NTSB · Safety Recommendation
Safety Recommendation A-21-050
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Revise Order 8900.1, Flight Standards Information Management System, to include a formalized transition procedure to be used during a changeover of certificate management team personnel responsible for overseeing a certificate holder that is undergoing significant organizational change (for a reason described in volume 6, chapter 2, section 18 of the order) to ensure that incoming personnel are fully aware of potential safety risks.
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
We note that the FAA’s Safety Assurance System (SAS) includes information on all Part 121 air carriers, including details about any organizational changes they may be experiencing. We also note that Order 8900.1, Volume 3, Chapter 34, section 1, SAS: Mergers and/or Acquisitions of Operational Assets, states that all FAA personnel involved in a merger and acquisition should maintain constant communication, have a robust documentation process, and use SAS tools to ensure that the operators continue to operate at the highest level of safety.
We do not believe SAS or the section of 8900.1 that you referenced are responsive to this recommendation, which focuses on changes in FAA personnel that occur within a certificate management team that is overseeing a certificate holder undergoing significant change. In this accident, the POI and FLM for PenAir had been in those positions for 3 and 4 months, respectively, at the time of the accident, and neither had previous experience overseeing an air carrier merger. The POI’s transition to the position did not involve a formalized procedure that highlighted the former POI’s knowledge about challenges resulting from PenAir’s bankruptcy and subsequent acquisition and merger.
We continue to believe that Order 8900.1 should include a formalized transition procedure that ensures any incoming FAA personnel are made aware of potential safety issues that a certificate holder might be experiencing as a result of the significant organizational changes. However, because you have not taken or planned any actions to address this concern, the Board has classified Safety Recommendation A-21-50 CLOSED-- UNACCEPTABLE ACTION.
September 14, 2023 · Recipient Response · FAA
-From Kathryn B. Thomson, Deputy Administrator: The FAA continues to believe that current practices are sufficient. The FAA’s Safety Assurance System (SAS) provides aviation safety inspector-collected information on every Part 121