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Safety Recommendation Details

Safety Recommendation A-05-008
Details
Synopsis: On July 13, 2003, about 1530 eastern daylight time, Air Sunshine, Inc. (doing business as Tropical Aviation Services, Inc.), flight 527, a Cessna 402C, N314AB, was ditched in the Atlantic Ocean about 7.35 nautical miles west-northwest of Treasure Cay Airport, Treasure Cay, Great Abaco Island, Bahamas, after the in-flight failure of the right engine. Two of the nine passengers sustained no injuries, five passengers and the pilot sustained minor injuries, and one adult and one child passenger died after they evacuated the airplane. The airplane sustained substantial damage. The airplane was being operated under the provisions of 14 Code of Federal Regulations (CFR) Part 135 as a scheduled international passenger commuter flight.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Review the procedures used during its oversight of Air Sunshine, including those for the Surveillance and Evaluation Program and Regional Aviation Safety Inspection Program, to determine why the inspections failed to ensure that operational and maintenance issues that existed at the company were corrected. On the basis of the findings of this review, modify Part 135 inspection procedures to ensure that such issues, including maintenance record-keeping and practices, are identified and corrected before accidents occur.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Treasure Cay, Bahamas
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: MIA03FA141
Accident Reports: In-Flight Engine Failure and Subsequent Ditching Air Sunshine, Inc., Flight 527, Cessna 402C, N314AB, About 7.35 Nautical Miles West-Northwest of Treasure Cay Airport
Report #: AAR-04-03
Accident Date: 7/13/2003
Issue Date: 4/8/2005
Date Closed: 8/27/2009
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Oversight, Records, Maintenance

Safety Recommendation History
From: NTSB
To: FAA
Date: 8/27/2009
Response: The FAA previously indicated to the NTSB on February 8, 2008, that, in response to this recommendation, it had revised FAA Order 8300.10, Airworthiness Inspectors Handbook. The FAA also pointed out that it had replaced Order 8300.10 with FAA Order 8900.1, Flight Information Management Systems, and that the revisions to Order 8300.10 were included in Order 8900.1. On September 9, 2008, the NTSB replied that these actions were responsive to the recommendation but asked the FAA to describe the reviews of its oversight of Air Sunshine that were completed after the flight 527 accident and the revisions to Order 8900.1, Order 1800.56, National Flight Standards Work Program Guidelines, or other guidance that had resulted from these reviews. Pending an answer to that question, Safety Recommendation A-05-8 remained classified Open Acceptable Response. In its current letter, the FAA indicates that a team of aviation safety inspectors from the Southern Region Evaluation Services Office (SESO) conducted a focused oversight inspection of Air Sunshine and produced a final report providing detailed findings and recommended actions, which it has supplied to the NTSB. Based on SESO’s findings, the FAA revised the following sections of Order 8900.1: Volume 2, Chapter 1, Section 2, assignment of Federal Aviation Administration Responsibilities (paragraph 2-30) Volume 6, Chapter 2, Section 32, inspect Part 91 Subpart K Program Manager or Part 135 (Nine or Less) Air Carrier Volume 6, Chapter 2, Section 35, Inspect Section 135.422(a)(l) Operator’s Maintenance Records The SESO review and report and the resulting revisions to Order 8900.1 complete the recommended action; accordingly, Safety Recommendation A-05-8 is classified CLOSED—ACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 3/27/2009
Response: Letter Mail Controlled 4/7/2009 12:43:10 PM MC# 2090204: Lynne A. Osmus, Acting Administrator, FAA, 3/27/09 In the Board’s last letter, it noted that the Federal Aviation Administration had not indicated whether any revisions to Orders 8300.10 or 1800.56 were made as a result of the Air Sunshine accident, or whether any review of the oversight of Air Sunshine was conducted as a result of the Board’s findings. A team of aviation safety inspectors from the Southern Region Evaluation Services Office (SESO) conducted a focused oversight inspection of Air Sunshine from March 8, 2004 through March 11, 2004. The team’s final report provides details of the findings and actions of the inspection (enclosed). The areas of inspection were as follows: 1.Operations a.Operations Training; and b.Crew Qualifications 2. Airworthiness a. Management; b. Manuals and Procedures; c. Records Systems; d.Minimum Equipment List/Deferred Maintenance; e. irworthiness Directive Compliance; f. aintenance Programs; and g. ajor Repair and Alteration Conformity The SESO discussed issues raised during the inspection with company personnel and the principal inspectors, supervisors, and manager of the certificate holding district office in San Juan, Puerto Rico. Those issues not satisfactorily resolved became findings in the body of this report. The FAA made revisions, which are listed below, to sections of FAA Order 8900.1, Flight Information Management Systems (copies enclosed). FAA Order 8900.1, volume 2, chapter 1, section 2, Assignment of Federal Aviation Administration Responsibilities (paragraph 2-30); FAA Order 8900.1, volume 6, chapter 2, section 32, Inspect part 91 Subpart K Program Manager or Part 135 (Nine or Less) Air Carrier; and FAA Order 8900.1, volume 6, chapter 2, section 35, Inspect Section 135.422(a)(l) Operator’s Maintenance Records I believe that the FAA has effectively addressed this safety recommendation, and I consider our actions complete.

From: NTSB
To: FAA
Date: 9/9/2008
Response: On August 15, 2005, the FAA wrote to the Safety Board concerning this recommendation. At that time, the FAA stated that to address the issues in this recommendation, it intended to review and revise the Airworthiness Inspector’s Handbook, FAA Order 8300.10. The FAA also noted that the SEP was not applicable to Air Sunshine because SEP was designed for, and utilized by, 14 CFR Part 12l operators, and Air Sunshine was a Part 135 operator. The FAA further indicated that FAA Order 1800.56, National Flight Standards Work Program Guidelines, provided guidelines for the establishment of a surveillance work program for Part 135 operators. The FAA revised Order 8300.10, Airworthiness Inspectors Handbook, to provide information to enhance inspectors’ awareness of inadequate record-keeping systems, timely correction of record-keeping discrepancies, and potential risk factors that may indicate undocumented maintenance, deficient maintenance programs, and ongoing systemic operator deficiencies that warrant additional followup surveillance. This information is also now available in FAA Order 8900.1, Flight Standards Information Management System, Volume 6, Surveillance, Section 32, Inspect Part 135 (Nine or Less) Air Carrier, and Section 35, Inspect §135.411 (a)(l) Operator’s Maintenance Records. The revisions made by the FAA to Order 8300.10 and to successor documents are commendable; however, the FAA has not indicated whether any revisions to Order 8300.10 or 1800.56 were made as a result of the Air Sunshine accident as recommended or whether any review of the oversight of Air Sunshine was conducted as a result of the Safety Board’s findings in this accident investigation. The Board asks the FAA to describe what reviews of its oversight of Air Sunshine have been completed and what revisions to Order 8900.1, Order 1800.56, or other guidance resulted. Pending the answer to this question, Safety Recommendation A-05-8 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 2/8/2008
Response: Letter Mail Controlled 2/19/2008 12:17:19 PM MC# 2080073: Robert A. Sturgell, Acting Administrator, FAA, 2/8/08 The Federal Aviation Administration completed the revision to FAA Order 8300.10, Airworthiness Inspectors Handbook, volume 3, chapters 39 and 41. This information enhanced inspectors’ awareness of inadequate recordkeeping systems, timely correction of recordkeeping discrepancies, and potential risk factors that may indicate undocumented maintenance, deficient maintenance programs, and ongoing systemic operator deficiencies that warrant additional follow-up surveillance. That same information is now available in FAA Order 8900.1, Flight Standards Information Management System, volume 6, Surveillance, section 32, Inspect part 135 (Nine or Less) Air Carrier, and section 35, Inspect § 135.411 (a)(l) Operator’s Maintenance Records. We have enclosed a copy of each section.

From: NTSB
To: FAA
Date: 1/18/2006
Response: The Safety Board notes that the FAA will review and revise the Airworthiness Inspector's Handbook, FAA Order 8300.10, volume 3, Chapter 39, Inspect FAR Part 135 (9 or Less) Air Carrier, Section 2 and Chapter 41, Inspect Section 135.41I (a)(1) Operator's Maintenance Records, Sections 1 and 2, Background and Procedures, to enhance inspectors' awareness of inadequate record-keeping systems; timely correction of record-keeping discrepancies; and potential risk factors that may indicate undocumented maintenance, deficient maintenance programs, and ongoing systemic operator deficiencies that warrant additional followup surveillance. The FAA notes that because SEP is designed and used for Part 12l operators, it is not applicable to Air Sunshine. For Part 135 (9 or less) operators such as Air Sunshine, the FAA states that FAA Order 1800.56, "National Flight Standards Work Program Guidelines," provides guidelines for the establishment of a surveillance work program. Pending the FAA's making revisions to Order 8300.10, Safety Recommendation A-05-8 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/15/2005
Response: Letter Mail Controlled 8/22/2005 10:56:53 AM MC# 2050386: Marion C. Blakey, Administrator, FAA, 8/15/05 Based, in part, on the Air Sunshine accident investigation, the Federal Aviation Administration will review and revise the Airworthiness Inspector's Handbook, FAA Order 8300.10, volume 3, Chapter 39, Inspect FAR Part 135 (9 or Less) Air Carrier, Section 2. and Chapter 41, Inspect Section 135.41I (a)(1) Operator's Maintenance Records, Sections 1 and 2, Background and Procedures, to enhance inspectors' awareness of inadequate recordkeeping systems; timely correction of recordkeeping discrepancies; and potential risk factors that may indicate undocumented maintenance, deficient maintenance programs, and ongoing systemic operator deficiencies that warrant additional followup surveillance. The revisions will serve to address the Board's concern regarding improvement of inspection oversight procedures of 14 CFR Part 135 (9 or less) operators to correct maintenance oversight procedures of 14 CFR Part 135 (9 or less) operators to correct maintenance recordkeeping and systemic operator deficiencies. The FAA plans to revise the process at the next revision for the Inspector's Handbook, which is due to be released in October 2005. The Surveillance Evaluation Program (SEP) is not applicable for Air Sunshine. SEP is designed and utilized for 14 CFR Part 12l operators. SEP is not a tool used for surveillance of 14 CFR Part 135 (9 or less) operators. FAA Order 1800.56, National Flight Standards Work Program Guidelines, provides guidelines for the establishment of a surveillance work program for such an operator. The frequency of surveillance inspections may be increased based on the regulatory compliance posture of the 14 CFR Part 135 operator. I will keep the Board informed of the FAA's progress on this safety recommendation.