NTSB · Safety Recommendation
Safety Recommendation A-21-047
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Require the submission and consideration of system safety assessments addressing the landing gear antiskid system for the certification of future transport-category airplane designs. The certification should ensure that the system safety assessments are consistent with the intent of Advisory Circular 25.1309, System Design and Analysis, and that the assessments evaluate and mitigate the potential for human error that can lead to a cross-wiring error.
Safety Issue and Context
This report discusses the October 17, 2019, accident involving a Saab SA-2000 airplane, operated by Peninsula Aviation Services Inc. d.b.a. PenAir flight 3296, which overran the end of runway 13 at Unalaska Airport, Unalaska, Alaska. The airplane was substantially damaged during the runway overrun; as a result, of the 3 crewmembers and 39 passengers aboard, 1 passenger sustained fatal injuries, and 1 passenger sustained serious injuries. Eight passengers sustained minor injuries, most of which occurred during the evacuation.
Safety issues identified in this report include the potential for cross-wiring of airplane antiskid brake systems; insufficient Federal Aviation Administration (FAA) guidance to identify safety risks for air carriers experiencing significant organizational changes, including bankruptcy, acquisition, and merger; lack of FAA consideration of runway safety area dimensions during the process of authorizing an air carrier to operate its aircraft at a specific Title 14 Code of Federal Regulations Part 139 certificated airport, and the benefits of safety management systems for design, manufacturing, and maintenance organizations.
As a result of this investigation, the National Transportation Safety Board makes six new safety recommendations to the FAA, three new safety recommendations to the European Union Aviation Safety Agency, and one new recommendation to the Saab Group.
Response History
February 26, 2025 · NTSB Correspondence · FAA
In our March 2, 2023, comments responding to your “System Safety Assessments” notice of proposed rulemaking (NPRM), we informed you that the NPRM, as proposed, would not satisfy this recommendation. Specifically, we expressed our concern that the guidance contained in draft AC 25.1309-1B only applied to analyzing some failures in the brake system, and that the NPRM did not propose any requirements for SSAs related to human error that could lead to cross-wiring of antiskid brake system components, including the wheel speed transducers.
We are aware that, on August 27, 2024, you published the SSA final rule and, on August 30, 2024, you published AC 25.1309-1B. We note, however, that the final rule and AC do not address the concerns we raised in our NPRM comments. Because you have not reported any additional plans to address this recommendation, the Board has classified Safety Recommendation A-21-47 CLOSED-- UNACCEPTABLE ACTION.
March 7, 2024 · Recipient Response · FAA
-From Michael G. Whitaker, Administrator: The Federal Aviation Administration (FAA) received the Board’s letter, dated April 19, 2023, offering the following notes: • The existing regulations, policies, and guidance were implemented prior to the PenAir accident.
• The system safety assessments (SSA) did not address the failure mode related to the cross-wiring of the wheel speed transducers during maintenance or overhaul, nor propose any requirements related to human error in these instances.
• Comments responding to the SSA Notice of Proposed Rulemaking (NPRM) state the guidance contained in draft Advisory Circular (AC) 25.1309-1B would apply to analyzing some failures in the brake system, but it doesn’t propose any requirements for SSAs related to human error that could lead to cross-wiring of antiskid brake system components.
The FAA intends to address the Board’s comments concerning the proposed rule as part of the final rule. We are unable to address these comments in this letter due to the restrictions in the Department of Transportation’s ex parte communication guidance. In the 2023 Fall Unified Agenda, the FAA noted that it expects to publish the final rule in May 2024. Additional information for this regulatory action is available at the following website: