Saab 2000Peninsula AviationServices Inc.,

TO THE FEDERAL AVIATION ADMINISTRATION: 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.

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.

TO THE FEDERAL AVIATION ADMINISTRATION: Require organizations that design, manufacture, and maintain aircraft to establish a safety management system.

TO THE FEDERAL AVIATION ADMINISTRATION: 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.

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.

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.

TO EUROPEAN UNION AVIATION SAFETY AGENCY: 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.

TO THE EUROPEAN UNION AVIATION SAFETY AGENCY: 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 Acceptable Means of Compliance 25.1309, Systems Design and Analysis, and that the assessments evaluate and mitigate the potential for human error that can lead to a cross-wiring error.

TO THE EUROPEAN UNION AVIATION SAFETY AGENCY: Require organizations that design, manufacture, and maintain aircraft to establish a safety management system.

TO THE SAAB GROUP: Redesign the wheel speed transducer wire harnesses for the Saab 2000 airplane to prevent the harnesses from being installed incorrectly during maintenance and overhaul.