety issue, Safety Recommendation A-20-13 is classified OPEN-- ACCEPTABLE ALTERNATE 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 Kathryn B. Thomson, Deputy Administrator: The Federal Aviation Administration (FAA) hires aviation safety inspectors (ASIs) and POIs (who are essentially lead ASIs) based on minimum qualification standards set by the Office of Personnel Management (OPM) in Aviation Safety Series 1825. These minimum qualifications standards are based on education, skill, and experience and are available at the following website: https://www.opm.gov/policy-data-oversight/classification-qualifications/general-schedule-qualification-standards/1800/aviation-safety-series-1825

Additionally, the FAA requires initial training for all newly hired ASIs, which enables ASIs to perform their basic job functions. The FAA also offers and conducts recurrent and specialized training in specific areas, using subject matter experts in the FAA to serve as course mentors.

Under current and historic hiring practices, the FAA would be unable to fill important ASI/POI positions if it implemented this recommendation. ASIs and POIs with any rotorcraft experience are difficult to hire, which becomes more challenging when limiting experience to HAA. Many ASIs with extensive, varied experience often become POIs. The FAA values an ASI’s diversity of experience, as best practices are often transferred to various operations, including HAA. Requiring HAA experience to become an HAA POI would not only eliminate good, qualified ASIs, but a de facto stove piping would occur, limiting overall safety. For these reasons, the FAA cannot implement Safety Recommendation A-20-13.

I believe the FAA has effectively addressed Safety Recommendation A-20-13 and consider our actions complete.

You reported that this recommendation requires further coordination with various offices within the FAA; however, you did not specify which offices will be involved or the specific actions those offices are taking. Pending our review of a more detailed plan, Safety Recommendation A 20-13 remains classified OPEN--AWAIT RESPONSE.

-From Steve Dickson, Administrator: The Federal Aviation Administration (FAA) is currently reviewing this safety recommendation. Due to its complexity and the involvement of various stakeholders, this recommendation will require further coordination with various offices throughout the FAA.

The attached letter from the NTSB Chairman provides information about the NTSB’s May 19, 2020, report Helicopter Air Ambulance Collision with Terrain, Survival Flight Inc., Bell 407 Helicopter, N191SF, near Zaleski, Ohio, January 29, 2019, NTSB/AAR-20/01. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary.

The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (for example, A-20-13 and -17). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply exceeds 20 megabytes, including attachments, please e mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response.

This letter provides information about the National Transportation Safety Board’s (NTSB) May 19, 2020, report Helicopter Air Ambulance Collision with Terrain, Survival Flight Inc., Bell 407 Helicopter, N191SF, near Zaleski, Ohio, January 29, 2019, NTSB/AAR-20/01. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov.

As a result of this investigation, the NTSB identified the following safety issues:

• Survival Flight’s lack of comprehensive and effective flight risk assessment and risk management procedures. • The lack of a positive safety culture endorsed by Survival Flight management and the lack of a comprehensive safety management system. • Need for flight data monitoring programs for helicopter air ambulance (HAA) operators. • Lack of HAA experience for principal operations inspectors assigned to HAA operations. • Lack of accurate terminal doppler weather radar data available on the HEMS (helicopter emergency medical services) Weather Tool. • Lack of a flight recorder.