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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.
TO THE FEDERAL AVIATION ADMINISTRATION: Require 14 Code of Federal Regulations Part 121 air carriers to 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:
Open - Unacceptable Response
Charlotte, NC, United States
Loss of Pitch Control During Takeoff Air Midwest Flight 5481, Raytheon (Beechcraft) 1900D, N233YV
Addressee(s) and Addressee Status:
FAA (Open - Unacceptable Response)
Safety Recommendation History
The FAA’s last letter concerning Safety Recommendation A-04-8, dated May 25, 2010, stated that you had revised operations specification D091 to replace the term “substantial maintenance” with “essential maintenance,” defined as maintenance that would result in a failure effect that would endanger the continued safe flight and landing of the airplane if it were performed improperly or if improper parts or materials were used. You stated that this new term and definition would help ensure that air carriers and FAA offices consistently apply appropriate maintenance guidance or procedures. Our November 23, 2010, reply stated that, to complete the action recommended in A 04-8, the FAA would need to ensure that all Part 121 carriers had incorporated original equipment manufacturers’ post-maintenance functional checks/tests in their maintenance manuals. Pending completion of that effort, Safety Recommendation A-04-8 remained classified “Open—Acceptable Response.” Although Safety Recommendation A-04-8 is now 12 years old, we are not aware of any requirement you have issued for operators to include the recommended procedures in their existing maintenance manuals. Accordingly, we request an update on any actions that you have taken or planned to address this recommendation. In the meantime, Safety Recommendation A 04-8 is classified OPEN—UNACCEPTABLE RESPONSE.
To fully evaluate the FAA's response to this recommendation, we also considered the FAA's August 13,2009, letter to the NTSB concerning related Safety Recommendation A-04-7, which asked the FAA to require manufacturers of aircraft operated under 14 CFR Part 121 to identify procedures for a complete functional check of each critical flight system; determine which maintenance procedures should be followed by such functional checks; and, if necessary, modify existing maintenance manuals so that they contain procedures for a complete postmaintenance functional check. In its August 13, 2009, letter, the FAA indicated that, for critical aircraft systems, it would 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 planned to sample original equipment manufacturers' (OEM) current practices for selecting PFCTs and examine how these are incorporated into their maintenance documentation. On April 6, 2010, the NTSB wrote to the FAA that the 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 was responsive to the recommendation. Pending the FAA's completing those actions, Safety Recommendation A-04-7 remained classified "Open-Acceptable Response." To complete the recommended action, the FAA will need to ensure that carriers incorporate all maintenance manual revisions that result from FAA actions in response to Safety Recommendation A-04-7. Pending completion of that effort, Safety Recommendation A-04-8 remains classified OPEN – ACCEPTABLE RESPONSE.
Letter Mail Controlled 6/16/2010 MC# 2100201 - From J. Randolph Babbitt, Administrator: The Federal Aviation Administration published new guidance in the form of a FAA Notice 8900.1 03 (enclosed). This change revises operations specification (OpSpec) D091 to address a change in terminology and meaning from the previously used term "substantial maintenance" to the new term "essential maintenance." A standard term and definition will help ensure that air carriers and FAA offices consistently apply appropriate maintenance guidance or procedures. The following definition of essential maintenance is maintenance that would result in a failure effect that would endanger the continued safe flight and landing of the airplane if it was performed improperly or if improper parts or materials were used. Essential maintenance includes the accomplishment of the Required Inspection Item. Part 121 air carriers must accomplish their maintenance with the highest possible level of safety. This part requires that each aircraft released to service is airworthy and has been properly maintained for operation. They are required to have a manual that contains adequate instructions to ensure that aircraft are released to service in an airworthy condition. This includes instructions to perform any required checks to verify the effectiveness of any corrective actions taken prior to further flight. If any instructions are found to be ineffective, the air carrier must modify their existing manual to correct any deficiencies noted. Part 121 air carriers are also required to ensure that any person who accomplishes maintenance on his or her aircraft is adequately trained to complete the maintenance instructions provided in the maintenance manual. Again, if deficiencies are noted, corrective actions must be taken at whatever level necessary (air carrier or original equipment manufacturer (OEM)) to correct the issue. This may include additional training or in some cases correcting the instructions to ensure the desired outcome. The FAA believes that the new standardized definition of essential maintenance, along with part 121 air carriers' incumbent responsibility to ensure that their aircraft are released in an airworthy condition, the effectiveness of their manual system and training, including the completion of any work or task cards, and the air carriers' normal interface with the OEMs, effectively address the intent of the Board's recommendations. We consider our actions complete.
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.
Letter Mail Controlled 6/28/2004 3:14:12 PM MC# 2040357 - From Marion C. Blakey, Administrator: The FAA will issue a flight standards information bulletin to inspectors to notify their assigned air carriers of the need to review and, if necessary, modify the carriers' maintenance manual procedures to ensure that a functional check of each critical flight system is performed after maintenance. It is anticipated that the bulletin will be issued by October 2004.
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