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Safety Recommendation Details

Safety Recommendation A-07-029
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: On the basis of the results of the evaluation requested by Safety Recommendation A-07-28, ensure that personal flotation devices manufactured in compliance with Technical Standard Order C13f remain usable throughout the manufacturer’s 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: 1/19/2018
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: 1/19/2018
Response: e note that, on February 3, 2017, you published TSO C13g, “Life Preservers,” which is consistent with the updated inflation requirements provided in Society of Automotive Engineers International Aerospace Standard 1354, “Individual Inflatable Life Preserver.” The revised TSO includes improved performance and inspection criteria for life preservers that are donned multiple times a day, as well as contains requirements to prevent the inflation cylinder from backing out and to use a visual indicator to make inflation system inspection easier. The TSO also includes new requirements to make it easier to understand the donning instructions on the life preserver, to operate the retention mechanism, and to open the life preserver packages. Further, the TSO includes testing that simulates the reduced dexterity that a person may experience during an emergency in a cold and wet environment. We believe that the revised TSO satisfies the intent of Safety Recommendations A-07-29 and A-10-85, which are classified CLOSED--ACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 8/25/2017
Response: -From Michael P. Huerta, Administrator: On February 3. 2017, the Federal Aviation Administration (FAA) published the newly revised Technical Standard Order (TSO)-C I 3g, Life Preservers. that includes the inflation requirements in Society of Automotive Engineers (SAE) International Aerospace Standard (AS) 1254. Individual Inflatable Life Preserver. The revised TSO ensures that the floats remain usable throughout the manufacturer's inspection interval. such as life preservers in an air-tour operating environment. Additionally, TSO-CI 3g contains requirements to incorporate a means to prevent the inflation cylinder from loosening and coming out of the inflater and provide a visual indicator to verify the inflation system is functional. Copies of TSO-C I 3g and AS 1254 are enclosed. I believe the FAA has effectively addressed this safety recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 9/6/2016
Response: We note that on February 29, 2016, the SAE International Aerospace Council S9 Cabin Safety Provisions Committee published Aerospace Standard (AS) 1354, “Individual Inflatable Life Preservers.” The new standard includes improved performance and inspection criteria for life preservers that are donned multiple times a day, such as in an air-tour operating environment, as well as requirements to prevent the inflation cylinder from backing out and to have a visual indicator to ease inflation system inspection. These revisions were the result of the investigations and analysis that you performed to satisfy Safety Recommendation A 07 28. We further note that you are currently revising TSO C13 to include revisions from AS 1354. We remain concerned because, although you are making progress, the length of time it is taking to complete the recommended action is excessively long. We encourage your timely issuance of the revised TSO as recommended. In the meantime, pending your issuing a revision to TSO C13 that contains the newly revised AS 1354 standards, Safety Recommendation A 07 29 remains classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/3/2016
Response: -From Michael P. Huerta, Administrator: FAA Comment. On February 29, 2016, the SAE International Aerospace Council, S9 Cabin Safety Provisions (SAE S9) Committee published Aerospace Standard (AS) 1354, Individual Inflatable Life Preservers (enclosed). AS 1354 includes the improved performance and inspection criteria for life preservers that are donned multiple times a day, such as in an air-tour operating environment. The SAE S9 Committee also added requirements to incorporate a means to prevent the inflation cylinder from backing out and to have a visual indicator to ease the inspection of the inflation system. The FAA is revising Technical Standard Order (TSO)-C13 to include revisions from AS 1354. However, the revised TSO-C 13 must go through a review process (e.g., internal, field, and public review) before it can be published. I will keep the Board informed on the progress of this safety recommendation and provide an update by July 30, 2017.

From: NTSB
To: FAA
Date: 12/12/2014
Response: We note that you continue to work with the SAE International Aerospace Council, S9 Cabin Safety Provisions Committee, to include standards for PFDs in Aerospace Standard (AS) 1354 that will ensure proper inflation and quick and correct donning by passengers. Although we are disappointed to learn that the issuance of AS 1354 has been delayed, we continue to believe that your efforts thus far are positive steps toward implementing both of these safety recommendations. You previously indicated that, once AS 1354 were finalized, you would revise TSO C13f as recommended in Safety Recommendation A-07-29 and would consider revising it as recommended in Safety Recommendation A-10-85. Although we are encouraged that you are making progress, the length of time it is taking to complete the recommended actions is excessively long. We encourage your timely issuance of the revised TSO as recommended; in the meantime, Safety Recommendation A 07-29 and A-10-85 are classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/8/2014
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) continues to work with the SAE International Aerospace Council, S9 Cabin Safety Provisions (SAE S9) Committee, to include requirements to address life preserver donning and the inflation issue in Aerospace Standard (AS) 1354, Individual Inflatable Life Preservers. In April 2014, the FAA met with the SAE S9 Committee and Civil Aerospace Medical Institute (CAMI) researchers to discuss preliminary findings from the CAMI study of donning test parameters and the relationship between the pre-flight briefing and successful life preserver donning. In addition, the FAA is working to improve the performance and inspection criteria for life preservers that are donned multiple times a day, such as in an air-tour environment. For example, the current draft of AS 1354 contains proposed requirements that would require the life preserver to incorporate a means to prevent the inflation cylinder from backing out, and a visual indicator that allows for easy inspection of the inflation system. Due to the SAE S9 Committee's current consideration of these findings and CAMI's anticipated report publication date of September 2014, SAE S9 is delaying the issuance of AS 1354 until December 2015. Once the SAE AS 1354 standard is finalized, Technical Standard Order-C 13f will be revised to include the new requirements. I will keep the Board informed on the progress of these safety recommendations and provide an update by February 2016.

From: NTSB
To: FAA
Date: 1/27/2012
Response: We note that, once the SAE International’s S-9 Cabin Safety Provisions Committee has finalized Aerospace Standard 1354, the FAA plans to revise TSO C13 to include the new requirement. Pending issuance of the revised TSO as planned, Safety Recommendation A-07-29 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/18/2011
Response: - From J. Randolph Babbitt, Administrator: Our previous letter dated November 21, 2010, stated that in an air tour environment, where personal notation devices (PFDs) are donned and removed several times a day, the design of the PFD inflation system and maintenance instructions provided may not be adequate to ensure that the carbon dioxide (C02) cartridge remains seated in its original manufactured position. We further stated that the Federal Aviation Administration minimum performance standard for Technical Standards Order (TSO) C13f, Life Preservers, was reviewed and found to lack adequate criteria to address this issue. We asked the Society of Automotive Engineers (SAE) S-9, Cabin Safety Provisions Committee, to include requirements to address this inflation issue in Aerospace Standard (AS) 1354, a draft standard they are developing on PFDs. The current draft of AS 1354 includes performance and inspection criteria to address the CO2 cartridge issue; however, it has not completed the SAE approval process. We will continue to work with the SAE S-9 Committee and anticipate AS 1354 will be completed in Fiscal Year 2012. Once the AS 1354 standard is finalized, TSO-CI3fwiJI be revised to include the new requirements. I will keep the Board informed of the FAA's progress and provide an updated response to this recommendation by December 2012.

From: NTSB
To: FAA
Date: 2/15/2011
Response: Based on the results of the review performed in response to Safety Recommendation A-07-28, the FAA asked the Society of Automotive Engineers S-9 Cabin Safety Provisions Committee to include a performance requirement to address this inflation issue in Aerospace Standard (AS) 1354, a draft AS that the S-9 committee is developing on PFDs. Once the S-9 committee issues AS 1354, the FAA plans to revise TSO C13 to include the new requirement. Pending issuance of the revised TSO as planned, Safety Recommendation A-07-29 is classified OPEN – ACCEPTABLE RESPONSE.

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.