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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 implement a program in which carriers and aircraft manufacturers review all work card and maintenance manual instructions for critical flight systems and ensure the accuracy and usability of these instructions so that they are appropriate to the level of training of the mechanics performing the work.
Original recommendation transmittal letter:
Closed - Unacceptable 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 - Unacceptable Action)
Safety Recommendation History
The NTSB disagrees that the FAA's new standardized definition of essential maintenance, combined with 14 CFR Part 121 air carriers' responsibilities to ensure that their aircraft are released in an airworthy condition; that their maintenance manuals and training are current and effective, including the completion of any work or task cards; and the air carriers' normal interface with the aircraft manufacturers effectively addresses the intent of this recommendation. As discussed in the letter that transmitted this recommendation to the FAA and in our previous letter, dated October 12, 2005, in several accident investigations (including the investigations of ValuJet Airlines flight 592, Fine Airlines flight 101, Emery Worldwide Airlines flight 17, Colgan Air flight 9446, and Air Midwest flight 5481), the NTSB found a lack of compliance with operators' written maintenance procedures. FAA-sponsored research suggests that the usability of maintenance procedures affects mechanics' adherence to them.! FAA-sponsored research also indicated that the processes used by aircraft manufacturers to develop maintenance procedures and supporting documentation did not adequately address human factors issues. Specifically, an FAA-sponsored survey of aviation maintenance technical manuals reported that manufacturers con1nl0nly made reactive rather than proactive use of user evaluations, made limited use of user input and procedure validation, did not attempt to systematically track errors, and lacked standards for measuring document quality. Moreover, many aviation maintenance technicians surveyed believed the procedures were inefficient and often failed to adequately consider the demands of the maintenance environment.2 This recommendation was issued to address these shortcomings in aviation maintenance technical n1aterial by developing a program to increase the consideration of human factors principles to ensure that improvements in the accuracy and usability of aviation maintenance technical materials made by individual operators are shared throughout the aviation industry. In its current letter, the FAA indicates its belief that the responsibilities of 14 CFR Part 121 carriers to ensure that their aircraft are released in an airworthy condition, to ensure that their maintenance manuals and training are current and effective, and to coordinate aircraft manufacturers meet the intent of this recommendation. However, this recommendation was issued because our investigations revealed that these responsibilities were not, in some cases, being effectively met. In the 6 years since this recommendation was issued, the FAA has not taken the recommended action; consequently, Safety Recommendation A-04-13 is classified CLOSED – UNACCEPTABLE ACTION.
Letter Mail Controlled 6/16/2010 11:20:28 AM MC# 2100201: - From J. Randolph Babbitt, Administrator: In our last response to the Board we stated that in January 2004 we issued an improved set of Air Transportation Oversight System (ATOS) data collection tools (DCT) for part 12 1 air carriers. The DCTs address the procedures air carriers must have in place to ensure the correction of maintenance program deficiencies. The DCTs include Element Performance Inspection (EPI) 1.3.1 1 and Safety Attribute Inspection (SAI) 1.3.1 1 for CASS . The Federal Aviation Administration uses these DCTs as part of the ATOS process for ensuring the proper design and performance of an air carrier's CASS. The baseline interval for all design assessments is once every 5 years. Once the initial design assessment for an element is complete, another assessment must be scheduled within the next 5 years. The baseline interval for performance assessments is once every 6 months for high-criticality elements, once a year for medium-criticality elements, and once every 3 years for low criticality elements. After completing the initial performance assessment for an element, another assessment must be scheduled within the applicable baseline intervals. Enclosed is a copy of EPI 1.3.1 1 and several datasheets for an air carrier as an example of the system's use. Please note that "yes" answers to EPI questions do not require a narrative. Only "no" answers require an explanation and action taken. As of December 3 I, 2007, all part 12 1 air carriers were transitioned to ATOS, and therefore, we did not issue a Flight Standards Information Bulletin as we discussed in our last letter to the Board. Additionally, on July 7, 2009, the FAA revised the following chapters of FAA Order 8900.1, to verify that part 12 1 air carriers have procedures for identifying deficiencies and incorporating changes to the carrier's maintenance programs, and that maintenance personnel use these procedures: Volume 3, Chapter 24, Evaluate 14 CFR Part 91 Subpart W12 11135.41 1 (a)(2) Maintenance Training Program Record, Section 1, Training Program Evaluation (enclosed); Volume 3, Chapter 32, Manuals, Procedures, and Checklists for 14 CFR Part 91 K, 12 1, 125, and 135, Section 1 1, Evaluate a Maintenance Company ManualIRevision for a 14 CFR Part 121 or 14 CFR Section 135.41 1 (a)(2) Program (enclosed); and Volume 3, Chapter 44, Assess Continuing Analysis and Surveillance System for Parts 12 1 and 135, Section 1, Evaluating an Air Carrier's CASS (enclosed). The FAA also developed and has taught CASS Training course #257 12, which has been taught to part 12 1 and 135 airworthiness inspectors since June 2005. Participants learn root cause analysis functions and processes as the basis for understanding CASS functions, and how the air carrier should use CASS to measure effectiveness and performance of all elements of its maintenance program. Instructions are given on: Auditing techniques; Qualitative and quantitative analytical methods and techniques; Thought processes used to establish or modify scheduled maintenance tasks and intervals; and How to determine the effectiveness of the scheduled maintenance program. We believe the FAA has effectively addressed this safety recommendation, and I consider our actions complete.
In its response to this recommendation, the FAA stated that the term "critical flight systems" requires a definition and that it will work with the manufacturers to clarify the meaning of critical flight systems and to develop appropriate procedures as part of its response to Safety Recommendation A-04-07. Upon resolution of Safety Recommendation A-04-07, the FAA will issue an FSIB directing its inspectors to ensure that air carrier maintenance manuals address maintenance procedures for critical flight systems. The Safety Board does not believe that the FAA's response addresses the intent of Safety Recommendation A-04-13, which asked the FAA to implement a program (emphasis added) to ensure that procedures for flight critical systems described by airline work cards and maintenance manuals are both accurate and usable. Directing inspectors to ensure that maintenance manuals address the maintenance procedures on critical flight systems does not meet this intent. In several accident investigations conducted over the last few years, including the investigations of ValuJet Airlines flight 592, Fine Airlines flight 101, Emery Worldwide Airlines flight 17, Colgan Air flight 9446, and Air Midwest flight 5481, the Safety Board found a lack of compliance with operators' written maintenance procedures. Problems have been found with the accuracy and the clarity of operators' written maintenance procedures. The accuracy of maintenance materials can affect safe completion of aircraft maintenance work. However, as cited in the Air Midwest flight 5481 investigative report, FAA-sponsored research suggests that the usability of maintenance procedures may also affect mechanics' adherence to them. Recent FAA-sponsored research indicates that the processes used by aircraft manufacturers to develop maintenance procedures and supporting documentation do not adequately address human factors issues. Specifically, an FAA-sponsored survey of aviation maintenance technical manuals reported that manufacturers commonly make reactive rather than proactive use of user evaluations, make limited use of user input and procedure validation, do not attempt to systematically track errors, and lack standards for measuring document quality. Moreover, many aviation maintenance technicians surveyed believed the procedures were inefficient and often failed to adequately consider the demands of the maintenance environment. The Safety Board believes that the shortcomings in aviation maintenance technical material cited above can be rectified by the FAA developing a program to improve aviation maintenance technical materials through consideration of human factors principles. Such a program would ensure that improvements in the accuracy and usability of aviation maintenance technical materials made by individual operators are shared throughout the aviation industry. As discussed, the FAA's plan to issue an FSIB does not adequately address the intent of this recommendation, which is to establish a program to ensure that procedures for flight-critical systems described by airline work cards and maintenance manuals are both accurate and usable. Pending the recommended action being taken, Safety Recommendation A-04-13 is classified OPEN -- UNACCEPTABLE RESPONSE.
Letter Mail Controlled 6/28/2004 3:14:12 PM MC# 2040357 - From Marion C. Blakey, Administrator: The term "critical flight systems" requires definition. In response to Safety Recommendation A-04-7, the FAA will work with the manufacturers to clarify the meaning of critical flight systems and develop appropriate procedures. Upon the resolution of Safety Recommendation A-04-7, the FAA will issue a flight standards information bulletin to inspectors to ensure air carrier maintenance manuals address the maintenance procedures on critical flight systems. It is anticipated that the bulletin will be issued by March 2005.
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