Summary of Federal Aviation Administration Responses to National Transportation Safety Board Safety Recommendations

quarter covered by the report. Acesio ,l Fo DTTC Ar jus: " aIV " ilr-I III_--- ("OPETED TABLE OF CONTENTS Initial FAA Responses: NTSB Rec. No. Subject Pa.e A-81-73 Italian Agusta 109A helicopter accident, Pittsburgh, Pennsylvania January 16, 1981 A-81-74 Cascade Airways Beech 99A crash 5 southwest of Spokane, Washington January 20, 1981 A-81-75 & -76 Cascade Airways Beech 99 crash 9 near Spokane, Washington January 20, 1981 A-81-80 & -81 Mitsubishi MU-2 accident 14 near Sky Harbor Airport Henderson, Nevada April 23, 1980 A-81-83 & -84 Beechcraft Model B19 crash after 19 takeoff from Kinston, N. Carolina June 23, 1980 A-81-88 thru Beetchcraft E-90 crash near 24 -91 Michigan City, Indiana December 7, 1980 A-81-92 Lockheed Jet Star crash at 32 Westchester County Airport near White Plains, New York February 11, 1980 A-81-93 Israel Aircraft Industries 35 Model 1124 accident near Iowa City, Iowa September 2, 1980 A-81-94 & -95 Rockwell Aero Commander 690A 39 crash south of Will Rogers Airport Oklahoma City, Oklahoma January 30, 1980 A-81-96 Piper PA-32R nose landing guar collapse during rollout after landing at Raeford, N. Carolina September 3, 1980 v TABLE OF CONTENTS (con't) Initial FAA Responses Continued: NTSB Rec. No. Subject A-81-97 & -98 Eastern Airlines incident flying 47 from New Orleans, Louisiana, to John F. Kennedy International Airport, New York, New York April 8, 1981 A-81-99 & -100 Ransome Airlines Nord 262 51 decompression in flight December 3, 1980 A-81-101 & -102 Robinson R-22 helicopter crash 55 at Granby, Connecticut September 1, 1981 A-81-104 thru McDonnell Douglas DC-9-80 skidded 60 -112 & A-81-122 off runway attempting simulated & -123 hydraulic systems inoperative landing at Yuma International Airport, Yuma, Arizona June 19, 1980 A-81-115 thru NTSB report on aircraft structural 75 -118 iting A-81-119 & -120 Summit Airlines Convair 580 85 incident departing Norfolk, VA December 30, 1980 A-81-121 Interstate Airlines Convair 580 89 incident at Logan International Airport, Boston, Massachusetts August 7, 1980 A-81-124"thru World Airways DC-10-30 inflight 93 -127 accident from Baltimore-Washington International Airport to Gatwich International Airport, United Kingdom September 19, 1981 A-81-128 thru NTSB special investigation of the 99 -131 evacuation of United Airlines DC-8-61 December 29, 1980 vi TABLE OF CONTENTS (con't) Followup FAA Responses: NTSB Rec. No. Subject Page A-80-90 thru 95 NTSB "Special Study--General 121 Aviation Accidents: Post Crash Fires and How to Prevent or Control Them" A-81-1 thru -5 Lockheed L-1011-200 in-flight 129 failure of main landing gear inboard wheel flange A-81-39 thru -42 Beech B-99 accident 4.5 miles 140 southwest of Spokane International Airport, Spokane, Washington JanuRry 20, 1981 A-81-59 & -60 Bell 206L-1 helicopter engine 148 flame out March 25, 1981 A-79-5 General Aviation engine-starter 155 system failures A-76-97 thru Accidents involving light twin-engine 169 -100 performance characteristics A-81-33 Avions Marcel Dassault Breguet Falcon 182 10, N253K, crash into Lake Michigan on January 30, 1980 A-81-19 & 20 Boeing 727 crash into water near 189 Pensacola, Florida May 8, 1978 A-81-24 Scenic Airlines Cessna 404 crash 198 during takeoff from Grand Canyon National Park Airport, Tusayan, Arizona July 21, 1980 A-81-45 Bellanca 7 KCAB Decathlon crash in 207 Queenstown, Maryland March 7, 1979 vii ILI. .. .. -: l-:lilll- TABILE OF CONTENTS (con' t) Initial FAA Responses Continued: NTSB Rec. No. Subject. A-k1-132 thru NTSB Special lnvestig.,,:ion Report - 106 -13,i "Air.:raft Separ.,tiorn Inc ident nt Hartsfield Atlanta International Airport, Atlanta, Gcorgi; October 7, l1,,O A-1-1II4 U.S. Air McDonnell Douglas DC-9-30 113 incident, Dulles Inter-i-itional Airport June 21, 19%lI A-61-153 Swearingen SA-226 Metro 1I incident 117 at Indianapolis Internatioi.1 Airport February 13, 1981 New Recommendations 41'3 Followup FAA Responses 121 viii TABLE OF CONTENTS (con't) Followup FAA Responses: NTSB Rec. No. Subject A-S1-70 Northwest Airlines, Inc. DC-1O-40 215 No. 3 engine failure while climbing on departing Dulles International Airport January 31, 1981 A-76-136 & 137 Incidents involving wet runway 224 overruns A-73-2 & -5 Special Study; In-flight Safety of 245 Passengers and Flight Attendants Aboard Air Carrier Aircraft A-74-98 Board's investigation of two fires 251 that occurred in lavatory waste containers of a Boeing 747 and Boeing 727 A-74-102 & -103 Trans World Airlines B-707 263 accident at Los Angeles, California, on January 16, 1974 A-79-9 & -10 National Airlines B-727 crashed 269 into Escamhia Bay on May 8, 1978 A-78-57 & -58 Semco Model T hot air balloon 274 accident near Mosquero, New Mexico, on November 6, 1977 A-73-66 Mohawk Airlines FH-227B accident 286 at Albany, New York, on March 3, 1972 A-76-64 Overseas National Airways, DC-10-30F 291 accident at John F. Kennedy International Airport on November 12, 1975 A-77-43 & -44 Beechcraft Baron 58 crashed after 309 takeoff from the Chillicothe Municipal Airport, Chillicothe, Missouri on August 3, 1976 A-81-14 United Air Lines, DC-8-61 aircraft, 323 crash near Portland International AirIpor" , llort laid, Orc ol, on I ' , r :'4, 178 ix TABLE OF CONTENTS (cont'd) Followup FAA Responses: NTSB Rec. No. Subject A-79-21 thru -24 Learjet Model 24B, Nl4BC, 333 incident while en route from Greensboro, North Carolina to Nashville, Tennessee on March 9, 1979 A-78-36 Aero Tek Quni glider accident 347 at Moriarty, New Mexico on May 23, 1977 A-81-63 Northwest Orient Flight 79 353 incident at Dulles International Airport on January 31, 1981 A-80-41 deHavilland DHC-6-200 crash 361 at Knox County Regional Airport, Rockland, Maine on May 30, 1979 A-79-79 Boeing 707-323C accident 373 approaching Chicago O'Hare Airport on September 18, 1979 A-80-123 Bell 206B helicopter crashed 381 near Brighton, Utah, on May 9, 1980 A-79-48 & -49 Antilles Airboats Grumman G-21 369 accident near St. Croix, U.S. Virgin Islands, A-80-106 Aerospatiale 341G Gazelle helicopter 407 incident on May 14, 1980 x NEW RECOMMENDATIONS Following is a listing of the 27 new recomendations received during the fourth quarter of 1981: NTSB Rec. No. Subject Page A-81-128 thru -131 United Airlines, DC-8-61, 413 incident on December 29, 1980, at Phoenix, Airzona A-81-132 thru -138 NTSB Special Investigation of an 417 incident which occurred on October 7, 1980, at 1artsfield International Airport, Atlanta, Georgia A-81-139 thru -143 NTSB Special Study regarding 419 Cabin Safety in Large Transport Aircraft A-81-144 U.S. Air McDonnell-Douglas 423 DC-9-30, incident at Washington National Airport, Washington, D.C., on June 23, 1981 A-81-145 thru -147 NTSB Special Investigation of 425 the ATC System of the United States regarding fatigue & stress A-81-148 & -149 Beechcraft Model E 90, accident 428 on December 7, 1980, after departing O'Hare International Airport, Chicago, Illinois A-81-153 Swearingen SA-226 Metro 11 431 airplane incident on February 13, 1981, at Indianapolis International Airport. A-81-154 thru -156 NTSB Special Investigation of 433 ATC System of the United States regarding controller workforce levels xi SUMMARY Statistics for CY 1980 included: 156 new recommendations issued to the iAA 105 recommendations officially "closed" during this period The following exchanges of NTSB/FAA correspondence concerning NTSB Safety Recommendations occurred during the fourth quarter, October I - December 31, 1981: o FAA initial responses to NTSB recommendations: 22 letters involving 58 recommendations. o FAA letters to NTSB discussing reconsideration of earlier responses, current status, or followup actions: 29 letters involving 54 recommendations. o FAA "final report" letters to NTSB: 41 letters involving 63 recommendations. Officially "Closed" by the NTSB during this quarter: 31 reconmendations. xii National Transportation Safety Board WasWhmgton, D.C. 20584 November 13, 1981 Office of the Chairman Honorable J. Lynn Helms Administrator Federal Aviation Administration Washington, D.C. 20591 Dear Mr. Helms: Thank you for your letter dated October 6, 1981, responding to National Transportation Safety Board Safety Recommendation A-81-73 issued July 21, 1981. This recommendation stemmed from our investigation of an Agusta 109A helicopter accident in Pittsburgh, Pennsylvania on January 16, 1981. We recommnended that the Federal Aviation Administration (FAA) revise the Agusta 109A helicopter maintenance manual to specify a more detailed daily inspection requirement, a maintenance service interval for lubrication, and an approved lubricant to be used on tailrotor driveshaft bearinqs. The FA's responsive actions more than fulfill Safety Recommendation A-81-73 which is now classified "Closed--No Longer Applicable." Sincerely yours, 61, A 0 US Department (t , of Transporltton LU Federal Aviation Administration October 6, 1981 The Honorable James B. King Chairman, National Transportation Safety Board 800 Independence Avenue, SW. Washington, D.C. 20594 Dear Mr. Chairman: This is in response to NTSB Safety Recommendation A-81-73 issued by the Board on July 21, 1981. A-81-73. FLvise the Agusta 109A helicopter maintenance manual to specify a more detailed daily inspection requirement, a maintenance service interval for lubrication, and an approved lubricant to be used on tailrotor driveshaft bearings. FAA Comment. The Federal Aviation Administration (FAA) concurs in this reooimendation. A revision to the helicopter maintenance manual dated January 29, 1981, prescribes daily inspections of the tailrotor driveshafts, supports, and hangar bearing assemblies. Agusta Service Bulletin 109-30 issued March 25, 1981, prescribes procedures for inspection and lubrication of the tailrotor driveshaft bearings with MIL-G-21164C (Aeroshell Grease 17) at 600-hour intervals. In addition the FAA is currently processing an airworthiness directive to require daily inspections of the tailrotor driveshaft bearings and inspection and lubrication at 600-hour intervals in accordance with Service Bulletin 109-30. Enclosed are copies of the maintenance manual revision and Service Bulletin 109-30. We believe these measures are fully responsive to Safety Reommendation A-81-73, and the FAA considers action completed on this reccimendat ion. Sincerely, J. Lynn Helms Administrator Enclosures (W2b NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. ISSUED: July 21, 1981 Forwarded to: Honorable J. Lynn Helms Administrator Federal Aviation Administration SAFETY RECOMMENDT 10S (S) Washington, D.C. 20591 A-81-73 On January 16, 1981, the National Transportation Safety Board investigated an aircraft accident in Pittsburgh, Pennsylvania, involving an Italian Agusta 109A helicopter. The investigation disclosed that the No. 7 tailrotor driveshaft bearing had failed, which resulted in the failure of the tubular tailrotor shaft tubing. The exact reason for the failure of the bearing could not be determined; however, there was no lubrication on the bearing parts. This is the first known failure of the bearing and driveshaft assembly. There are no overhaul or replacement time limits on either the driveshaft or its seven bearings; however, they are required to be inspected visually during preflight. The No. 7 bearing and its support are located in the base of the vertical stabilizer assembly and previously could only be inspected by removing a piece of skin. The inaccessibility of the bearing and its support could have been a factor in whether or not an adequate daily preflight inspection was performed. Access to six bearings for inspection involves removing the hinged tailcone cover. Since the accident, all similar aircraft in this country have had an inspection door installed in order to perform inspections of the No. 7 bearing more easily. All aircraft coming off the assembly line now have an inspection door installed. While the bearing accessibility problem has been solved, the maintenance manual, Chapter 65-30-17, page 204, does not describe clearly the manner of inspecting and maintaining the bearings. It does not require the removal of the bearing covers to examine the internal areas of the bearings for lubrication and general condition. The manual does not require inspection of the overall condition of the rubber collars which clamp the bearing's inner race to the tailrotor driveshaft. Although required by the maintenance manual, there were no slippage marks on the No. 7 bearing, on the other six driveshaft bearings, or on the tailrotor driveshaft. Also, the lubrication requirements stated in the maintenance manual do not specify a lubricant nor lubrication intervals for the tailrotor driveshaft bearings. The failure to specify lubrication intervals and an approved lubricant may have contributed to the lack of lubrication in this case. 3297 of, -2- Therefore, the National Transportation Safety Board recommends that the Federal Aviation Administration: Revise the Agusta 109A helicopter maintenance manual to specify a more detailed daily inspection requirement, a maintenance service interval for lubrication, and an approved lubricant to be used on tailrotor driveshaft bearings. (Class II, Priority Action) (A-81-73) KING, Chairman, DRIVER, Vice Chairman, MeADAMS, GOLDMAN, and BURSLEY, Members, concurred in this recommendation. . O m ! I G4 US Deporlment 2. e o he Ao s:,1d, , , ' ol Trorsc)oriOtion Federal Aviation Administration OCT 27 1981 The Honorable James B. King Chairman, National Transportation Safety Board 800 Independence Avenue, SW. Washington, D.C. 20594 Dear Mr. Chairman: This is in response to NTSB Safety Recornendation A-81-74 issued by the Board on July 28, 1981. This recommendation resulted from the Board's investigation of the crash of Cascade Airways, Inc., Flight 201, a Beech 99A near Spokane, Washington, on January 20, 1981. Investigation of the accident revealed that Flight 201, operating on an instru- ment flight rules (IFR) flight plan in instruTent meteorological conditions, was initially vectored for an instrument landing system (ILS) approach to runway 21 after contacting.Spolane approach control. When the active runway was later changed to runway 3, Flight 201 was vectored to the final approach course even though activation of the localizer for runway 3 was delayed to allow another aircraft to oorplete its ILS approach and landing on runway 21. When the localizer for runway 3 was activated, Flight 201 was advised promptly and given the aircraft's position as 6 miles from the OLAKE intersection. Based on an analysis of the investigative evidence and the operation and display of the distance mxasuring equipment (EME) mode selector installed in the accident aircraft, the Safety Board concluded that the crew probably used the LJE from the Spokane ADRTAC (located 4.2 miles from the end of the runway) rather than the E[ME associated with the localizer (located at the end of the runway). A-81-74. Require in future radio navigation instrument installations, that all frequencies being received through navigational receivers that are providing essential navigational information (directional guidance or distance) be dis- played so that the source of the navigational signal can be readily discerned by the pilot. FAA Coumment. The Federal Aviation Administration (FAA) concurs in the intent of Reconimendation A-81-74. However, we plan no regulatory amendments relative to this recornmndation because current regulations, specifically Sections 23.1301, 25.1301, 27.1301, and 29.1301, are considered adequate for iiijpl(iiietation of the requiremnents def ined in the .ecoinendation. 2 In order to satisfy the intent of this recoit-vendation, w plan to review thu feasibility of including a new requirement in future radio navigation instru.ment design criteria. This addition would insure that all frequencies or station identifiers providing essential navigational information (directional guidance or distance) be displayed in such a way that the source of the navigational signal can be readily discerned by the pilot. If the results of our feasibility review indicate a need for new requireitents in future design criteria, the PAA will then issue guidance Taterial and pursue further appropriate action. The Board will be infonid of the results of our efforts in this area. Sincerely, J. Lynn Helms Administrator k.i NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. ISSUED: July 28, 1981 Forwarded to: Honorable J. Lynn Helms Administrator Federal Aviation Administration SAFETY RECOMMENDAT ION S W.ashington. T).(-. 20591 A-81-74 On January 20, 1981, Cascade Airways, Inc., Flight 201, a Beech 99A, crashed about 4.5 miles southwest of Spokane International Airport, Spokane, Washington. The flizht was operating as a scheduled commuter under 14 CFR Part 135. The National Transportation Safety Board's investigation of the accident revealed that Flight 201, operating on an instrument flight rules (IFR) flight plan in instrument meteorological conditions, was initially vectored for an instrument landing system (ILS) approach to runway 21 after contacting Spokane approach control. When the active runway was later changed to runway 3, Flight 201% was vectored to the final approach course even though activation of the localizer for runway 3 was held up to allow another aircraft to complete its ILS approach and landing on runway 21. When the localizer for runway 3 was activated, Flight ?01 was advised promptly and given the aircraft's Dosition as 6 miles from the OLAKL intersection. Based on an analysis of the investigative evidence and the operation and disln of the distance measuring equipment (DME) mode selector installed in the accident aircraft. the Safety Board concluded that the crew probably used the DMIE from the SDokane VORTAC (located 4.2 miles from the end of the runway) rather than the DME associated with the localizer (located at the end of the runway). Cascade 201 was equipped with a DME-select switch which had four positions labeled "DME 1", "DME hold", "DME 2", and "RNAV." This feature allows the pilot to do the following: with the "DMIE I" button depressed, the DME is automatically tuned to the same frequency as the No. 1 navigation radio. If the pilot then pushes the "DME hold" button and retunes the No. I navigation radio, the DME remains on the frequency previously selected on the No. 1 navigation radio. As a result, the DME mileage is generated from a frequency which is not displayed anywhere in the cockpit. The pilot must remember the navigation aid from which the distance information is derived. The Safety Board believes that the captain of Cascade 201 probably used the airborne DME equipment in the manner just described and forgot that the DME equipment was actually tuned to the DME associated with the Spokane VORTAC when the localizer was activated by the tower. The Safety Board believes that a direct readout of the actual frequency being used for navigation should he visuallv available to the flighterew at all times. 31791E in C7 -2- Although an amber light is activated on the DME mode selector when the "DME hold" function is in use, the light may be overlooked by the pilot in certain situations. While the "DME hold" feature provides the pilot with more flexibility by allowing him to preselect navigation frequencies, this advantage may be offset by the need to remember the source of the DME mileage display during periods of increased cockpit workload. Therefore, the National Transportation Safety Board recommends that the Federal Aviation Administration: Require in future radio navigation instrument installations, that all frequencies being received through navigational receivers that are providing essential navigational information (directional guidance or distance) be displayed so that the source of the navigational signal can be readily discerned by the pilot. (Class II, Priority Action) (A-81-74) KING, Chairman, DRIVER, Vice Chairman, McADAMS, GOLDMAN, and BURSLEY, Members, concurred in this recommendation. IBy Ja.mes King Chair mah.... 'Wa8 US De:ortment Cf :e me A m,-PIralo' ' A, S of Traq-sportotion 2-+,,,,t . + , -,: Federal Aviation Administration OCT :2 1981 The Honorable James B. King Chairman, National Transportation Safety Board 800 Independence Avenue, SWq. Washington, D.C. 20594 Dear Mr. Chainnan: This is in response to NTSB Safety Recormirndations A-81-75 and A-81-76 issued by the Board on July 28, 1981. These recommrendations resulted from the Board's investigation of the crash of Cascade Airways Flight 201, a Beech 99, near Spokane International Airport on January 20, 1981. The aircraft crashed while the pilot was making a localizer approach to runway 3. Seven people were killed, including the flightcrew, and two passerijers were injured seriously. Flight 201 was operating under 14 CFR 135.99; under this regulation two pilots are required, and the corpany's flight manual requires specific crew coordi- nation procedures. However, neither the regulations nor coripany procedures required interphone cor munication in the operation, and none was provided between the captain and first officer on Flight 201. A-81-75. Establish for aircraft used in coinnercial operation the maximum cEpit noise levels which will perit adequate direct voice comaunication between flight crewmembers under all operating conditions. FAA Comment. The Federal Aviation Administration (FAA) concurs in the intent of this recorvnendation. Because of the many variables associated with the establishent of a noise level, we have asked our Office of Aviation Medicine to conduct a Research, Development, and Engineering (RD&E) effort on this subject. A copy of our internal correspondence relative to this subject is enclosed. Some of the variables associated with the project are noise measurement unit (metric), noise measurement methodology, acceptable intelligibility level, and the degree of raised voice level for conmunication. Our preliminary literature search also indicates that the use of earplugs has a significant effect on speech intelligibility in noisy cockpits. Diclosed is a copy of Advisory Circular 91-35 which addresses this subject. Whether this improvement is adequate to overcoine noise levels encountered in the class of airplanes involved is one question we hope to answer in the course of the RD&E study. e I 2 Upon capletion of our study effort, we will detennine if sufficient data have been developed to warrant publication of additional guidance on crew coriunica- tions in noisy cockpits. The Safety Board will be informed of our findings. A-81-76. Require the installation and use of crew interphone systems in t-he cockpits of those aircraft in which noise levels reach or exceed tUie inaximu'm level established for adequate direct voice coaaunication between flight creznembers under all operating conditions. FAA Conient. Action on this recoonendation is dependent upon the results of the RD&E study referenced in Recomnndation A-81-75. We will inform the Board of our findings resulting from this study effort. Sincerely, J. Lynn Helms Administrator Enclosures NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. ISSUED: July 28, 1981 Forwarded to: Honorable J. Lvnn 4elms Administrator SAFETY RECOMMENDATION(S) Federal Aviation Administration Washington, D.C. 205cil A-81-75 through -7r Ahout 11:27 D.s.t.. on January 20. 1981, Cascade Airways Flie'ht 201, a Beech 99 operatinq from Voses Lake to Spokane, Washington, crashed about 4.5 miles southwest of Spokane International Airport. The aircraft crashed while the pilot was making a localizer approach to runway 3. Seven people were killed, including the flighterew. and two oassenvers were injured seriously. Flight 201 was operating under 14 CFR Part 135.99; under this regulation two pilots were required and the company's flight manual required specific crew coordination procedures. However. neither the regulations nor company procedures renuired interphone communication in the operation, and none was provided between the captain and fi t officer on Flight 201. After the accident. the Safety Board took noise measurements in the cockpit of a Cascade Beech q9 to the right of the captain's head. Measurements were taken in flight at 95 percent rpm with 1,100 ft/lbs of tornue; the noise level was 97 dF(A). 1/ These measurements aaree in general spectral shane and level wil.l) Bieech 99 cockpit noise measurements taken by the Beech Aircraft Corporetion. Thc sneech interference level between the captain and the first officer was ealculnted Pt JR5.5 d13(A). Speech interference values indicate the sound pressure at which the speech signal must he st the listener's ear for a given noise condition in order to he heard reliably. Noise experts agree that in this particular noise environment, face-to-face communication is difficult and falls in the voice range between shoutinr 1/ The human ear is not equally sensitive at all frequencies. Therefore. for 7measurement purposes, a weighting scale is used to alter the sensitivity of the sound level meter with respect to frequency so that the instrument is less sensitive at frequencies where the ear is less sensitive. The A-weighting scale, dB(A), is the most widely used in noise control. 3179D 4)1I1 and maxim umn VOCAi effort. a 'r(ln, S.(fti ( '' the Beech A ircraft Corp or'itin iMPWOa ma. Q- harei 9;1' approach is 94.1 dH(Ah Tho- v-ulv. Olkhough lua *th'* t' l i In sW 9p A-C-o level in which face-to-fmcr veri nal Ac~munatc an2 d am neliP H' ''iT',' PO17 of shouting or greatev. I hu re. Inot inI ign wx dort ouveN W B~ec W-4 aircraft cockpit noise lovely qreeluck eff '--mv' wr'N cn w-hl ial Furt htw ev'idence of ,, mar la or'I) '!Li P 0c of Fligh t 2 01 h imsn,elIf w ho h ac ;)r ;_".1-aC U d(-,1 11 1', il e O! 1 Gt 1 3.1c-n the cockpit ic-Ciuuv lie Wtie' C -I - speech. lirerfore, cl -n WIe KCP correct an operwtotii noviidh'I wahk w, essential, the cockpit ru -e l--'nG rcu e' -' I lTme Cock7'it flI' WEinxlc Inn WC~i''idni Wi-* WS Md5 0Q rA report NTSR- \AH--( h in "Tick no fNO> ofilar OW '5' Q l i-th difficulties ex-verienced wit rn-co00' -v caminnviu ''' -Li-- o, k ; ,!,et and inter phone, Thesv same views were~ exvp-- nv 00 o pW n0'~v the Safety Board spepificall'; slan'-h'ithe Ov--i 00we' ', :1A. r should be considered in ihght of v n.i, c at rhoinr AnKP C ~r- p hy not directly related to arniicrr wonkpi nos - low- 5WI RWr the ground proximity warnina syslo'n !(PA-11 ils ,f inthe 'm Roeing 727 in Pensacola, H-orids, on \jy 8, !91 it -WTwo ,--j jiPIr- of system hud impeded tc-o nr-olp2oim'' -N recent National Aeronautics and Sronoc , Am 0 ,c sl Ai.' I ' flighterews who cornmunicated les-s frequCIn' \Tit 0cm-oil \Oij C &Qt toIO ii.. ii: performance errors than crewis who corn umpc wrcoften. A ,it MRV hr lnp 140 In normal operntions flifrhterews cleveloir ari-, w.- )oin, r a-d' i i 1.' .1 -eta-- , I commutn ication so t hatI verbal co murnioation is nAc necessa rv-. Hoawever, H 'i ' emergency sitatin do anxi's ninmPliunuN nit os ',a i and effice cnt U!cii 0 M inform at ion between the AM.ts T'he Safe' v Board helie\'es that the noi5;e lcvvlv vi lsir- in the Beech 99 a i ernf preclude efi oiont, unh~aitruoiis verhal cormuniencut Trhe Sa fet, Board is eon-ceinedI ht vckpi t noise lc'vols "reO loi' vnowu1 " inter ferc with verbal corn rnuni cntion bet wcen flightA c r'wribet's. (9urrenl ... Own, aire iic certificat ion standwAs Wr Ifia tim hllowable cooicit (111eV el' fo(a I i ('cv Iti' verbal communication. Therefore, the National Pronsportatiri Snfet v Hioma'd r-conrrimd 1r:0 ti I 1Oderal -Nviation Admoinistratiotn; Establish for aircraft used in commeuinrcial oper-ation tie max inumcovkp. noise levels which iAll pe'mi adequtit co!roolOco co; ara in - om hot wef; flight crewmeinhers under all opoiw~ny condiion. (I'Inv-- H, Priority' 'otion l (A-8 1-75) 2/ There are established relationships for face-to-face speech cointn unictlt ion in noise environments. Noise experts are in general Rizi-eement as to the icommunication difficulties in various noise environm-rents M'. various sak--itonrdistanc. .1/ Foushee, H.C. (N:\S'\-A.MFS Resenri-h ('entor) fnd Macros, K.L. (U.'K Air Force Academy), rockpil comrmmntatioil patterns 8n! Whe perlorinanie of R'iKhtcrews. FORlUMII- The Inter nat-inal Sc-iety* of Ai Waon S'V 0mmcC~primng, 193 po, 19 M Require the installation and use of crew interphone systems in the cockpits of those aircraft in which noise levels reach or exceed the maximum level established for adequate direct voice communication between flight crew- members under all operating conditions. (Class I!,Priority Action) (A-81-76) KING, Chairman, DRIVER, Vice Chairman, McADAMS. GOLDMAN, and BURSLEY, lembers, concurred in these recommendations. P4. Ja m e F.King i 01hair an 013 US Deportfrf n! (jtl,cP of Vle AJ, s',a:o, . .- - of Tronsp rOrlion v, -; ' L - Federal Aviation Administration October 19, 1981 The Honorable James B. King Chairman, National Transportation Safety Board 800 Independence Avenue, SW. Washington, D.C. 20594 Dear Mr. Chairman: This is in response to NTSB Safety Ricomendations A-81-80 and A-81-81 issued by the Board on August 3, 1981. These recommendations resulted from the Board's investigation of the crash of a Mitsubishi MU-2 aircraft, N307MA, near Sky Harbor Airport, Henderson, Nevada, on April 23, 1980. The aircraft was a night visual flight rules (VFR) arrival, and the pilot had intended to land at McCarran International Airport, Las Vegas, Nevada. At 8:38 p.m., the pilot declared an emergency low-fuel status. McCarran Approach Control acknowledged the emergency and advised the pilot that McCarran International Airport was at 12 o'clock and that Sky Harbor Airport was at 10 o'clock. The ontroller then asked, "Are you going to try for McCarran or do you want to go to Sky Harbor? It's about 5, 6 miles to McCarran, 4 miles to Sky Harbor." The pilot replied that he was "heading for Sky Harbor at this point." The pilot later reported, "I don't see the airport, sir." The controller then asked another aircraft, N35211, that had been in the vicinity of the Sky Harbor Airport, "Were the lights out at Sky Harbor when you went over there?" N35211 replied, ". . . negative lights at Sky Harbor." The controller then said, "OK we're going to call now to get them on .... The controller then asked N35211 aircraft ". . . change to unicorn, click your mike twice and see if that'll get the lights on there at Sky Harbor." Shortly thereafter, N35211 reported that the Mitsubishi just crashed and that there was a "big explosion upon inpact." Witnesses later reported that the aircraft "started to climb, snapped over, and went into a spin." Investigation of the accident revealed that the Sky Harbor Airport is an unlighted airport (there were no lights available to be turned on), there was sufficient fuel (about 17 gallons at the time of impact) to fly to McCarran International Airport, and the aircraft had no mechanical malfunctions. The NTSB concluded that the pilot diverted his attention from the operation of his aircraft while searching for the unlighted airport. Terminal S'ysl.a&2', (ALwc t ~->;~r ) informnation icli c')I I,-' I~- l Ai rport. intenL 3.. t --- in nIALIt -'~, !-ILjk C r! I tCA4C~at-r)& io- 1 a 31 27 AlS112 ' 1 begi.ilTdj.'' -t * G~han~es rx&o irnprovew,-,ent- * Because 0: 'Vi)C d le V infonuation ',; -L~n Lk -i 4- i' to 1 t on utt fund-s are uho ii' t'- *-r Althoucjh t-here i- --I r~ vn- -nn -vr icr 3wit' rt infornmitiun, i7*.icc, 'o 7-i.31-F,~~~liiA r(e-p-iures all facilitnres (terfminals, :t-nter6, ars id r revo i ILIrIS) to )rintain biders for ready reference at appropriate vxork area!. hes references in] uric, em-.ergency pro -cdures and a location li',tinq of airrx- rrs. Lncludinq runway al iqner't, lighting, surface, and length. Thec FAvA LntendFr tco take no further actj(on on Safety Reourndation A-<v,1-80. A-83--81. Ino rfxorate- t-, fe-atures reuvuicej- ro enable ell .cOLIe oo:rlesto display emergency airportc itrfonrmtion, such as that currently displayed at the Houston Inte'rnational Airo t, in future (i route air traffic ou1:ntrI olrriputer system. FAA Corinent. The FAA concurs in Lhis rem~rdrion. The einerg..:ncy airport infoririation fedituc- wil) ie iprioiritized and iml!inealong,) %..ith ontr air traffic re-luirement *, in thc, treo ?~ii coptisysten (14020R). Adniini str atot NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. ISSUED: August 3, 1981 ------------------------- Forwarded to: Honorable J. Lynn Helms Administrator Federal Aviation Administration SAFETY RECOMMENDATION (S) Washington, D.C. 20591 A-81-80 and 81 -------------------------------- At 8:41 p.m., on April 23, 1980, a Mitsubishi MU-2 aircraft, N307MA, crashed about 1/2 mile north of Sky Harbor Airport, Henderson, Nevada. The aircraft was a night visual night rules (VFR) arrival, and the pilot had intended to land at McCarran International Airport, Las Vegas, Nevada. At 8:38 p.m., the pilot declared an emergency low-fuel status, MeCarran Approach Control acknowledged the emergency and then advised the pilot that McCarran International Airport was 12 o'clock and that Sky Harbor Airport was at 10 delock. The controller then asked, "Are you going to try for McCarran or do you want to go to Sky Harbor? It's about 5, 6 miles to McCarran, 4 miles to Sky Harbor." The pilot replied that he was "heading for Sky Harbor at this point." The pilot later reported, "I dondt see the airport, sir." The controller then asked another aircraft, N35211, that had been in the vicinity of Sky Harbor Airport, "Were the lights out at Sky Harbor when you went over there?" N35211 replied, "... negative lights at Sky Harbor." The controller then said, "OK we're going to call now to get them on...." The controller then asked N35211 aircraft "... change to unicorn, click your mike twice and see if that'll get the lights on there at Sky Harbor." Shortly thereafter, N35211 reported that the Mitsubishi just crashed and that there was a "big explosion upon impact." Witnesses later reported that the aircraft "started to climb, snapped over, and went into a spin." Investigation of the accident revealed that the Sky Harbor Airport is an unlighted airport (there were no lights available to be turned on), there was sufficient fuel (about 17 gallons at the time of impact) to fly to McCarran International Airport, and the aircraft had no mechanical malfunctions. The Safety Board concluded that the pilot diverted his attention from the operation of his aircraft while searching for the unlighted airport. 3295 0.17 -2- The Safety Board is aware of the existence of an ATC software modification which would have insured that the controller relayed conrect information to the pilot., Houston International Airport is currently using the Airport Data, Point to Point Range and Bearing Slew Entry (an Automated Radar Terminal System--ARTS ll progreant patch) to provide a controller with complete airport information, such as runways. elevation, lighting, and range and bearing fpom an aircraft's position to the airport. This informution is presented on the controller's radar display. Any ARTS facility has the eapability of utilizing this feature, which was developed by ihe Federal Aviation Administration's (FAA) Data Systems Staff at the Houston international Ai-povt. The Safety Board believes that the emergency airport data is a vaiuable saiety feature and that the accident at the Sky Harbor Airport, as well as othet-s that tYre Safety Board has investigated, could have been prevented had sucth data been immediatel: avaflaole to the controller. The Safety Board does not believe that tris feature should be a substitute for local area knowledge required of the controller but should be consioered to be a type of reinforcement much like the checklist in an aircraft. The Safety Board also believes that the same type of emergency airport data should be made available to the en route controller when the next Air Route Traffic Control Czlnter (ARTCC) comput~Et equipment is implemented. Therefore, the National Transportation Safety Board recommends that the Federal Aviation Administration: Require that all terminal facilities utilizing Automated Radar Terminal Systems (ARTS automation) incorporate an emergency airport information feature, such as that cum-rently used at the Houston International Airport. (Class H, Priority Action) (A-81-80) Incorporate the features required to enable en route controllers to display emergency airport information, such as that currently displayed at the Houston International Airport, in future en route air traffic control computer systems. (Class fl,Priority Action) (A-81-81) KING, Chairman, DRIVER, Vice Chairman, MeADAMS, GOLDMAN, and BURSLEY, Members, concurred in these recommendations. /7 , / By: J -as If hair ma US Deportment l1ce o?tre Aa ,ss,'ao, I : 'Coeu3e . A,..- of Tronsporation '!' Federal Aviation Administration October 8, 1981 The Honorable James B. King Chairman, National Transportation Safety Board 800 Independence Avenue, SW. Washington, D.C. 20594 Dear Mr. Chairman: This is in response to NTSB Safety Recommendations A-81-83 and A-81-84 issued by the Board on August 3, 1981. These recommendations resulted from the Board's investigation of the crash of a Beechcraft Model B19, N60BW, after takeoff from Kinston, North Carolina, on June 23, 1980. The pilot stated that he was unable to maintain lateral control. A-81-83. Require that the actions outlined in Beechcraft Class II Service Instruction No. 0858-151 as revised be ompleted on the affected aircraft at the next 100-hour or annual inspection. FAA Comment. The FAA does not concur in this reconmendation. Although lateral control is affected by rod end/bearing failures, this type of failure does not comprise the total set of lateral control related accidents cited in the safety recommendation data. Only two of the six accidents cited were related to rod end/bearing failures, and we are not aware of any fatalities which have occurred as a result of rod end/bearing failures. Most rod end/bearing failures are related to inattentive maintenance over an extended period of time. An FAA airworthiness directive (AD) to require rod end inspections and replacement in accordance with Beechcraft Class II Service Instruction No. 0858-151 procedures is not warranted since we have no evidence to indicate that operators are choosing to ignore the maintenance procedures recommended by the manufacturer. In our judgment, there is adequate mainte- nance information available to maintain the rod ends and maintenance personnel typically conduct required inspections in an acceptable manner. This position is in concert with Amendment 3 to Part 21 and Amendment 106 to Part 39 which, in part, state, "The Agency, accordingly, will not issue ADS as a substitute for enforcing maintenance rules.m The General Aviation Airworthiness Alert system is designed to identify and to emphasize maintenance significant items like the one identified in the NTSB investigation preceding Recomendation A-81-83. This is the most appropriate I I II I II IIII I I I fl ? ~ ~~~*L ,J ... . 1.. : -- l l l l 2 way to ensure efficiency of future rnaintenari- of the aileroa. ro ends. As noted in the text of the safety recomrindation letter, this ark-a was the subject of an October 1980 airworthiness alert b-) authorized iLZs['.cLors and repair stations reinforcirJg the irportance of inspection ae i.icat ion of rod ends in accordance with rec Lvndej nhntenar:( oro.e.iioc , T---rt- havr been no further service difficuLtty Lve-jxrts since the Oct " 90 -alerl- We will continue to monitor service difficulty repocm for tiiis ,..j iOi, out in the absence of documented failure, ve do not pc to pursue ths ritter. further and consider action oomieted oi. S-;eL- .e. dst o . A-81-84. Require installation of access plates on all Beechcraft Niijels S19, 23, 24, and 24R series aircraft manufacture.d before 1977 to provid,: access to the aileron push-pll rod.s, bellcraakc, and cable attachrnents fo ins-pection or servicing. FAA Ccmrent. Access doors that provide a- aI tetTate means of ILIricution and inspection of rod end bearinjs wod faci.itiate maintcnance of utic pre-1977 aircraft noted in this safety reoonir.endation. H ever, we do 110t C10nCr in the requirement for mandatoiy installation of such access doors by AD action. As stated in our response to RecanTcndation A-81-83, adequate rraintz-nance information and access are available, and Ue vast m-jority of maintenance personnel are conducting required inspections in an acceptable ma-nnr An FAA Airwor-thiness Alert is the aFpi)opriate method to provide this information to repair stations and maintenance personnel. We are presently working with the manufacturer to develop a new airworthiness alect item which will provide the installation instructions rej<uired to add such access doors to pre-1977 Models 19, 23, 24, and 24!z aircraft. With the issuance of this alert, the FAA considers action cti Saiety Pee-'mendation A-81-84 onpleted. Since'Celyi J. Lynn Helms Administrator NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. ISSUED: August 3, 1981 Forwarded to: Honorable J. Lynn Helms Administrator Federal Aviation Administration SAFETY RECOMMENDAT ION (S) Washington, D.C. 20591 A-81-83 and -84 On June 23, 1980, a Beecheraft Model B19, N60BW, crashed shortly after takeoff from Kinston Jet Port, Kinston, North Carolina. The pilot, who received minor injuries, stated that he was not able to maintain lateral control. The investigation revealed that the left aileron push-pull rod end, which is connected to the aileron bellerank inside the wing, had failed. The left aileron push-pull rod was examined by an independent engineering testing company, which reported that: (1) the push-pull rod failure was caused by fatigue in reverse bending, (2) the reverse bending force was apparently transmitted from a seized bearing connection to the minimum cross-section of the rod at the root of the machined threads, and (3) the bearing connection at the failed end of the rod was seized because of inadequate bearing lubrication and the subsequent formation of corrosion products which prevented rotational and lateral movement in the bearing connection. The aircraft records indicated that the last annual inspection was completed on August 20, 1979, 130 tachometer hours before the accident. However, the Safety Board could not determine whether the rod end bearings were lubricated during the inspection. The Beechcraft lubrication diagram in the maintenance manual recommends that the ends of the aileron push-pull rod be lubricated at every 100-hour inspection. On July 8, 1975, Beecheraft issued a Safety Communique to all owners of Beecheraft Models B19, 23, 24, and 24R series aircraft. The communique indicated that some flight control system pivots and moving parts subject to wear may not have been lubricated adequately, and urged that the flight controls be checked for freedom of movement during each walk-around inspection and before each flight. It further recommended that the controls be serviced and lubricated at proper intervals to insure proper functioning of the flight controls. 3310 02± In August 1975, Beecheralt issued Clam 0I Servue instruction No. 0'76ti-.Ol , which pertained to specific Beechcraft Models B19, '-; ?4, and 2411 series aircraft. Service Instruction No. 0760-010 recommended, duriap' ,n!-.0n mainrenanee, a general inspection or replacement, or both, of rod end bearings used on engine controls, iading gear retraction systems, nose landing gear steering mecihanisrns, and flap, ailerol, elevator, rudder, and tab controls. The purpose of the service insiuciion, in part, wtas t.; advise all owners that, on occasion, some ,-oc end be.ring - nian faekired by i-ippo: %I'initure Bearing Corporation had seized in service tn- ' . tnvwo.e,'s discrotion, ":ne r'od end bearings should be replaced bv :orresponding pari- r-uai.ciu lured by other vendor-:. In August 1976, ieechraft issued Ciass ii Sier,'i,- l;I'uction No. 0 -- 51A, which pertained to specific Beechzr:ft ,Models B19, 2. , m:c ".. sc.-res air.iafy The )urpose of Service Instruction No- 0858-151 was ic ':s c_,t fe>dorn of moveneni ar, p,'oper functioning of all flight conu-o! r'od ends and o-,ivCai poincs. In Part, ihe service instruction referred specifically co the ailero, push-pul! -od ends, indic"ted that restricted movement of ihe i-od end iadicai s ca ior: thE i00 e.i- , .. I 'ied that if corrosion is noted both existing for.:aO aiod rod ends showid b,- ' ] ,ith new rod ends (P'N 169-38068t2-3). The Safety Board could not determine Ii L-e aileron roO ends oi, NL0F;ou were inspected in accordance tith the Beecheraft Class 1i service insikructions. Hovvever, examination of the failed forwaid aileron push-pulU rzd end indicated that the filed rod end (PN HM-4U-M) was rmanufactured by Heim Cominy The aft pusi.pu-l rodi end (PN HM-4, NMB) which dia not fail was maui'ac'ec iy !,,ippon Miifiiaru!-? aiering Corporation. However, this push-pull rod end beari n did niot m-otatr all directions. Based on the identifieaion of the reaied push-pull rod end, the forward rod end was installed in accordance with Beechen'aft Class F! Service instruction No. C'.'60-O 10, but the aft rod end was not replaced as recommended .n tnat service instruction. The Safety Board's aircraft accident data indicate thac between 1964 and 1979 six accidents have involved Beechcraft Models B19, 23, arid 24R aircraft in which lateral control was found to be a cause or factor. These aecidents -esulted in five iatal injuries, two serious injuries, and minor or no injuries to five persons. One accident resulted from frozen rod end bearings and another resultect fronm a failed rod end. The remaining four accidents resulted from improper instiallation of the aileron after maintenance. A review of the Federal Aviation Administration's Service Difficulty Records from January 1976 through January 8, 1981, revealed 15 occur-ences of problems with aileron push-pull rod end bearings on Beecheraft Models Bi9, 23, 24, and 24H series aircraft. Fourteen were related to seized or broken rod ends. Bsed on the continuing reports of similar failures, the FAA published this information in its General Aviation Alert, Advisory Circular 43-16, dated October 1980. On earlier models of Beecheraft B19, 23, 24, and 24R series aircraft, such as N6OBW, the forward aileron push-pull rod end bearings, aileron belierank pivotal point, and cable attachments are relatively inaccessible for routine inspections and maintenance because panels were not installed in the wings for inspetion purposes. The ailerons and guard strap from the closure strip must be removed to perform an inspection or routine maintenance. To improve access to those push-pull rod ends, an aircraft and powerplants mechanic employed by a Kinston facility, on his own initiative, installed inspection access panels using approved inspection plates and doublers on a similar aircraft. The mechanic was later nominated for a General Aviation Mechanics Safety Award. L. __ __ __ -3- Since 1977, Beechcraft has Incorporated aileron access panels in the wings on its Models B19, 23, and 24 series aircraft. The wing access panels provide an opening through which mechanics can inspect and service the forward aileron push-pull rod end bearings without removing the ailerons--thus reducing the man-hours required for inspection and maintenance and eliminating the need to remove the ailerons. The Safety Board believes that the installation of these pahels in aircraft manufactured before 1977 would improve the maintainability of these aircraft by making it easier for mechanics to inspect and lubricate the rod end fittings without having to remove the ailerons. This would also reduce the possibility of an improper installation of the aileron by reducing the number of times they must be removed and reinstalled. In view of the continuing reports on this problem and the hazards associated with a loss of aileron control, the National Transportation Safety Board recommends that the Federal Aviation Administration: Require that the actions outlined in Beechcraft Class U Service Instruction No. 0858-151 as revised be completed on the affected aircraft at the next 100-hour or annual inspection. (Class U1, Priority Action) (A-81-83) Require installation of access plates on all Beechcraft Models B19, 23, 24, and 24R series aircraft manufactured before 1977 to provide access to the aileron push-pull rods, bellcrank, and cable attachments for inspection or servicing. (Class U1,Priority Action) (A-81-84) KING, Chairman, DRIVER, Vice Chairman, MeADAMS and GOLDMAN, Members, concurred in these recommendations. BURSLEY, Member, did not participate. N 6 B a Jes . i US Deportmen , of Tronsporlation Federal Aviation Administration November 16, 1981 The Honorable James B. King Chairman, National Transportation Safety Board 800 Independence Avenue, SW. Washington, D.C. 20594 Dear Mr. Chairman: This is in response to NTSB Safety Recommendations A-81-88 through A-81-91 issued by the Board on August 26, 1981. These recommendations resulted from the Board's investigation of the crash of a Beechcraft E-90, N2181L, near Michigan City, Indiana, on December 7, 1980. According to the Safety Board's findings, there is evidence that some or all of the four occupants survived the initial crash. The Board states that when South Bend, Indiana, approach control lost radar and radio communications with N2181L, a facility supervisor alerted the Indiana State Police to the possibility of a missing aircraft, rather than calling the Chicago Air Route Traffic Control Center (ARICC) as he was required to do by Federal Aviation Administration (FAA) Handbook 7110.65B, dated January 1, 1980. About 3 hours after radar and radio communications were lost with N2181L, Chicago ARTCC was advised of the missing aircraft by the U.S. Air Force Search and Rescue Center at Scott Air Force Base, Illinois. The Chicago ARICC con- tacted South Bend approach control to confirm that the aircraft was missing. Consequently, the Chicago ARPCC, which is responsible for issuing an alert notice for missing or overdue aircraft, was more than 3 hours late issuing an alert notice. A-81-88. Take steps to make search and rescue operations less vulnerable to human error either by changes in terminal air traffic control accident notifi- cation procedures, or by changes in training, supervision, or performance monitoring. FAA Comment. The FAA does not concur in this recommiendation. FAA Handbook 7110.65, paragraph 1575, requires personnel to consider that an emergency exists and to inform the Rescue Coordination Center (RCC), or Air Route Traffic Control Center (ARICC), and alert the Direction Finding net when, in addition to other requirements, an emergency is declared by facility personnel. Additionally, the paragraph explicitly states that an example of | • 2 an emergency which should be declared by facility personnel is simultanleous unexpected loss of radar contact and radio conmunications with an aircraft. Paragraph 1576 requires terminal facilities to notify the ARICC when an aircraft is considered to be overdue or in emergency status. Paragraph 1580 requires ARTCC's to alert the RCC when an aircraft is considered to be overdue or in emergency status. In each case, there arc specific requirenents concerning the kinds of information to be forwarded to the designated facilities. We are aware of the importance of pronj~t, precisl- emergency notification and search and rescue coordination. Therefore, all developnental controllers (trainees) are thoroughly indoctrinated in search and rescue procedures for VFR and IFR aircraft. Our training and procedural requirements in this vital area are explicit to the point of being very structured and largely inflexible. While w do not condone "human error" as an excuse for procedural misapplica- tion, we know that it is inevitable that human involvement introduces 'he possibility of human error. Significant numbers of occurrences of this kind of error, in any one area, usually indicate the need to change procedures, training, or regulations on a systemwide basis. Relatively isolated occurrences normally require some kind of remedial action of a more parochial nature. We agree with Board member Goldman's comments and we have no indications that our national procedures, training, supervisory requirements, and performance monitoring are inadequate. Therefore, we do not intend to take any systemwide action in an attempt to solve a problem which appears to have been caused by an isolated instance of deviation from prescribed procedures. Rather, we believe t!he following remedial actions are sufficient: 1. The supervisor involved was counseled concerning the correct notification procedures. 2. All operational personnel at South Bend Approach Control attended briefings involving the review of accident notification, emergency, and search and resue procedures. 3. The Great Lakes Region published an Air Traffic Bulletin informing all personnel of the importance of coitplying with established search and rescue procedures. 4. Chicago AR!MC has been added to the South Bend Facility accident notification record. The FAA considers action on Recoimendation A-81-88 conpleted. A-81-89. Require air traffic control facilities to maintain current area maps that are standardized and coordinated with those used by local police and search and rescue authorities so that accurate search areas can be readily identified. .1'%- 3 FAA Coment. The FAA does not concur in this reccniendation. 1 our knowledge, there is no national standard for charts used by law enforcement agencies. In each ARTCC's area, there are literally hundreds of Federal, state, county, and municipal law enforcement agencies. Since these agencies can use dozens of different chart types from road maps to highly detailed large scale grid charts, coordination would be a formidable, if not an impossible, task. Each AR1CC has a selection of aeronautical charts such as sectionals, VFR terTninal area charts, area charts, and low/high altitude en route controller charts. Positions may be plotted on each of these chart types in teons of latitude/longitude or bearing and distance from a known point. Additionally, the RCC is responsible for coordinating all physical search and rescue activities. The National Search and Rescue Manual states that ". . . the charts maintained in the RCC should include the appropriate selection of aero- nautical charts, pilot charts, bathynetric charts, operating area and warninj area charts, oceanic vessel track charts, lake survey and geologicdl sucv0e!y charts, topographical charts, s,-all craft nautical charts, marine waterway charts, civil defenst c arts of water reservoirs and military airfields, population density charts, township maps, road maps, and thr,:?e-dimnensional terrain and ocean bottan charts." This exhaustive list would seem to insure that RCC's have the capability to plot positions accurately using any standard systail. Should the RCC or any other agency/individual require a position in terms of latitude/longitude, it would be a relatively sinple matter to trans- late a bearing/distance or intersecting radial plot to latitude/longitude using the appropriate aeronautical chart available at the ARJC. The FAA considers action completed on Safety Recommendation A-81-89. A-81-90. Issue an Airworthiness Directive to reluire that Beech kit No. 101-3062-1 be installed on all Beech aircraft which have the remote ELT switch installed. FAA Camment. The FAA does not concur in this recommendation. We have reviewed this matter and our actions as discussed below and find that the issuance of an airworthiness directive (AD) against Beech airplanes having Collins/ Cormunication Components Corporation's (CCC) CIR-11-2 Emergency Locator Transmitter (ELT) is not warranted. We have investigated the reasons the CCC CIR-11-2 ELT failed to transmit when the Beech Model airplane contacted the water. Our findings agree with NTSB's analysis as to why the ELT failed to activate. Thie ELT "ARM-ON-OFF" switch was found in the "OFF" position which prevented operation of the unit upon iipact. We reviewed the installation data and the operating proceaure of the ELT and found these to be adequate. However, it was determined that the ELT could be operated by a remote test switch if the ELT "ARM-ON-OFF" switch was placed in the "OFF" position. The "OFF" position disables the internal impact switch of the ELT preventing operation of the unit upon impact, but does not prevent testing of the unit from the remote test switch. Therefore, it is imprative 4 that the installer follow the operating procedures, placing the "AF -ON-UFF" switch in the "ARM" position when a remote switch is part of the installation. As a result of the failure of the ELT, Collins General Aviation Division has issued Service Infornation Letter 1-81, dated July 15, 1981, defining the proper function of tile ELT switch positions and linitition of the remo te operating features of the ELT. Collins has also revised the CiR-ll owner's Manual, Document No. 9500012, dated March 20, 1981. This revision delfines the i proper function of the ELT switch positions and limitation of the remotei operating features of the ELT. Beech Aircraft Corporation has issued King Air 200 Communique No. 31, dated February 27, 1981, and Executive Airplane Service ConanunitIu., "40. 56, dateld March 31, 1981, to advise operators of the proper use of tht2 CIR-1I-2 BliP. Beech Kit No. 101-3062-1, which insures that the "AR1I-ONI-OFF" switch is positioned to the "A1AM" setting at completion of installation of the EI]m unit, is referenced in the ooniuniques. We are also issuing a General Aviation Airworthiness Alert, which advises owners/operators of the updated ELT Owner's Manual. We believe this action is fully responsive and, accordingly, the FAA considers action co[rtleted on Safety FLcommendation A-81-90. A-81-91. Issue a General Aviation Airworthiness Alurt advising all owners of ELT Model CIR-11-2 that they should obtain an updated owner's manual, Doculment 950012, for use in the installation and operation of this unit. The changes in the manual should also be summarized in the Airworthiness Alert. FAA Comment. The FAA concurs in the intent of this recommendation and has prepared a General Aviation Airworthiness Alert. An alert is addressed to maintenance personnel. Therefore, we have requested that owners/operators of CIR-11-2 ELT's be advised through this mechanism of the availability of the updated owner's manual, Document 950012, dated March 20, 1981. In this documlent the owners are advised that the ELT is only armed if the function switch on the ELT is set to "ARM," and that the renote "ON" test does not verify that the ELT is armed. The ELT must be visually checked to ensure the function is in the "ARM" position. The FAA is also considering dissemination of tile above information to owners/operators of the ELT through the Accident Prevention Safety Program and the General Aviation News Magazine. With issuance of this General Aviation Airworthiness Alert, the FAA considers action copleted on Safety Recommendation A-81-91. Sincerely, 4,' J. Lynn He Administrator NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. ISSUED: August 26, 1981 Forwarded to: Honorable J. Lynn Helms Administrator Federal Aviation Administration SAFETY RECOMMENDAT ION (S) 800 Independence Avenue, S.W. Washington, D.C. 20591 A-81-88 through 91 On December 7, 1980, a Beechcraft E-90, N2181L, crashed near Michigan City, Indiana. There were no survivors, however, there is evidence that some or all of the four occupants survived the initial crash. Had the aircraft's last known position been correctly and expeditiously communicated to the proper authorities a rescue might have been effected. When South Bend, Indiana, approach control lost radar and radio communications with N2181L, a facility supervisor alerted the Indiana State Police to the possibility of a missing aircraft, rather than calling the Chicago Air Route Traffic Control Center (ARTCC) as he was required to do by Federal Aviation Administration (FAA) Handbook 7110.65B, dated January 1, 1980. 1/ About 3 hours after radar and radio communications were lost with N2181L, Chicago ARTCC was advised of the missing aircraft by the U.S. Air Force Search and Rescue Center at Scott Air Force Base, Illinois. The Chicago ARTCC contacted South Bend approach control to confirm that the aircraft was missing. Consequently, the Chicago ARTCC, which is responsible for issuing an alert notice for missing or overdue aircraft, was more than 3 hours late issuing an alert notice. About 45 minutes after N2181L was lost on radar, the Indiana State Police alerted the Michigan City Coast Guard facility. The U.S. Coast Guard (USCG) mission coordinator called South Bend approach control to determine the search location. The USCG mission coordinator was advised that the aircraft's last position was 3 to 5 miles west of the intersection of the 2330 radial of the Keeler VOR and the 2710 radial of the South Bend VOR. The USCG mission coordinator was trained to plot latitudes and longitudes, and he did not have the aeronautical charts possessed by his FAA contact. The USCG search ior the missing aircraft began in the wrong location because FAA tower personnel did not follow established notification procedures. However, based on the USCG mission coordinator's estimate of the accident site, the search area was moved to a new location, which was also too far west. 1/ For more information read, "Special Investigation Report: Search and Rescue Procedures and Arming of Emergency Locator Transmitter, Aircraft Accident Near Michigan City, Indiana, December 7, 1980." (NTSB-SIR-81-2.) 3316 O. jI -2- About 3 1/2 hours after loss of radar contact with N2181L, a policeman observed lights flashing off the beach near Michigana Shores. Based on this information, the search area was moved to still another site where floating fuel was found on the surface of Lake Michigan -- 4 hours after radar and radio communication with N2181L was lost. No survivors were found. The emergency locator transmitter (ELT) instaUed aboard N2181L did not activate when the aircraft hit the water, and consequently, no electronic signals were generated to guide rescuers to the crash site. Examination of the wreckage revealed that the ELT transmitter function switch was in the OFF position so the ELT could not be automatically activated under any circumstances. Because the ELT unit was recessed in the fuselage of N2181L and was inaccessible to the pilot, a remote switch had been installed on the right side of the fuselage. The remote switch could be used for test purposes to turn the ELT on regardless of the position of the transmitter function switch on the unit itself. This could have led the pilot to believe that the ELT was functioning properly when, in fact, the ELT was not activated. Because of this potential problem the manufacturer, Collins General Aviation Division, has drafted a Service Information Letter and updated the ELT owner's manual, Document 950012, to address this issue. Additionally, Beech Aircraft Company has provided a modification kit No. 101-3062-1 for all Beech aircraft with the CIR-11-2 ELT. When the kit is installed, a bracket will not allow the remote switching plugs to be inserted into the unit unless the ELT transmitter function switch is in the ARM position. As a result of its special investigation of this accident, the National Transportation Safety Board recommends that the Federal Aviation Administration: Take steps to make search and rescue operations less vulnerable to human error either by changes in terminal air traffic control accident notification procedures, or by changes in training, supervision, or performance monitoring. (Class 11, Priority Action (A-81-88) Require air traffic control facilities to maintain current area maps that are standardized and coordinated with those used by local police and search and rescue authorities so that accurate search areas can be i eadily identified. (Class U, Priority Action) (A-81-89) Issue an Airworthiness Directive to require that Beech kit No. 101-3062-1 be installed on all Beech aircraft which have the remote ELT switch installed. (Class I, Priority Action) (A-81-90) Issue a General Aviation Airworthiness Alert advising all owners of ELT Model CIR-11-2 that they should obtain an updated owner's manual, Document 950012, for use in the installation and operation of this unit. The changes in the manual should also be summarized in the Airworthiness Alert. (Class II, Priority Action) (A-81-91) DRIVER, Vice Chairman, and McADAMS, Member, concurred in these recommendations. KING, Chairman, and BURSLEY, Member, did not participate. B . J mesB. _g hairin -3- GOLDMAN, Member, concurred in Recommendations A-81-89 through 91, but disapproved Recommendation A-81-88 and filed the following comments: I do not believe Recommendation A-81-88 is justified, even though I agree with its general objective. We must always strive to minimize the opportunity for human error. Nevertheless, this special investigation was based on only one accident and did not include a thorough evaluation of the existing procedures, training, or supervision. Therefore, the "human error" identified in this accident may have been an isolated incident not justifying the breadth of the recommendation. 031 US Depcriment o lrarsporlahion Federal Aviation Administration OCT 2 I81 The Honorable James B. King Chairman, National Transportation Safety Board 800 Independence Avenue, SW. Washington, D.C. 20594 Dear Mr. Chairman: This is in response to NITSB Safety Recoinendation A-81-92 issued by the Board on August 26, 1981. This reco mendation resulted from the Board's investigation of the crash of a Lockheed JetStar model 1329 operating as a corporate flight for Texasgulf Aviation, Inc., near White Plains, New York, on February 11, 1981. While on an instrument landing system (ILS) approach to runway 16 at Westchester County Airport, the aircraft crashed about 6,000 feet from the approach end of runway 16 and about 2,300 feet to the right of the ILS centerline. The aircraft was about 360 feet below the glide slope when it first hit trees. The aircraft was destroyed, and the eight occupants were killed. The investigation revealed that the aircraft electrical system had been modified by incorporation of Federal Aviation Administration (FAA) Supple- mental Type Certificate (STC) No. SA 1596 CE on January 30, 1981. This modification consisted of wiring changes and replacement of the generator control units (GCU) with new, solid state units manufactured by Phoenix Aerospace, Inc., Phoenix, Arizona. A-81-92. Review the approval of Supplemental Type Certificate SA 1596 CE and the effect of the installation of the SW in Lockheed JetStar Model 1329 aircraft. FAA Camnent. The FAA's Central Region Aircraft Certification Progran Office has initiated a re iew of the STC and is corunicating with several operators/installers as well as Colt Electronics, the STC holder in this case. Working with Colt Electronics personnel, a system fault analysis is being conducted. Service information is being obtained from those operators that have incorporated this STC into JetStar aircraft. In view of the conplex nature of the generator control and ground fault isolation systes, we do not expect to conclude our review before November 15, 1981. Upon conpletion, the Board will be informed of our findings. Sincerely, NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. ISSUED:August 26, 1981 Forwarded to: Honorable J. Lynn Helms Administrator Federal Aviation Administration SAFETY RECOMMENDAT ION (S) 800 Independence Avenue, S.W. Washington, D.C. 20591 A-81-92 On February 11, 1981, a Lockheed JetStar Model 1329, operating as a corporate flight for the Texasgulf Aviation, Inc., from Toronto, Canada, to Westchester County Airport crashed on an instrument landing system (ILS) approach to runway 16 at Westchester County Airport, near White Plains, New York. The aircraft crashed about 6,000 feet from the approach end of runway 16 and about 2,300 feet to the right of the ILS centerline. The aircraft was about 360 feet below the glide slope when it first hit trees. The aircraft was destroyed, and the eight occupants were killed. During the flight from Toronto to Westchester County, the flightcrew reported that they had lost a navigational radio and that they had difficulty with the landing gear after takeoff. They did not report any other problems during the flight. During the investigation, the Safety Board learned that the aircraft electrical system had been modified by incorporation of Federal Aviation Administration Supplemental Type Certificate (STC) No. SA 1596 CE on January 30, 1981. This modification consisted of wiring changes and replacement of the generator control units (GCU) with new, solid state units manufactured by the Phoenix Aerospace, Inc., Phoenix, Arizona. Following installation of the STC by AiResearch Aviation, Inc., the aircraft was ground checked to verify operation of the electrical systems. The No. 4 generator system malfunctioned and was repaired. Test flights were performed on January 31, to check out the engines and the electrical systems operations. During those test flights, the No. 2 generator tripped in flight and was reset; shortly thereafter, Nos. 1, 2, and 3 generators tripped and were reset; before the flight landed, all four generators tripped. AiResearch personnel found a problem in the aircraft wiring and repaired it. Another test flight was conducted and the No. 2 generator tripped; the generator was reset and operated satisfactorily for the rest of the flight. No maintenance was performed as a result of this malfunction. 3225B -2- On February 1, 1981, the aircraft was dispatched on a company flight to Chicago, Illinois, during which the No. 2 generator tripped twice. On the return flight at night from Chicago to Westchester County Airport, the Nos. 1, 2, and 3 generators tripped at the same time; they were reset but they tripped again about 10 minutes later. The crew reset Nos. 1 and 4 generators and they continued to operate for the remainder of the flight. Colt Electronics and Phoenix Air Space personnel inspected and repaired the system. A subsequent test flight was conducted and when the speed brakes were extended No. 2 generator dropped off the line. It was reset and operated normally. No maintenance was performed after this flight. On February 11, 1981, the morning of the accident, the aircraft was dispatched to Toronto, Canada. En route, the No. 2 generator tripped, was reset and tripped again. Later in the flight, all the generators tripped and were off for 9 minutes before they reset. The aircraft landed safely at Toronto and the copilot, who was a certificated mechanic, discussed the problem with the director of maintenance for Texasgulf. The Safety Board could not determine what, if any, maintenance was performed on the aircraft before the return flight to Westchester County. Our investigation indicated that both d.c. and a.c. electrical power were available for systems operation during the approach to Westchester County Airport down to about 1,000 feet m.s.l. and when the aircraft struck the ground. The Safety Board has not been able to determine the cause of the loss of the navigational radio. We also have not been able to determine whether there was an interruption in electrical power during the approach that was corrected by the crew before impact. A sister aircraft owned by Texasgulf was similarly modified and had similar problems. After the accident on February 11, 1981, the STC was removed from this aircraft and the wiring was restored to its original configuration. The Safety Board is aware that modifications similar to STC SA1596 CE were made to two other Lockheed Model 1329 aircraft using similar components. The operators of these aircraft reported that they had problems with the electrical systems similar to those described above. They have subsequently had the systems corrected and they are now working satisfactorily. In view of the problems associated with the installation of this STC in N520S and its sister aircraft, and in view of the possibility that an electrical malfunction may have been a causal factor in this accident, the National Transportation Safety Board recommends that the Federal Aviation Administration: Review the approval of Supplemental Type Certificate SA 1596 CE and the effect of the installation of the STC in Lockheed JetStar Model 1329 aircraft. (Class UI, Priority Action) (A-81-92) MeADAMS, GOLDMAN, and BURSLEY, Members, concurred in this recommendation. KING, Chairman, and DRIVER, Vice Chairman, did not participate. B. J es B g ha* an O2US Departmnent Ofce of Ire Admirnstrator F9U Inoepe'ien e Ave S A of Tronsportola on Was,,nglr. D C Federal Aviation Administration October 19, 1981 The Honorable James B. King Chairman, National Transportation Safety Board 800 Independence Avenue, SW. Washington, D.C. 20594 Dear Mr. Chairman: This is in response to NTSB Safety IRecoimmendation A-81-93 issued by the Board on August 26, 1981. This recommendation resulted from the Board's investiga- tion of an accident involving an Israel Aircraft Industries Model 1124 near Iowa City, Iowa, on September 2, 1980. While cruising at 35,000 feet, a cabin fire was experienced. Most of the pilot's instruments failed; the pilot's instrument lights went out; the omputer for the left engine fuel control became inoperative; and control of several other systems was lost. Warning lights did not come on, and no circuit breaker opened. The fire was extin- guished but reignited twice during the descent and landing. Because fuel could not be dumped, an overweight (21,000 pounds), night, emergency landing was accomplished. Landing flaps and thrust reversing were unavailable, the antiskid was inoperative, and because heavy braking was used, the brakes caught fire and subsequently failed. As a result, the aircraft overran the runway and stopped beyond the end where the passengers and crew disembarked. The fire was extinguished and there were no injuries; however, the aircraft was substantially damaged. Investigation disclosed that a wire bundle located behind a coffeemaker chafed and shorted to the rear of the coffeemaker case. As a result, the bundle burned through and separated. The wire bundle contained communication and accessory distribution wiring to the cockpit from the remote-control circuit breaker panel located in the aft luggage opartment. The remote-control circuit breaker (100 amp) used to protect the accessory and communications bus did not open. The remote-control circuit breaker is designed to provide protection through a thermal sensor which opens a 0.5-amp circuit breaker in the cockpit. Both the 0.5-amp circuit breaker and the remote-control circuit breaker were tested, and they functioned properly. 2 A-81-93. Evaluate the adequacy of the electrical system fault protection devices on Israel Aircraft Industries 1124 aircraft to ensure that the protective devices will minimize hazards to the aircraft when short circuits occur. FAA Comment. The Federal Aviation Administration (FAA) concurs in this recosmrendation. A simulation test is underway to study the behavior of the circuitry associated with this incident. We anticipate finalization of test results by January 15, 1982. Upon review of the simulator test results and study, the FAA will take further appropriate action. The Board will be informed of our findings. Sincerely, J. Lynn Helms Administrator 4 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. ISSUED: August 26, 1981 - ----------------------------- Forwarded to: Honorable J. Lynn Helms Administrator Federal Aviation Administration SAFETY RECOMMENDAT ION (S) Washington, D. C. 20591 A-81-93 ------------------------------- On September 2, 1980, an Israel Aircraft Industries Model 1124 experienced a cabin fire while cruising at 35,000 feet near Iowa City, Iowa. Most of the pilot's instruments failed; the pilot's instrument lights went out; the computer for the left engine fuel control became inoperative; and control of several other systems was lost. Warning lights did not come on, and no circuit breaker opened. The fire was extinguished but reignited twice during the descent and landing. Because fuel could not be dumped, an overweight (21,000 pounds) night, emergency landing was accomplished. Landing flaps and thrust reversing were unavailable, the antiskid was inoperative, and because heavy braking was used, the brakes caught fire and subsequently failed. As a result, the aircraft overran the runway and stopped beyond the end where the passengers and crew disembarked. The fire department extinguished the fire. There were no injuries; however, the aircraft was substantially damaged. The Safety Board's investigation disclosed that a wire bundle located behind a coffeemaker chafed and shorted to the rear of the coffeemaker container case. As a result, the bundle burned through and separated. The wire bundle contained communication and accessory distribution wiring to the cockpit from the remote-control circuit breaker panel located in the aft luggage compartment. The remote-control circuit breaker (100 amp) used to protect the accessory and communications bus did not open. The remote-control circuit breaker is designed to provide protection through a thermal sensor which opens a 0.5-amp circuit breaker in the cockpit. Both the 0.5-amp circuit breaker and the remote-control circuit breaker were tested, and they functioned properly. On September 3, 1980, the manufacturer took action to reroute the wire bundle so that it could not contact the coffeemaker. The Federal Aviation Administration subsequently issued Airworthiness Directive (AD) 80-19-15 to remove the potential of chafing. However, the AD did not require any modification of the circuit protection. 3320 ( I -2- As required in 14 CFR 25.1357, Circuit Protective Devices, automatic protective devices must be used to minimize distress to the electrical system and hazard to the airplane in the event of wiring faults or serious malfunction of the system or connected equipment. With regard to this incident, the Safety Board believes that the aircraft's automatic electrical circuit protection should have prevented the overheating and fire that destroyed important electrical wiring. Further, we believe that the provisions of 14 CFR 25.1357 were not satisfied in that the installed automatic protection device did not open the circuits it was designed to protect. Therefore, the National Transportation Safety Board recommends that the Federal Aviation Administration: Evaluate the adequacy of the electrical system fault protection devices on Israel Aircraft Industries 1124 aircraft to ensure that the protective devices will minimize hazards to the aircraft when short circuits occur. (Class II, Priority Action) (A-81-93) KING, Chairman, MeADAMS, and GOLDMAN, Members, concurred in this recommendation. DRIVER, Vice Chairman, and BURSLEY, Member, did not participate. amesB. 1 Chairma ,National Transportation Safety Board 0 \-<,'z i Washington, D.C. 20594 91075P December 10, 1981 Office of the Chairman Honorable J. Lynn Helms - ,h"/- t Administrator Federal Aviation Administration Washington, D.C. 20591 Dear Mr. Hels: .. Thank you for your letter of November 10, 1981, responding to National Transportation Safety Board Safety Recommendations A-81-94 and -95 issued August 31, 1981. These recommendations stemmed from our investigation of several weather-related accidents in which the weather briefing provided to the pilot by the Flight Service Station (FSS) specialist was not in accordance with the Flight Services Handbook. The noncompliance with procedures in the Handbook resulted in the omission of critical weather information during the briefina. A-81-94. We are informed that the FSs Modernization Flan will provide position recording for each operational position at the 61 automated FSS's and that adequate records retention requirements already exist. The status of this recommendation is classified "Closed--Acceptable Action." A-81-95. We are pleased to note that the FAA is developing a more comprehensive quality control program to ensure that FSS personnel who provide weather briefinqs comply with published procedures. The status of this recommendation is also classified "Closed--Acceptable Action." Sincerely yours, III Imes R i S-- L_- . ... .. . US Deparment or Trnrspoocrton Federal Aviation Administration NOV 10 1981 The Honorable James B. King Chainnan, National Transportation Safety Board 800 Independence Avenue, SW. Washington, D.C. 20594 Dear Mr. Chaiman: This is in response to NTSB Safety Recomtendations A-81-94 and A-81-95 issued by the Board on August 31, 1981. These recosnvendations resulted from the Board's investigation of several weather-related acridents in which the Board contends that the weather briefing provided to the pilot by the flight service station (FSS) specialist .-,as not performed in: accordance with the Flight Services Handbook. Noncompliance with the procedures in the Handbook resulted in the omission of critical weather information during the briefing. A-81-94. Audio-record all weather briefings provided by FSS personnel anm retain such records for a reasonable period of time. FAA Ccx;aent. The Federal Aviation Administration (FAA) concurs in this recomme-ndation. The FSS Modernization Plan will provide position recording for each op>erational position at the 61 automated FSS's. It is neither cost beneficial nor feasible to provide audio recorders at existing FSS's because of the short duration anticipated until the automated FSS's are operational. Adequate records retention requirements already exist and, accordingly, there is no need for additional action in this regard. The FAA considers action coirpleted on Safety Recoimiendation A-81-94. A-81-95. Take steps to ensure that all FSS personnel who provide weather briefings comply with the weather briefing procedures published in Flight Services Handbook 7110.10. FAA Comurent. The FAA concurs in this recomnendation. A pilot weather briefing evaluation program was initiated earlier this year and has been successful in identifying discrepancies such as those noted in the text of this reco(mendation. Development cf a more comprehensive quality control program has been initiated by FAA headquarters and will require more accountability for positive followup corrective action at the facility and regional air traffic division level. We believe this program is fully responsive to this reccimendation and, accordingly, the FAA considers action completed on Safety Recomendation A-81-95. Sincerely, J. lynn !le m:; A,imi i i .t r aor NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. ISSUED: August 31, 1981 Forwarded to: Honorable J. Lynn Helms Administrator Federal Aviation Administration SAFETY RECOMMENDAT ION(S) 800 Independence Avenue, S.W. Washington, D.C. 20591 A-81-94 and -95 About 1630 c.s.t. on January 30, 1980, a Rockwell Aero Commander 690A, XB-AEA, crashed 9 miles south of the Will Rogers Airport, Oklahoma City, Oklahoma. The aircraft was en route from Dallas, Texas, to Oklahoma City, Oklahoma, on an instrument flight rules (IFR) flight plan. At 1338 c.s.t., a specialist at the Fort Worth Flight Service Station (FSS) Fort Worth, Texas, briefed the pilot. Subsequent investigation by the Safety Board revealed that the weather briefing the pilot received was not performed in accordance with Flight Services Handbook 7110.10. During the briefing, the specialist did not inform the pilot of a National Weather Service (NWS) forecast for significant icing in Oklahoma. On February 12, 1980, Beech Baron N1ZW crashed about 1905 e.s.t. while attempting an instrument landing system (ILS) approach to runway 23 at Saranac Lake, New York. The aircraft was on an IFR flight plan from Teterboro, New Jersey, to Saranac Lake, New York. About 1531 e.s.t., the pilot of N1ZW called a specialist at the Teterboro FSS and requested a weather briefing. Investigation by the Safety Board revealed that the weather briefing provided to the pilot by the specialist was not performed in accordance with the Flight Services Handbook. During the weather briefing, the pilot did not receive NWS forecasts for occasional moderate turbulence and light to occasionally moderate icing that were pertinent to the route of flight of N1ZW. In addition to the two accidents cited above, the Safety Board has investigated four other accidents in 1980 1/ in which the weather briefing provided to the pilot by the FSS specialist was nolt performed in accordance with the Flight Services Handbook. Again, noncompliance with the procedures in the Handbook resulted in the omission of critical weather information during the briefing. Since the safety of I/ Beech Airera t Bonanza (BE-35), N621T, February 14, 1980, Barksdale, Texas - fort Worth,Texas FSS. Cessna Aircraft (C-172), N3912F, May 10, 1980, Napanee, Indiana - South Bend, Indiana FSS. Grumman American (AA5B), N28252, October 16, 1980, Madill, Oklahoma - Oklahoma City, Oklahoma FSS. Beech Aircraft Baron (BE-55), N171W, October 29, 1980, Canisteo, New York - Buffalo, New York FSS. 3328 Sf -2- flight depends on the availability of critical weather information to the pilot, the Safety Board believes that the FAA must take steps to ensure that FSS personnel comply with the weather briefing procedures in Flight Services Handbook 7110.10. 2/ The FAA is responsible for monitoring the quality and content of weather briefings. One method, which is considered the most efficient, is the review of audio-recorded weather briefings at FSS's. However, only about 40 percent of the FSS's have this capability. The Safety Board believes that by expanding the audio-recording capability to all FSS's the monitoring process will be enhanced and consequently the quality and content of weather briefings provided by FSS personnel will be improved. Therefore, the National Transportation Safety Board recommends that the Federal Aviation Administration: Audio-record all weather briefings provided by FSS personnel and retain such records for a reasonable period of time. (Class II, Priority Action) (A-81-4) Take steps to ensure that all FSS personnel who provide weather briefings comply with the weather briefing procedures published in Flight Services Handbook 7110.10. (Class II, Priority Action) (A-81-95) KING, Chairman, DRIVER, Vice Chairman, and GOLDMAN and BURSLEY, Members, concurred in these recommendations. McADAMS, Member, did not participate. 2/ For more information read "Special Investigation Report: Flight Service Station Weather Briefing Inadequacies." (NTSB-SIR-81 -3.) US Deoormen• O Tronsportaion Federal Aviation Administration OCT 28 if1 The Honorable James B. King Chairman, National Transportation Safety Board 800 Independence Avenue, Siq. Washington, D.C. 20594 Dear Mr. Chairman: This is in response to NTSB Safety P orniendation A-81-96 issued by the Board on September 10, 1981. This recommrendation resulted frn the Board's inves- tigation of an aircraft accident caused 1-y a slowly collapsed nose landing gear on a Piper PA-32R, N2252Q, during rollout after a normal landing. This accident occurred at Raeford, North Carolina, on SeptemLer 3, 1930. The pilot stated that just before touchdown he saw three green landing gear light indications. Examination of the nose landing gear asseimbly revealed that the nose landing gear dow.nlock retaining screw, P/N 410011, was loose, worn, and bent. The retaining nut, P/N 404887, had backed off but was still on tie threads. This looseness in the retaining nut allowed the eccentric bushing, P/N 35662-02, to rotate and slide. This would randoraly result in misaligniint of the nose gear downlock, P/N 38078-02, and the cbwlock bearing (fixed). Althoigh the microswitch could engage and illuminate the green nose gear landing light on the instrument panel, the mechanical doyniock would not necessarily be positively engaged. On April 10, 1981, a Federal Aviation Administration (FAA) Systers Analysis and SLmary Report was issued which pointed out that a review of Service Difficulty Reports indicated an upward trend in nose landing gear downlock failures in PA-32R aircraft. There were 18 reports over a 4-year period ending March 5, 1981. Nine of these reports were received during the period April 21, 1980, through March 5, 1981. In addition, a review of FAA accident/incident reports shows that there have been nine incidents in which the nose landing gear has collapsed due to a failure of the nose landing gear downlock, P/N 38078-02. One incident occurred in 1978, six occurred in 1980, and two occurred in 1931. The cutoff date for these data was March 13, 1981. A-81-96. Issue an Air.%orthiness Dire,:tiv, ir. in te ]ruvisij-;; of Pie ry - Aircraft Corpx)ration Service Bulletin N;. 721 nan.ator for all P- 2P --. aircraft. FAA Carment. The F;A concurs in tils recip,ndation. Prior to issjn:- " (: Safety Recomr-enJation A-81-96, the Lord ha, been infon.,aly advis>d t2-,at Piper's corrrective action would' be - isned ,i:.:fric' Bul1:'tin 'co. - Havever, in subsequent action, on Oct 'e>,r 2, 1981, tn. service .~lic~tto' was reidentified and will be publishe ] xs S--r-vice Letter No. 927. An airworthiness directive (AD) is currently in preparation and will be published to coincide withi publication of Piuer Service Letter No. 927 an!] the availability of the associated Servic.? Fit, Piper part nutr,5ir 764-135V. Piper states that the publication and p7arts availability began duri!>i the week of October i2, 1981. The AD will be published under Docket Nurnber 81-SO--57, and a copy will be forwarded to the Safety Board when pulAished. With issuance of the AD, the FAA considers action coiipleted on Safety Reco;mnendation A-K1-96. Sincerely, J. Lynn Helms AI ,