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Safety Recommendation Details

Safety Recommendation A-04-007
Details
Synopsis: On January 8, 2003, about 0847:28 eastern standard time, Air Midwest (doing business as US Airways Express) flight 5481, a Raytheon (Beechcraft) 1900D, N233YV, crashed shortly after takeoff from runway 18R at Charlotte-Douglas International Airport, Charlotte, North Carolina. The 2 flight crewmembers and 19 passengers aboard the airplane were killed, 1 person on the ground received minor injuries, and the airplane was destroyed by impact forces and a postcrash fire. Flight 5481 was a regularly scheduled passenger flight to Greenville-Spartanburg International Airport, Greer, South Carolina, and was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require manufacturers of aircraft operated under 14 Code of Federal Regulations Part 121 to identify appropriate procedures for a complete functional check of each critical flight system; determine which maintenance procedures should be followed by such functional checks; and modify their existing maintenance manuals, if necessary, so that they contain procedures at the end of maintenance for a complete functional check of each critical flight system.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: Charlotte, NC, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA03MA022
Accident Reports: Loss of Pitch Control During Takeoff Air Midwest Flight 5481, Raytheon (Beechcraft) 1900D, N233YV
Report #: AAR-04-01
Accident Date: 1/8/2003
Issue Date: 3/5/2004
Date Closed: 3/27/2017
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Maintenance,Procedures

Safety Recommendation History
From: NTSB
To: FAA
Date: 3/27/2017
Response: You indicated that, on February 16, 2016, you issued Policy Statement PS-ANM-25-18, “Post Maintenance Checks and Tests,” which provides guidance to manufacturers of aircraft operating under part 121 to identify appropriate post-maintenance functional checks/tests (PFCTs) based on safety impact and to include them in the instructions for continued airworthiness. Although we believe that Policy Statement PS-ANM-25-18 contains valuable guidance, we are concerned because it applies only to newly type-certificated designs. We note that, on August 3, 2016, in an effort to address in-service aircraft, you published Special Airworthiness Information Bulletin (SAIB) NM-16-20, “Scheduled Maintenance Checks.” However, we do not believe that the SAIB, which reinforces commonsense procedures that maintenance personnel should already be performing, is an acceptable alternate solution to this problem. Previously, we emphasized that an acceptable response to this recommendation would require the modification of existing maintenance manuals to include PFCTs where appropriate. Although we are aware of the challenges associated with modifying existing manuals, we continue to believe that PFCTs are a best practice that should be consistently incorporated into maintenance manuals. However, because you indicated that your actions are complete, Safety Recommendation A-04-7 is classified CLOSED--UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 12/15/2016
Response: From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) issued Policy Statement PS-ANM-25-18, Post Maintenance Checks and Tests, on February 16, 2016 (available at rgl.faa.gov). This policy provides guidance to manufacturers of aircraft operating under part 121 to identify appropriate post-maintenance checks or tests based on safety impact, and include them in the instructions for continued airworthiness (ICA). This policy will only apply to new certification programs, including new, amended, and supplemental type certification projects and not to unchanged in-service aircraft. In order to incorporate the intent of the policy into unchanged in-service aircraft, we would have to find that there are specific unsafe conditions in the fleet that warrant airworthiness directive actions. We have not found any such unsafe conditions. Furthermore, if this policy were applied to unchanged in-service aircraft there would be great potential to incorporate errors into maintenance manuals due to the nature of the complex change process. At type certification, manufacturers develop ICA and each operator establishes their own maintenance program based on these instructions, which may include changes from the original intended ICA. To apply this policy to unchanged in-service airplanes, the manufacturers would have to review each maintenance task relative to the policy criteria, and then develop changes to the ICA for incorporation by operators. This would require a great deal of analysis and coordination for thousands of aircraft and thousands of maintenance procedures. Operators would then have to revise their maintenance programs based on the TCA changes. The risk of introducing errors in the ICA might outweigh any benefit that may be gained. In addition, many aircraft currently in-service were certified to earlier regulations that did not require detailed system safety assessments, which are specified in PS-ANM-25-18 as the basis for identifying necessary post-maintenance checks or tests. Therefore, the necessary data may not be available to support implementation of the policy for unchanged, in-service aircraft. To address in-service aircraft, the FAA published Special Airworthiness Information Bulletin (SAIB) NM-16-20, Scheduled Maintenance Checks, on August 3, 2016 (also available at rgl.faa.gov). This SAIB reinforces that if maintenance personnel perform full, partial, or limited maintenance tasks, they should conduct all post-maintenance inspections, checks, and tests for that system. If a partial or limited maintenance task for a system does not list a specific set of post-maintenance inspections, checks, and tests. then all system inspections, checks, and tests should be completed. This ensures that regardless of whether the mechanic performs full partial, or limited maintenance tasks, the airplane is adequately evaluated to be returned to service per§ 43.13(a) and (b), Performance rules (general). The SAIB also states that if there are questions about which inspections, checks, and tests apply to a specific maintenance task or subtask, maintenance personnel should contact their principal inspector or local Flight Standards District Office as appropriate for clarification. I believe the FAA has effectively addressed this recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 2/10/2014
Response: We note your position that post-maintenance functional checks/tests (PFCTs) are a best practice that should be incorporated into maintenance manuals consistently. We further note that you reviewed original equipment manufacturers (OEM) and found that, although some have defined systems to implement this best practice, other OEMs do not. As a result, you have drafted a policy calling for OEMs to develop an internal process to ensure that PFCTs are included when appropriate. Your review of manufacturers’ PFCTs is a positive step in addressing this recommendation, and the proposed policy may complete the recommended action. However, we have two concerns. Our first concern is that this recommendation is now 10 years old, and you have not yet even proposed the policy for public comment. We believe that actions in our recommendation should generally be completed within 3 to 5 years after a recommendation is issued. We emphasize that Safety Recommendation A-04-7 recommends the modification of existing maintenance manuals to include PCFTs where appropriate. The review of OEMs should have allowed you to identify manuals in need of revisions. Our second concern is that the policy you are developing will apply only to newly type-certificated designs, and will not require the modification of existing maintenance manuals. An acceptable response to this recommendation will require the modification of existing maintenance manuals, most likely the ones that you found were not currently incorporating the best practice. Therefore, please describe how the policy you are developing will result in needed revisions to existing maintenance manuals. Pending our receipt of your reply and timely issuance of the policy, Safety Recommendation A-04-7 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 12/13/2013
Response: -From Michael P. Huerta, Administrator: As stated in our letter dated January 4, 2012, the Federal Aviation Administration (FAA) believes this recommendation represents a best practice, and that post-maintenance functional checks/tests (PFCTs) should be incorporated into maintenance documentation consistently. We conducted a review and found that some original equipment manufacturers have defined systems to implement this best practice and some have not. As a result, we drafted a policy calling for transp011 category airplane manufacturers to develop an internal process to ensure that they identify and include appropriate post-maintenance checks or tests based on safety impact. We expect to issue the draft policy for public comment by June 2014. I will keep the Board informed of the FAA's progress on this recommendation and provide an update by September 30, 2014.

From: NTSB
To: FAA
Date: 4/25/2012
Response: The FAA had previously informed the NTSB that, in response to this recommendation, it planned to do the following: • Define post-maintenance functional checks/tests (PFCTs) for all critical aircraft systems • Verify that the PFCTs meet the criteria they planned to devise • Ensure that PFCTs are included in all appropriate maintenance procedures In February, 2009, the FAA requested that original equipment manufacturers (OEMs) provide information on their systems to implement PFCTs. Although some OEMs have responded, many foreign manufacturers have not respond, and so, the FAA recently sent a second request, to which the foreign OEMs are currently responding. Once the FAA receives all of the requested information, it plans to begin development of an appropriate policy. A current NTSB investigation is examining the role that PFCTs play in preventing accidents caused by the performance of incorrect maintenance. On September 1, 2011, an Atlantic Southeast Airlines flight operating as Delta Connection flight 5058, a Bombardier CL-600-2B19, landed in Baton Rouge, Louisiana, with the left main landing gear retracted (NTSB accident number CEN11IA615). Interviews conducted during the investigation of this event have revealed that the mechanic who installed the uplock had never installed one before nor received training on how to do so. An inspector for this required inspection item (RII) repair had conducted the inspection, performing PFCTs several times. Nevertheless, the airplane was dispatched with a problem remaining in the landing gear. This incident illustrates the importance of fully testing the system with an appropriate PFCT and the need to be aware that, at times, a PFCT may not reveal a problem that a visual inspection might. The NTSB believes that PFCTs must be carefully developed to ensure that they fully check a system’s operation and that they be used only when appropriate. The FAA’s plan to define PFCTs for all critical aircraft systems, verify that the PFCTs meet the criteria they have devised, and then ensure that PFCTs are included in all appropriate maintenance procedures is responsive to this recommendation. Accordingly, pending the FAA’s completing those actions, Safety Recommendation A-04-7 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 1/4/2012
Response: -From Michael P. Huerta, Acting Administrator: We believe this recommendation represents a best practice, and that post-maintenance functional checks/tests (PFCTs) should be incorporated into maintenance documentation consistently. We found that some original equipment manufacturers (OEMs) have defined systems to implement this best practice. We are awaiting responses from several OEMs to understand their systems regarding PFCTs. We initially requested this information in 2009; however, the foreign manufacturers were unresponsive. We recently sent a second request to which they are responding. This additional data is needed to better understand current industry practice for post-maintenance checks of critical systems and ensure new policy results in consistent implementation of PFCT best practices. We expect to have responses from all manufacturers by January 2012 and intend to draft policy and begin coordination by May 2012. I will keep the Board informed of the FAA's progress on this safety recommendation and provide an update by January 31, 2013.

From: NTSB
To: FAA
Date: 4/6/2010
Response: Initially, the FAA planned to (1) respond to this recommendation by soliciting aircraft manufacturers to provide functional testing requirements for critical flight systems after maintenance has been completed and then (2) take appropriate action after determining which airplanes were at risk. However, the FAA has found that this approach is not workable for a number of reasons, including the requirements imposed by the Paperwork Reduction Act. For critical aircraft systems, the FAA will define an appropriate set of post-maintenance functional checks/tests (PFCT) that will be required to (1) verify that the maintenance met the intended purpose and (2) ensure that completion of the maintenance did not result in an unsafe system condition. The FAA plans to sample original equipment manufacturers’ (OEM) current practices for selecting PFCTs and will evaluate how these are incorporated into their maintenance documentation. The FAA will request OEMs to provide data to determine who has a standard process for selecting PFCTs, and the FAA will determine whether the processes are adequate to verify items 1 and 2 above. The FAA’s plan to define PFCTs for all critical aircraft systems, verify that the PFCTs meet the criteria they have devised, and then ensure that PFCTs are included in all appropriate maintenance procedures is responsive to this recommendation. Pending the FAA’s completing those actions, Safety Recommendation A-04-7 remains classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/13/2009
Response: Letter Mail Controlled 9/1/2009 9:17:59 AM MC# 2090544: - From J. Randolph Babbitt, Administrator: Initially the FAA proposed to solicit aircraft manufacturers to provide functional testing requirements for critical flight systems after completing maintenance, and then take appropriate action after determining which airplane models were at risk. It became apparent that this approach was not workable for a number of reasons, including the requirements imposed by the Paperwork Reduction Act. The FAA is now proposing an alternative plan that will better address this recommendation. We believe that this new approach will lead to more systemic solutions or guidance to ensure that faulty maintenance does not result in future accidents. The FAA has determined that an appropriate subset of a complete system functional check can be defined to detect improper maintenance that could affect safe operation of the system. Requiring a complete functional check for each system after very limited tasks could include many unnecessary checks or tests. The safety objective in the recommendation could be achieved by implementing an appropriate set of post-maintenance functional checksltests (PFCTs) for a critical system. These would be required to: 1.Verify that the maintenance met the intended purpose; and 2. Ensure that the maintenance task did not result in an unsafe system condition. PFCTs will mitigate the risks of accidents like that of the Beech 1900D. In this instance, if there were post maintenance functional checks that verified surface position and position limits, the maintenance crew would have discovered the misrigging. For example: (1) If an end-to-end rigging check had been done on the Beech 1900D, it would have shown incorrect elevator surface position with the column at neutral; and (2) If an elevator range of motion test had been done, it would have shown diminished elevator nose down authority. 'The FAA notes that in a similar fashion, following revisions to include functional checks in the Model 1900D Maintenance Manual A35 and the Model 190011 900C Maintenance Manual B17, the Board classified Safety Recommendation A-04-24 as "Closed Acceptable." The FAA plans to sample original equipment manufacturers' (OEMs) current practices for selecting PFTCs and will evaluate how these are incorporated into their maintenance documentation. We will request OEMs to provide us with data by February 2010 to determine who has a standard process for selecting PFCTs. We also will determine whether their processes are adequate to verify items 1 and 2 above. We anticipate having adequate information by December 2010. We will then use that information to provide the Board with an update on our findings and course of action. Additionally, we are developing key safety information (KSI) data. The KSI data include operation or maintenance procedures/tasks that must be done correctly and not altered throughout the life of an airplane without proper engineering analysis. A KSI is selected based on a determination that failure to correctly do a key procedure/task could lead to a hazardous or catastrophic failure condition. The system safety assessment in conjunction with a set of selection criteria are used to make this determination. Identification of a maintenance or operational procedure as KSI will give maintenance personnel a heightened sense of the criticality of the procedure or task that they are doing.

From: NTSB
To: FAA
Date: 10/12/2005
Response: The FAA's June 18, 2004, letter stated that its aircraft certification offices will ask aircraft manufacturers to provide functional testing requirements for critical flight systems after completing maintenance and will take appropriate action after determining which airplane models are at risk. The FAA also reported that (1) a draft order is being developed that will provide guidance on Instructions for Continued Airworthiness, which will address functional checks following maintenance on critical flight systems and (2) an FSIB will be issued instructing inspectors to review and, if necessary, modify maintenance manual procedures to ensure that a functional check of each critical flight system is performed after maintenance. The Safety Board notes that the FAA is asking aircraft manufacturers for functional testing requirements to determine which airplane models are at risk. The Board believes that all aircraft have systems-not limited to flight controls-in which the failure of one or more of its components could be catastrophic. Because all aircraft have these critical flight systems, this recommendation applies to all airplanes operated under Part 121. The Board appreciates the FAA's actions on these recommendations and requests an example of a critical flight system identified in its activities in response to Safety Recommendation A-04-07 and the associated functional testing requirements provided by a manufacturer. Although the Safety Board appreciates the FAA's positive actions including (1) proposed development of a draft order that will provide guidance on Instructions for Continued Airworthiness and which will address functional checks following maintenance on critical flight systems; (2) the issuance of an FSIB instructing inspectors to review and, if necessary, modify maintenance manual procedures to include functional checks for critical flight systems; and (3) asking aircraft manufacturers to identify functional testing requirements for critical flight systems, the Board notes that these actions were scheduled to be completed by September, October, and December 2004, respectively. Status inquiries from Board staff to FAA staff have revealed that none of these activities have been completed. The Board requests copies of the draft order and FSIB when they are issued. Pending identification of critical flight systems and the appropriate procedures for a complete functional check of these systems after maintenance and subsequent development of a draft order and issuance of an FSIB as they relate to critical flight system identification, Safety Recommendations A-04-06 through -08 are classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/18/2004
Response: Letter Mail Controlled 6/28/2004 3:14:12 PM MC# 2040357 - From Marion C. Blakey, Administrator: On March 13, 2004, FAA staff held a telecon with your staff to obtain clarification on the intent of this safety recommendation. Your staff indicated that the recommendation was intended to address: · all critical flight systems and not just flight controls; · all airplanes operated under 14 CFR Part 121, and not just smaller, mechanically controlled airplanes. To address the safety recommendation thoroughly, the FAA's Aircraft Certification Offices will be asking aircraft manufacturers for functional testing requirements of critical flight systems after accomplishing maintenance. After analysis of the information received, the FAA will be in a position to determine which airplane models are at risk and take appropriate action. It is anticipated that this effort will be completed by December 2004.