NTSB · Safety Recommendation
Safety Recommendation A-21-048
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Require organizations that design, manufacture, and maintain aircraft to establish a safety management system.
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
July 10, 2025 · NTSB Correspondence · FAA
From Aviation Investigation Report AIR-25-04, “In-Flight Separation of Left Mid Exit Door Plug, Alaska Airlines Flight 1282, Boeing 737 9, N704AL Portland, Oregon January 5, 2024” published on July 10, 2025:
1.11.2.3.2 Voluntary Safety Management System
According to the FAA, 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. It includes systematic procedures, practices, and policies for the management of safety risk” (FAA 2024c).
At the time of the accident airplane’s production, there was no Part 21 regulatory requirement for Boeing to have an SMS. Footnote: (a) On April 26, 2024, the FAA published its final rule requiring production certificate holders to implement SMS, effective May 28, 2024, with most organizations, including Boeing, required to comply within 36 months.
FAA personnel assigned to Boeing expressed no concerns about the company’s ability to implement its regulatory SMS in the specified timeline. (b) The SMS final rule was responsive to a Congressional statutory mandate (in division 5, section 102 of the Consolidated Appropriations Act, 2021), recommendations from two aviation rulemaking committees, and, in part, NTSB Safety Recommendation A 21 48, which asked the FAA to require organizations that design, manufacture, and maintain aircraft to establish an SMS. (c) Title 14 CFR Part 21 outlines the processes and standards for certifying aircraft, associated products, components, and equipment, along with the organizations responsible for their design and manufacturing.
The regulation covers three primary certification categories: type, production, and airworthiness. However, in December 2015, the FAA had required Boeing to create an SMS as part of a settlement agreement developed to address multiple alleged quality and certification lapses. Footnote: The settlement agreement, which also required Boeing to adopt a regulatory compliance plan and implement an internal auditing system for its organization designation authorization unit, among other activities, was entered into by the FAA and Boeing to resolve allegations documented in 13 FAA enforcement investigative reports.