March 4, 2011
A Safety Accomplishment is a positive change within the transportation environment that is attributed to some direct action of a regional employee. The positive change must be the result of an observation or action taken by the investigator and must be measurable and have supporting documentation to verify that the change occurred. Such changes will be considered safety accomplishments only if the action is taken without the issuance of a formal safety recommendation by the Board. In general, a safety accomplishment differs from a safety recommendation in that the safety enhancement is usually site-specific and local in nature and implementation can be effected by local officials or one of the parties to the investigation.
Listed below are some of the recipients of a Safety Accomplishment Award in 2010. Other recipients will be featured in upcoming issues of Across the Board.
Eliott Simpson
On January 5, 2010, a Bell 206B, operated by the California Department of Fish and Game (CDFG), while on a public use, deer surveying flight, collided with power lines near Auberry, California. The commercial pilot and the three passengers were killed. During interviews of the CDFG employees, Eliott Simpson discovered that the survey crews received no operational or safety training prior to onboard mission flights. Rather, the training was “on the Job” and limited to a quick preflight briefing with the pilot prior to the flights.
As a result of Simpson’s discussions with the CFDG, the Department put in place a training program for all of its survey flight crews.
Timothy Monville
On January 18, 2010, a Eurocopter AS 350 B2, operated by Liberty Helicopters, Incorporated, experienced a serious vibration while in cruise flight. The pilot landed the helicopter uneventfully at the West 30th Street Heliport, New York City. The pilot was not injured. A subsequent inspection of the helicopter revealed substantial damage to the tail rotor and surrounding area. During the ensuing investigation, Timothy Monville determined that during maintenance to the tail rotor assembly, a mechanic only partially assembled one tail rotor pitch change link to the tail rotor. Because the operator did not have a required items inspection as part of a quality assurance program, there was no way for the operator to detect the incomplete tail rotor assembly prior to returning the helicopter to service.
As a result of Monville’s discussions with the operator’s Director of Maintenance, the company modified its Federal Aviation Administration Approved Aircraft Inspection Program to include required inspection items following maintenance or repairs of safety of flight items.
Jose Obregon, Deepak Joshi, Donald Kramer
On February 15, 2010, a Cessna T337G crashed following separation of a 6-foot section of the outer right wing as it overflew the runway at Monmouth County Executive Airport, Farmingdale, New Jersey. The pilot and four passengers were killed. The airplane was the subject of a Supplemental Type Certificate which extended the wing fuel tip tanks and incorporated a wingtip fence. NTSB investigators were interested in the operation of the airplane at or near the airspeed limitations and the structural life of wings, which incorporate this modification.
As a result of the investigators’ discussions with the Federal Aviation Administration (FAA) Aircraft Certification Office, the FAA issued a Special Airworthiness Information Bulletin instructing operators of these airplane types to adhere to established operations limitations, and instructing maintenance personnel to inspect specific areas of the wing for indications of structural overstress.
Orrin K. Anderson
On February 23, 2010, a Diamond DA-20, while on a student solo cross-country flight, lost control and impacted off the side of a runway during a go-around attempt at the Delta Municipal Airport, Delta, Utah. The occupant was not injured. The investigation revealed that the operator’s training program showed several operational shortcomings as it related to student pilot training and student pilot solo cross-country flights.
As a result of Orrin Anderson’s discussions with the operator, the operator instituted a new training policy that required first-time solo cross-country flights be flown to airports at which the student had received prior training, that landings performed on student pilot solo cross-country flights be to either a full stop or stop and go, that student pilots undergo standardized go-around training, and that student pilots receive go-around evaluations during both stage and end-of-course checks.
Craig Hatch
On March 7, 2010, a Tecnam P92 Light Sport Airplane was substantially damaged when the right main landing gear fractured and collapsed during landing at the RWJ Airpark, Baytown, Texas. The instructor pilot and student pilot on board were not injured. An examination of the landing gear showed that all three mounting bolts had failed. Further examination at the NTSB Materials Laboratory revealed that the two outboard bolts showed crack arrest markings consistent with fatigue cracking from multiple origins.
As a result of Craig Hatch’s discussions with the airplane manufacturer and the FAA, the following safety measures were taken: (1) the FAA wrote a safety recommendation proposing a 100 hour inspection for the bolts; (2) the manufacturer issued a Service Information Alert recommending that the gear bolts be inspected and, if needed, be replaced; and (3) the manufacturer issued a Mandatory Service Bulletin based on the information contained in the Service Information Alert.