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Safety Recommendation Details

Safety Recommendation A-07-028
Details
Synopsis: On September 23, 2005, an Aerospatiale AS350BA helicopter, N355NT, operated by Heli-USA Airways, Inc., as a 14 Code of Federal Regulations Part 135 sightseeing air tour flight, encountered adverse weather and crashed into the Pacific Ocean several hundred feet off the coast of Kailiu Point, near Haena, Hawaii.1 Although three of the five passengers died of drowning or drowning-related circumstances, none of the passengers or the pilot received any serious injuries during the crash sequence. According to the pilot and the two surviving passengers, after the helicopter settled on the water, it rolled to the right and began to sink immediately.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Evaluate the design, maintenance, and in-service handling of personal flotation devices (PFDs) manufactured in compliance with Technical Standard Order C13f to determine the reason that some chambers fail to inflate when the inflation handles are pulled before the PFDs have reached the manufacturer’s recommended inspection interval.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Haena, HI, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: SEA05MA199
Accident Reports: Weather Encounter and Subsequent Crash into the Pacific Ocean, Heli-USA Airways, Inc., Aerospatiale AS350BA, N355NT
Report #: AAB-07-01
Accident Date: 9/23/2005
Issue Date: 2/27/2007
Date Closed: 2/15/2011
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Maintenance, Personal Floatation Device, Water Survival

Safety Recommendation History
From: NTSB
To: FAA
Date: 2/15/2011
Response: The FAA described the review it had conducted that determined (1) the failures were most likely due to the nature of use in the air-tours operating environment and (2) the design of the inflation system and maintenance instructions provided may not be adequate to ensure that the carbon dioxide cartridge remains seated in its original manufactured position after service in an air-tours environment, where PFDs are donned and removed several times per day. In addition, the FAA reviewed the minimum performance standard for TSO-C13f and found that the TSO lacks adequate criteria to address this issue. The review described fully satisfies Safety Recommendation A-07-28, which is classified CLOSED -- ACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 11/22/2010
Response: CC# 201000422: - From J. Randolph Babbitt, Administrator: In the Federal Aviation Administration's letter dated May 17, 2007, we stated that we were going to review PFDs with in-service inflation failures and the causes of these failures. We completed the first portion of the review and found no data to indicate issues with PFDs failing to inflate due to the inflation mechanism or inflation cartridges. We believe that the failures were most likely due to the nature of use in the air-tours operating environment. The FAA then reviewed design data used to obtain TSO authorizations for TSO-C13f PFDs from several manufacturers. We reviewed the detailed design of the inflation system and the maintenance instructions provided with the TSO-C13fPFDs, specifically the C02 cartridges used for inflation. It was determined that the design of the inflation system and maintenance instructions provided may not be adequate to ensure that the C02 cartridge remains seated in its original manufactured position after service in an air-tours environment where PFDs are donned and removed several times a day. In addition, the minimum performance standard for TSO-C13f, which is an FAA standard, was reviewed and found to lack adequate criteria to address this issue. Based on this review, we have asked the Society of Automotive Engineers (SAE) S-9 Cabin Safety Provisions Committee to include a performance requirement to address this inflation issue in Aerospace Standard (AS) 1354, a draft AS they are developing on PFDs. The current draft of AS 1354 includes performance criteria to address the C02 cartridge issue. Once the SAE S-9 Committee issues AS 1354, which is expected to be issued in September 2011, TSO-C13will be revised to include the new requirements. I will keep the Board informed of the FAA's progress on these safety recommendations, and I will provide an update by December 31, 2011.

From: NTSB
To: FAA
Date: 9/20/2007
Response: The FAA indicated that it is initiating a program to identify the specific life preserver models having in-service inflation failures and to determine the causes leading to the failures. Based on the results of this program, the FAA will consider needed revisions to TSO C13f. The actions described are responsive to these recommendations. Accordingly, Safety Recommendations A-07-28 and -29 are classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/17/2007
Response: Letter Mail Controlled 5/31/2007 8:43:36 AM MC# 2070239: - From Marion C. Blakey, Administrator: The Federal Aviation Administration agrees with the intent of these safety recommendations. A program is being initiated to identify the specific life preserver models having in-service inflation failures and to determine the design, maintenance, and handling causes leading to the failures. The information collected will provide insight to potential revisions to the standards of the Technical Standard Order C13f. I will provide the Board with a status update and course of action after the FAA has analyzed the results of this initial investigation. The anticipated date to provide this information is December 28, 2007.