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Safety Recommendation A-97-036
Details
Synopsis: ABOUT 5:05 P.M., CENTRAL STANDARD TIME, ON 11/19/96, UNITED EXPRESS FLIGHT 5925, A BEECH (BE) 1900C LANDING ON RUNWAY 13 AT THE BALDWIN MUNICIPAL AIRPORT IN QUINCY, ILLINOIS, COLLIDED AT THE INTERSECTION OF RUNWAY 13 & RUNWAY ON WITH A BEECH KINGAIR A-90 THAT WAS DEPARTING FROM RUNWAY 04. THE COLLISION RESULTED IN A FIRE THAT ENGULFED BOTH AIRPLANES. AS A RESULT OF THE COLLISION & FIRE, ALL 10 PASSENGERS & THE 2 CREWMEMBERS ABOARD THE UNITED EXPRESS FLIGHT & THE 2 CREWMEMBERS ABOARD THE KINGAIR A-90 WERE FATALLY INJURED.
Recommendation: THE NTSB RECOMMENDS THAT THE FAA: PROMPTLY REQUIRE THE INSPECTION OF THE COCKPIT VOICE RECORDER (CVR) & ASSOCIATED EQUIPMENT ON ALL BEECH 1900 AIRCRAFT & ENSURE THAT OPERATORS TAKE CORRECTIVE ACTION TO REPAIR DEFICIENT CVR SYSTEMS SO THAT THE INTELLIGIBILITY OF RECORDED COMMUNICATIONS, INCLUDING RADIO TRANSMISSIONS TO & FROM AIRPLANE, IS AS HIGH AS PRACTICABLE.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: QUINCY, IL, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA97MA009AB
Accident Reports: Runway Collision United Express Flight 5925 and Beechcraft King Air A90 Quincy Municipal Airport
Report #: AAR-97-04
Accident Date: 11/19/1996
Issue Date: 5/22/1997
Date Closed: 1/30/2001
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 1/30/2001
Response: WITH THE FINAL ISSUANCE OF AD 2000-20-07, THE FAA HAS COMPLETED THE ACTION RECOMMENDED. ACCORDINGLY, A-97-36 IS CLASSIFIED "CLOSED--ACCEPTABLE ACTION."

From: NTSB
To: FAA
Date: 12/4/2000
Response: THE SAFETY BOARD BELIEVES THAT THE FAA IS TAKING THE ACTION RECOMMENDED. PENDING ISSUANCE OF THE FINAL RULE TO ADOPT THE AD, A-97-36 REMAINS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 11/17/2000
Response: Letter Mail Controlled 11/22/2000 1:31:14 PM MC# 2001719: Raytheon designed an improved cockpit voice recorder (CVR) amplifier and new circuitry for the side-tone wiring and issued Raytheon Aircraft Company Service Bulletin (SB) 23-3094 recommending the incorporation of these changes. On September 26, 2000, the Federal Aviation Administration (FAA) issued Airworthiness Directive (AD) 2000-20-07 applicable to certain Beech 1900, 19OOC, and 1900D series airplanes. The AD mandates the CVR modifications in accordance with SB 23-3094. I have enclosed a copy of the AD for the Board's information. I consider the FAA's action to be completed on this safety recommendation.

From: FAA
To: NTSB
Date: 11/7/2000
Response: RAYTHEON DESIGNED AN IMPROVED COCKPIT VOICE RECORDER (CVR) AMPLIFIER AND NEW CIRCUITRY FOR THE SIDE-TONE WIRING AND ISSUED RAYTHEON AIRCRAFT COMPANY SERVICE BULLETIN (SB) 23-3094 RECOMMENDING THE INCORPORATION OF CHANGES. ON 9/26/00, THE FAA ISSUED AIRWORTHINESS DIRECTIVE (AD) 2000-20-07 APPLICABLE TO CERTAIN BEECH 1900, 1900C, AND 1900D SERIES AIRPLANES. THE AD MANDATES THE CVR MODIFICATIONS IN ACCORDANCE WITH SB 23-3094. I HAVE ENCLOSED A COPY OF THE AD FOR THE BOARD'S INFORMATION. I CONSIDER THE FAA'S ACTION TO BE COMPLETED ON THIS SAFETY RECOMMENDATION.

From: FAA
To: NTSB
Date: 9/5/2000
Response: Letter Mail Controlled 09/07/2000 3:38:39 PM MC# 2001237 RAYTHEON DESIGNED AN IMPROVED COCKPIT VOICE RECORDER (CVR) AMPLIFIER AND NEW CIRCUITRY FOR THE SIDE-TONE WIRING AND ISSUED SERVICE BULLETIN (SB) 23-3094 RECOMMENDING THE INCORPORATION OF THESE CHANGES. ON 6/6/00, THE FAA ISSUED A NOTICE OF PROPOSED RULEMAKING (NPRM) PROPOSING TO ADOPT AN AIRWORTHINESS DIRECTIVE (AD) TO MANDATE THE MODIFICATIONS SPECIFIED IN SB 23-3094. I HAVE ENCLOSED A COPY OF THE NPRM FOR THE BOARD'S INFORMATION.

From: NTSB
To: FAA
Date: 8/9/2000
Response: THE SAFETY BOARD IS PLEASED THAT THE FAA PLANS TO NOTIFY BEECH 1900 OPERATORS OF THE EXISTENCE OF AN OPTIONAL UPGRADE TO THE RECORDER AND WILL ISSUE AN NPRM TO MANDATE MODIFICATIONS SPECIFIED IN SB 23-3094. PENDING ADOPTION OF THE AD, A-97-36 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 5/26/2000
Response: Letter Mail Controlled 05/31/2000 3:12:11 PM MC# 2000691 RAYTHEON HAS DESIGNED AN IMPROVED COCKPIT VOICE RECORDER (CVR) AMPLIFIER AND NEW CIRCUITRY FOR THE SIDE-TONE WIRING AND HAS ISSUED SERVICE BULLETIN (SB) 23-3094 RECOMMENDING THE INCORPORATION OF THESE CHANGES. I HAVE ENCLOSED A COPY OF THE SB FOR THE BOARD'S INFORMATION. THE FAA PARTICIPATED IN THE FLIGHT TEST EVALUATIONS OF THIS MODIFICATION, WHICH INCLUDED ALL RECORDING POSSIBILITIES LIKE RADIO TRANSMISSIONS, AND DETERMINED THAT THE QUALITY OF THE RECORDINGS WAS GOOD IN ALL CIRCUMSTANCES. CONSEQUENTLY, THE FAA HAS RECONSIDERED ITS POSITION AND PLANS TO ISSUE A NOTICE OF PROPOSED RULEMAKING (NPRM) PROPOSING TO ADOPT AN AIRWORTHINESS DIRECTIVE (AD) TO MANDATE THE MODIFICATIONS SPECIFIED IN SB 23-3094. I WILL PROVIDE THE BOARD WITH A COPY OF THE NPRM AD AS SOON AS IT IS ISSUED.

From: NTSB
To: FAA
Date: 10/27/1999
Response: THE SAFETY BOARD REMAINS CONCERNED ABOUT THE QUALITY OF CVR RECORDINGS ON BEECH 1900'S. ALTHOUGH THE FAA MAINTAINS THAT IT IS SATISFIED THAT THE CVR'S INSTALLED ON BEECH 1900'S MEET THE RECORDING REQUIREMENTS OF 14 CFR PARTS 135.151 AND 23.1457, OUR STAFF HAS LISTENED TO THE ORIGINAL CERTIFICATION TAPES FROM THESE RECORDERS AND FOUND THE RECORDINGS TO BE OF UNACCEPTABLE QUALITY. ADDITIONALLY, RECORDED RADIO TRANSMISSIONS ARE OFTEN UNINTELLIGIBLE. THE SAFETY BOARD DOES NOT BELIEVE THAT MERELY NOTIFYING BEECH 1900 OPERATORS OF THE EXISTENCE OF AN OPTIONAL UPGRADE TO THE RECORDER WILL "ENSURE THAT OPERATORS TAKE CORRECTIVE ACTION TO REPAIR DEFICIENT CVR SYSTEMS," AS RECOMMENDED. THEREFORE, PENDING A RESPONSE FROM THE FAA INDICATING THAT IT WILL EITHER REQUIRE CORRECTIVE ACTION, SUCH AS INSTALLATION OF THE UPGRADED AMPLIFIER, OR THAT THE PREFLIGHT INSPECTION OF THE CVR ENSURES THAT IT RECORDS RADIO TRANSMISSIONS TO AND FROM THE AIRPLANE, A-97-36 IS CLASSIFIED "OPEN--UNACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 8/31/1999
Response: Letter Mail Controlled 9/2/99 2:34:12 PM MC# 990978: The Federal Aviation Administration (FAA) has evaluated the cockpit voice recorder (CVR) system installed on the Beech 1900 airplanes and is satisfied that the CVR meets the recording requirements of 14 CFR 135.151 and 14 CFR 23.1457. To ensure that the recorder and associated equipment are being properly maintained and meet acceptable recording standards, the FAA issued Flight Standards Information Bulletin for Airworthiness FSAW 99-04, Beech 1900C Cockpit Voice Recorder (CVR) Inspections. The bulletin provides principal avionics and maintenance inspectors with policy/guidance to evaluate CVR maintenance programs related to Beech 1900 CVR recorder systems. The bulletin informs inspectors that the maintenance programs must include a periodic functional test for checking recorder play-back clarity and that deficient CVR's should be replaced with serviceable or improved units. I have enclosed a copy of the bulletin for the Board's information. As stated in our letter dated February 1, 1999, the Beech 1900 Airplane Flight Manual calls for a preflight functional test of the CVR by the flightcrew to verify the proper operation of the system. The test includes a check for a meter indication, listening to a tone, and performing a voice play-back test. If an individual system fails any aspect of the preflight functional test, the Beech 1900 Maintenance Manual provides guidance for the replacement or repair of the unit. The CVR shop manual provides detailed inspection and test instructions to assure that CVR's returned to service after repair are of the highest quality and meet the performance standards of Technical Standard Order C84. I believe that the existing operational and maintenance requirements ensure that any defect in a Beech 1900 CVR will be identified and corrected. Raytheon is still designing an improvement to the CVR amplifier installed in the Beech 1900, which includes new circuitry for the side-tone wiring. The FAA plans to issue an alert notifying all Beech 1900 operators of the vailability of the design improvement and recommending its installation. Since existing operational and maintenance requirements ensure that any defect in a Beech 1900 CVR will be identified and corrected, I consider the FAA's action to be completed.

From: FAA
To: NTSB
Date: 2/1/1999
Response: Letter Mail Controlled 2/8/99 5:13:24 PM MC# 990114 THE FAA HAS EVALUATED THE COCKPIT VOICE RECORDER (CVR) SYSTEM INSTALLED ON THE BEECH 1900 AIRPLANES AND IS SATISFIED THAT THE CVR MEETS THE RECORDING REQUIREMENTS OF 14 CFR 135.151 AND 14 CFR 23.1457. TO ENSURE THAT THE RECORDER AND ASSOCIATED EQUIPMENT ARE BEING PROPERLY MAINTAINED AND MEET ACCEPTABLE RECORDING STANDARDS, THE FAA IS DEVELOPING A FLIGHT STANDARDS INFORMATION BULLETIN TO PROVIDE FAA INSPECTORS WITH POLICY/GUIDANCE TO EVALUATE CVR MAINTENANCE PROGRAMS RELATED TO BEECH 1900 CVR RECORDER SYSTEMS. THE BULLETIN WILL INFORM INSPECTORS THAT THE MAINTENANCE PROGRAM SHOULD INCLUDE A PERIODIC FUNTIONAL TEST FOR CHECKING RECORDER PLAY-BACK CLARITY AND THAT DEFICIENT CVR'S SHOULD BE REPLACED WITH SERVICEABLE OR IMPROVED UNITS. CURRENTLY, THE BEECH 1900 AIRPLANE FLIGHT MANUAL CALLS FOR A PREFLIGHT FUNCTIONAL TEST OF THE CVR BY THE FLIGHTCREW TO VERIFY THE PROPER OPERATION OF THE SYSTEM. THE TEST INCLUDES A CHECK FOR A METER INDICATION, LISTENING TO A TONE, AND PERFORMING A VOICE PLAY-BACK TEST. IF AN INDIVIDUAL SYSTEM FAILS ANY ASPECT OF THE PREFLIGHT FUNCTIONAL TEST, THE BEECH 1900 MAINTENANCE MANUAL PROVIDES GUIDANCE FOR THE REPLACEMENT OR REPAIR OF THE UNIT. FINALLY, THE CVR SHOP MANUAL PROVIDES DETAILED INSPECTION AND TEST INSTRUCTIONS TO ASSURE THAT CVR'S RETURNED TO SERVICE AFTER REPAIR ARE OF THE HIGHEST QUALITY AND MEET THE PERFORMANCE STANDARDS OF TECHNICAL STANDARD ORDER C84. I BELIEVE THAT THE EXISTING OPERATIONAL AND MAINTENANCE REQUIREMENTS ENSURE THAT ANY DEFECT IN A BEECH 1900 CVR WILL BE IDENTIFIED AND CORRECTED. ADDITIONALLY, THE PREVIOUSLY REFERENCED INFORMATION BULLETIN WILL EMPHASIZE THE MAINTENANCE PROGRAMS FOR THE BEECH 1900 CVR SYSTEMS. AS STATED IN EARLIER CORRESPONDENCE, RAYTHEON IS DESIGNING AN IMPROVEMENT TO THE CVR AMPLIFIER INSTALLED IN THE BEECH 1900, WHICH INCLUDES NEW CIRCUITRY FOR THE SIDE-TONE WIRING. WHEN THE DESIGN CHANGE IS COMPLETED, RAYTHEON PLANS TO ORDER THE NEW AMPLIFIERS AND CVR'S FOR PRODUCTION AND ISSUE AN OPTIONAL SERVICE BULLETIN TO THE FIELD ANNOUNCING THE AVAILABILITY OF A KIT TO IMPROVE IN-SERVICE AIRPLANES TO THE CONFIGURATION THAT IS (BY THEN) IN PRODUCTION. THE FAA PLANS TO ISSUE AN ALERT TO ALL BEECH 1900 OPERATORS NOTIFYING THEM OF THE AVAILABILITY OF THE DESIGN IMPROVEMENT AND WILL RECOMMEND ITS INSTALLATION. I BELIEVE THAT THE ACTIONS OUTLINED IN THIS LETTER ADDRESS THE FULL INTENT OF THIS RECOMMENDATION, AND I WILL KEEP THE BOARD INFORMED OF THE FAA'S PROGRESS ON THESE ACTIONS.

From: FAA
To: NTSB
Date: 7/21/1997
Response: The cockpit voice recorder (CVR) installed on the Beech 1900 series airplanes meets the recording requirements of 14 CFR 135.151 and 14 CFR 23.1457. The CVR's must record voice communications transmitted from or received in the airplane by radio and voice communications of flight crewmembers. Additionally, 14 CFR 23.1457 requires that components of the CVR system be located, adjusted, or supplemented so that the intelligibility of the recorded voice communications among flight crewmembers is as high as practicable. There are no deficiencies with the CVR that warrant the issuance of an airworthiness directive. However, to improve the effectiveness of the Beech 1900 CVR system, Beech is designing an improvement to the CVR amplifier installed on Beech 1900 airplanes that will increase the intelligibility of recorded radio transmissions. As soon as Beech completes its design improvement, the Federal Aviation Administration (FAA) will issue a Special Airworthiness Information Bulletin to alert all Beech 1900 operators of its availability and recommend its installation. I will keep the Board informed of the FAA's progress on this safety recommendation.