NTSB · Safety Recommendation
Safety Recommendation A-20-040
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Develop a system to automatically notify your inspectors of those flight instructors (within each inspector’s geographic area of responsibility) whose student pass rate in the Program Tracking and Reporting Subsystem has become substandard so that the inspectors can perform additional surveillance according to the guidance in Order 8900.1, Flight Standards Information Management System, volume 6, chapter 1, section 5, “Surveillance of a Certificated Flight Instructor.”
Safety Issue and Context
On June 21, 2019, about 1822 Hawaii-Aleutian standard time, a Beech King Air 65-A90 airplane, N256TA, impacted terrain after takeoff from HDH. The pilot and 10 passengers were fatally injured, and the airplane was destroyed by impact forces and a postcrash fire. The airplane was owned by N80896 LLC and was operated by Oahu Parachute Center LLC under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91 as a local parachute jump flight.
Response History
November 8, 2023 · NTSB Correspondence · FAA
We note that the FAA’s Safety Assurance System (SAS) includes a tool that enables your aviation safety inspectors (ASIs) to identify underperforming certified flight instructors (CFIs) when planning their surveillance activities and, therefore, you do not believe the system proposed in Safety Recommendation A-20-40 is needed.
We are concerned that no mechanism within SAS or PTRS notifies ASIs automatically when a CFI within their geographic area of responsibility has a substandard pass rate. In addition, because a CFI’s student pass rate during a 2-year period can change depending on when these systems are queried, random surveillance might not identify a weak CFI, especially if that surveillance is only conducted when the CFI’s certificate is scheduled for renewal. We point out that, although the accident pilot’s flight instructor had a substandard pass rate and was flagged in the PTRS, no surveillance activities had been performed.
We continue to believe that, if ASIs were automatically notified of CFIs with substandard student pass rates, the ASIs could perform, in a timely manner, the necessary surveillance to assess the CFIs’ performance. Therefore, we urge you to reconsider your position. In the meantime, pending the recommended action, Safety Recommendation A-20-40 is classified OPEN-- UNACCEPTABLE RESPONSE.
We issued Safety Recommendation A-20-41 because we realized the system proposed in Safety Recommendation A-20-40 could take some time to develop and, in the interim, we wanted you to direct ASIs to review PTRS on an ongoing basis to identify CFIs with a substandard pass rate. Although SAS contains a tool to assist ASIs in identifying underperforming CFIs, we are not aware of any action you have taken since this recommendation was issued to ensure that ASIs review this information on an ongoing basis, as recommended. Pending our timely receipt and review of a plan for taking this interim action, Safety Recommendation A-20-41 is classified Open—Unacceptable Response.
August 22, 2023 · Recipient Response · FAA
-From Kathryn Thomson, Deputy Administrator: The Federal Aviation Administration (FAA) previously stated it was developing a database tracking system to automatically alert field personnel of certificated flight instructors (CFI) who have a substandard pass rate for airmen applicants. After further review, we determined that our Safety Assurance System (SAS) has the capabilities to effectively address these recommendations.
The FAA is a data-driven organization using risk-based decision-making to guide its oversight and surveillance of CFIs. The SAS enables FAA Aviation Safety Inspectors (ASI) to focus on underperforming CFIs during their pre-inspection and surveillance planning phase by using the internal SAS Designee Management System (DMS) CFI Tool to identify student pass/fail rates. The DMS CFI Tool has a pass rate slider that allows ASIs to identify CFIs with a substandard 70 percent or below student pass rate, as outlined in Order 8900.1, Flight Standards Information Management System, Volume 6, Chapter 1, Section 5, Surveillance of a CFI. Per FAA guidance:
• The frequency of ASI surveillance for an individual CFI is based on many factors, including the number of students a CFI recommends for the practical test, with 20 applicants annually considered “high-activity.” Generally, an ASI will surveil a CFI with more students more frequently.
• The ASI is directed to initiate surveillance if the CFI has a student failure rate of 30 percent or more.
Order 8900.1 is available at the following website: drs.faa.gov
Due to these requirements, the FAA believes it is unnecessary to implement an automatic notification as recommended since an ASI must use SAS to develop a risk-based plan for their entire surveillance workload. The FAA considers these requirements, combined with an ASI’s use of SAS, to meet the intent of these recommendations.
I believe the FAA has effectively addressed Safety Recommendations A-20-40 and -41 and consider our actions complete.
August 24, 2021 · NTSB Correspondence · FAA
We note that you plan to develop a database tracking system that will automatically alert your inspectors of certified flight instructors (CFIs) who have a substandard pass rate for pilot applicants. We look forward to receiving updates as you progress toward this goal. In the meantime, pending completion of the recommended system, Safety Recommendation A-20-40 is classified OPEN-- ACCEPTABLE RESPONSE.
March 16, 2021 · Recipient Response · FAA
-From Steve Dickson, Administrator: The Federal Aviation Administration (FAA) will develop a database tracking system to automatically alert field personnel of certificated flight instructors (CFI) who have a substandard pass rate for airmen applicants. Appropriate agency guidance will also be established for the FAA’s aviation safety inspectors with airmen oversight responsibilities on how to conduct an increased level of surveillance of these CFIs.
I will keep the Board informed of the FAA’s progress on these safety recommendations and provide an update by April 30, 2022.
January 7, 2020 · NTSB Correspondence · FAA
The attached letter from the NTSB Chairman provides information about the NTSB’s December 16, 2020, report Provide Inspectors with Automatic Notification of Flight Instructors with Substandard Student Pass Rates, NTSB/ASR-20-06. 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.
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-20-40 through -42). 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) December 16, 2020, report Provide Inspectors with Automatic Notification of Flight Instructors with Substandard Student Pass Rates, NTSB/ASR-20-06. 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, we identified the following safety issues:
• Lack of a system to automatically notify Federal Aviation Administration (FAA) inspectors of flight instructors with substandard student pass rates • Need for better FAA inspector guidance regarding the circumstances necessitating surveillance of a flight instructor
Accordingly, the NTSB makes the following safety recommendations to the Federal Aviation Administration. Additional information regarding these recommendations can be found in the noted sections of the report.