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  3. NTSB A-21-051
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NTSB · Safety Recommendation

Safety Recommendation A-21-051

Recommendation

TO THE FEDERAL AVIATION ADMINISTRATION: Include the runway design code for runways of intended use among the criteria assessed when authorizing a scheduled air carrier to operate its airplanes on a regular basis at an airport certificated under Title 14 Code of Federal Regulations Part 139.

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

April 1, 2026 · NTSB Correspondence · FAA

On July 25, 2025, FAA Administrator Bryan Bedford informed us that the agency is continuing the work described in its previous letter regarding Safety Recommendation A-21-51. We look forward to receiving your next update.

July 25, 2025 · Recipient Response · FAA

-From Bryan Bedford, Administrator: The Federal Aviation Administration (FAA) is developing a new Advisory Circular (AC) for air carriers to use when establishing FAA approved procedures outlined in 14 CFR 121.97 and 14 CFR 121.117, Airports: Required Data, which requires air carriers to show the existence of an approved system for obtaining, maintaining, and distributing to appropriate personnel current aeronautical data to ensure safe operations at the airports used by the air carrier. Our intent is to have the draft AC published by March 2026. The new AC will provide guidance for evaluating airports certificated under 14 CFR 139, which will include runway design codes.

After the new AC is published, we will update Order 8900.1, Flight Standards Information Management System. The current order is available on the following website: https://www.faa.gov/documentLibrary/media/Order/Order_8900.1A.pdf

I will keep the Board informed of the FAA’s progress on Safety Recommendation A-21-51 and anticipate providing an update by April 30, 2026.

February 26, 2025 · NTSB Correspondence · FAA
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Recommendation Facts

Status
Open - Acceptable Response
Issued
November 18, 2021
Priority
CLASS II
Recipient
FAA
Adopted
November 2, 2021
Related Investigation
DCA20MA002
Related Report
AAR-21-05

We note that you are developing a new AC that will include guidance to assist air carriers with developing approved systems for obtaining, maintaining, and distributing current aeronautical data for airports they service. We also note that the AC will incorporate guidance for evaluating Part 139 airports that includes the intended use criteria of runway design codes. Accordingly, the Board has classified Safety Recommendation A-21-51 OPEN-- ACCEPTABLE RESPONSE.

April 24, 2024 · Recipient Response · FAA

-From Michael G. Whitaker, Administrator: The Federal Aviation Administration (FAA) is developing a new Advisory Circular (AC) for air carriers to use when establishing FAA-approved procedures outlined in 14 CFR 121.97 and 14 CFR 121.117, Airports: Required Data, which requires air carriers to show the existence of an approved system for obtaining, maintaining, and distributing to appropriate personnel current aeronautical data to ensure safe operations at the airports used by the air carrier.

The new AC will provide guidance for evaluating airports certificated under 14 CFR 139, which will include runway design codes.

I will keep the Board informed of the FAA’s progress on Safety Recommendation A-21-51, and anticipate providing an update by February 28, 2025.

September 6, 2023 · NTSB Correspondence · FAA

We note that you have extended the review-and-research phase of your assessment of the intended use criteria of runway design codes. Pending the completion of your assessment and a plan for completing the recommended action, Safety Recommendation A-21-51 remains classified OPEN-- ACCEPTABLE RESPONSE.

March 31, 2023 · Recipient Response · FAA

-From Billy Nolen, Acting Administrator: The Federal Aviation Administration (FAA) continues its assessment of the intended use criteria of runway design codes. Due to competing priorities and resources, the review and research phase of this assessment has been extended and is now expected to conclude no later than December 31, 2023.

I will keep the Board informed of the FAA’s progress on Safety Recommendation A-21-51 and provide an update by March 31, 2024.

September 1, 2022 · NTSB Correspondence · FAA

We note that you are researching the intended use criteria of runway design codes and assessing changes needed to adopt this recommendation. We believe these are necessary first steps to addressing this recommendation. Pending the completion of your research and a plan for completing the recommended action, Safety Recommendation A-21-51 is classified OPEN-- ACCEPTABLE RESPONSE.

January 25, 2022 · Recipient Response · FAA

-From Steve Dickson, Administrator: The FAA is currently reviewing and researching the intended use criteria of runway design codes and assessing changes needed to adopt this recommendation. I will keep the Board informed of the FAA’s progress on these safety recommendations and provide an update by February 28, 2023.

November 18, 2021 · NTSB Correspondence · FAA

The attached letter from the NTSB Chairman provides information about the NTSB’s November 2, 2021, report Runway Overrun During Landing, Peninsula Aviation Services Inc. d.b.a. PenAir Flight 3296, Saab 2000, N686PA, Unalaska, Alaska, October 17, 2019, NTSB/AAR 21/05. 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-21-46 through -51). 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) November 2, 2021, report Runway Overrun During Landing, Peninsula Aviation Services Inc. d.b.a. PenAir Flight 3296, Saab 2000, N686PA, Unalaska, Alaska, October 17, 2019, NTSB/AAR-21/05. The details of this 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:

• 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 • Safety management systems for organizations that design, manufacture, and maintain aircraft.

Accordingly, the NTSB makes the following safety recommendations to the FAA. Additional information regarding these recommendations can be found in the noted sections of the report.

• Identify all currently certificated transport-category airplanes for which system safety assessments for landing gear systems did not consider human error that could lead to cross-wiring of antiskid brake system components, including the wheel speed transducers, and require manufacturers of transport-category airplanes without such assessments to perform the assessments and then implement mitigations to prevent cross-wiring of antiskid brake system components. (A-21-46) (See section 2.3.4.1.)

• 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. (A 21-47) (See section 2.3.4.1.)

• Require organizations that design, manufacture, and maintain aircraft to establish a safety management system. (A-21-48) (See section 2.3.4.2.)

• Notify principal operations inspectors and frontline managers about the circumstances of this accident and emphasize the importance of existing Federal Aviation Administration guidance for detecting and mitigating the safety risks that can result when certificate holders experience significant organizational change, such as high personnel turnover, a reduction to route structures or flight schedules, bankruptcy, acquisition, and merger. (A-21-49) (See section 2.5.1.)

• 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. (A-21-50) (See section 2.5.1.)

• Include the runway design code for runways of intended use among the criteria assessed when authorizing a scheduled air carrier to operate its airplanes on a regular basis at an airport certificated under Title 14 Code of Federal Regulations Part 139. (A-21-51) (See section 2.5.2.)

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 (Safety Recommendations A-21-46 through -51). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply, including attachments, exceeds 20 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.