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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: Prohibit inspectors from performing required inspection item inspections on any maintenance task for which the inspector provided on-the-job training to themechanic who accomplished the task.
Original recommendation transmittal letter:
Closed - Acceptable Action
Charlotte, NC, United States
Loss of Pitch Control During Takeoff Air Midwest Flight 5481, Raytheon (Beechcraft) 1900D, N233YV
Addressee(s) and Addressee Status:
FAA (Closed - Acceptable Action)
Safety Recommendation History
The FAA reiterated its position that current regulations already prohibit people who provide OJT on a maintenance task from performing an RII inspection for that task. On March 26, 2003, the quality assurance inspector who performed OJT and the RII inspection for the mechanic who rigged the elevator that subsequently caused the Air Midwest accident was advised that the FAA would be investigating the inspector’s actions in “giving on-the-job training after work was assigned.” On September 30, 2003, the FAA notified the inspector that the investigation “did not establish a violation of the Federal Aviation Regulations.” The NTSB issued this recommendation to ensure that FAA regulations are revised as necessary to clarify that an inspector performing RII should not also provide OJT. The FAA has maintained since these recommendations were issued that the regulations already prohibit the actions and that it would clarify this in guidance for inspectors. On October 29, 2010, a revision to FAA Order 8900.1, “Flight Standards Information Management System (FSIMS),” volume 3, chapter 43, became effective, adding a new Section 2, “Evaluating the Required Inspection Element of a Continuous Airworthiness Maintenance Program.” Subsection 3-3886, paragraph H of this new section provides further clarification, preventing any individual providing OJT to another person performing any item of work from acting as an RII inspector for the same item of work. We agree that current regulations prohibit the chain of events that resulted in the Air Midwest accident. It is our understanding that the FAA uses FAA Order 8900.1 to help in interpreting its regulations and in determining whether there has been a violation of a given regulation. The guidance that became effective October 29, 2010, clarifies that a mechanic who provides OJT on a maintenance task and then performs an RII inspection for that task has violated Federal Aviation Regulations; consequently, Safety Recommendation A-04-9 is classified CLOSED—ACCEPTABLE ACTION.
-From Michael P. Huerta, Acting Administrator: Current regulations prevent any person who performs any item of work from performing any required inspection of that work. Sections 12 I.369 and 135.427 contain a list of items an operator must include in its manual. Specifically, the manual must include the following: • The method of performing required inspections and a designation by occupational title of personnel authorized to perform each required inspection (sections 121.369(b)(3) and 135.427(b)(3)); and • Instructions to prevent any person who performs any item of work from performing any required inspection of that work (sections 121.369(b)(7) and l35.427(b)(7)). Furthermore. sections 121.371 and 135.429 state that: • No person may use any person to perform required inspections unless the person performing the inspection is appropriately certificated, properly trained, qualified, and authorized to do so (sections 121.371 (a) and 135.429(a)); and • No person may perform a required inspection if he performed the item of work required to be inspected (sections 121.371 (c) and 135.429c)). Nevertheless, the Board stated in its October 2005 response letter that these regulations were unclear on this issue. The Board further stated that the issuance of an airworthiness handbook bulletin, as was originally intended by the Federal Aviation Administration (FAA), would not resolve the issue. To provide additional clarification, we issued a new section (Section 2) to FAA Order 8900.1, Flight Standards Information Management System (FSIMS) volume 3, chapter 43. This new Section 2, Evaluating the Required Inspection Element of a Continuous Airworthiness Maintenance Program (enclosed), provides additional information, clarification, and policy for evaluating the required inspection elements of a certificate holder's Continuous Airworthiness Maintenance Program (CAMP). Specifically, subsection 3-3886, paragraph H of this new section provides further clarification preventing any person who provides on-the-job training (OJT) to any person who performs any item of work from performing any required inspection of that work. This change to the Order was issued and became effective on October 29, 2010.
The Safety Board notes that the FAA agrees that people who provide OJT on a maintenance task must not perform an RII inspection for that task, and the FAA states its belief that current regulations prohibit this practice. The FAA stated that it planned to issue a handbook bulletin for airworthiness (HBAW) by October 31, 2004, clarifying that an inspector who provides OJT during a maintenance task may not serve as an inspector for that task. In the letter that transmitted this recommendation to the FAA, the Board indicated that on March 26, 2003, the quality assurance inspector who performed OJT and the RII inspection for the mechanic who did the elevator rigging that caused the Air Midwest accident was advised that the FAA would be investigating the inspector's actions in "giving on-the-job training after work was assigned." On September 30, 2003, the FAA notified the inspector that the investigation "did not establish a violation of the Federal Aviation Regulations." The Board notes that although the FAA may believe that current regulations already prohibit the practice that this recommendation seeks to prohibit, the FAA's enforcement action in response to the incident that prompted this recommendation shows that the current regulations are, at best, unclear on this issue. Because the FAA's investigation of the event that prompted this recommendation found there was no violation of the regulations, issuing a bulletin will not resolve this situation. Therefore, the Safety Board does not believe that an HBAW is an acceptable response to this recommendation. Further, the Board questions whether an HBAW will be effective several years after it is issued and potentially forgotten. Pending issuance of regulations that prohibit an inspector from performing the RII inspection for work for which the inspector provided OJT, Safety Recommendation A-04-09 is classified OPEN -- UNACCEPTABLE RESPONSE.
Letter Mail Controlled 6/28/2004 3:14:12 PM MC# 2040357 - From Marion C. Blakey, Administrator: Current regulatory language prohibits personnel who perform maintenance from performing required inspections on that maintenance. The FAA will issue an airworthiness handbook bulletin (HBAW) clarifying required inspection item (RII) procedures and the prohibition of an inspector, who is providing on-the-job training on a maintenance task, to perform a required inspection on that task. It is anticipated that the HBAW will be issued by October 31, 2004.
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