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Safety Recommendation Details

Safety Recommendation A-09-013
Details
Synopsis: On July 10, 2007, about 0835 eastern daylight time, a Cessna Aircraft Company 310R, N501N, part of the fleet operated by the National Association for Stock Car Auto Racing (NASCAR) corporate aviation division, crashed while performing an emergency diversion to Orlando Sanford International Airport (SFB), Orlando, Florida. The two pilots on board the airplane (a commercial pilot and an airline transport pilot [ATP]) and three people on the ground were killed. Four people on the ground received serious injuries. The airplane and two homes were destroyed by impact forces and a postcrash fire. The personal flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require that the contents of the safety alert for operators requested in Safety Recommendation A-09-12 be included in initial and required biennial training for general aviation pilots and maintenance personnel.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Aviation
Location: Sanford, FL, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: NYC07MA162
Accident Reports: In flight Fire, Emergency Descent and Crash in a Residential Area Cessna 310R, N501N
Report #: AAR-09-01
Accident Date: 7/10/2007
Issue Date: 2/18/2009
Date Closed: 9/28/2012
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s): General Aviation,

Safety Recommendation History
From: NTSB
To: FAA
Date: 9/28/2012
Response: The FAA has previously described a number of actions it has taken in response to these recommendations, including (1) issuing special airworthiness information bulletin (SAIB) CE 10 11, “Electrical: Fire Hazard in Resetting Circuit Breakers (C/Bs),” (2) publishing advisory circular (AC) 120-80, “In-Flight Fires,” (3) publishing a technical forum dedicated to aircraft wiring in two issues of Nuts and Bolts–a Newsletter Written by Mechanics for Mechanics and publishing summaries of several advisory circulars issued to address airplane wiring, and (4) distributing copies of the SAIB via email to over 300,000 pilots, instructors, and maintenance personnel. We previously responded that, although these actions constitute effective first steps in addressing these recommendations, we were concerned that after several years had passed, a one-time publication of this information would be unlikely to prevent a repeat of the chain of events that caused the accident in Sanford, Florida. Rather, we believed that a requirement for the recommended initial and recurrent training was needed before these recommendations could be closed in an acceptable status. We recognize that, in order for the FAA to issue a new regulation, it is required to perform a cost benefit analysis that must be reviewed by the Secretary of Transportation and by the Office of Management and Budget to ensure that the benefits of the new regulation are greater than the societal costs. In its current letter, the FAA stated that it has no way of estimating the number of lives that could be saved or the number of future accidents that could be prevented (the benefits of the recommended action) if recurrent training on circuit breakers were required for pilots and maintenance personnel. Therefore, the FAA believes that providing circuit breaker information through the actions it has already taken (issuing SAIB CE 10 11 and AC 120 80, and widely distributing this information to the aviation mechanic and general aviation pilot communities) addresses these recommendations to the best of its ability. We remain concerned with the need to periodically refresh awareness in the mechanic and pilot communities regarding resetting circuit breakers and best practices concerning aircraft wiring, but we also acknowledge that, at the current time, the FAA cannot issue the recommended regulations. We are also aware that, by emailing this information to over 300,000 people in the aviation community and publishing several articles, the FAA has done more than simply issuing guidance that may be overlooked, now or in the future, regarding these issues. Accordingly, we have determined that the actions taken by the FAA constitute an acceptable alternate response to Safety Recommendations A-09-13 and 15; accordingly, these recommendations are classified CLOSED—ACCEPTABLE ALTERNATE ACTION.

From: FAA
To: NTSB
Date: 7/24/2012
Response: -From Michael P. Huerta, Acting Administrator: As stated in the Federal Aviation Admini stration 's (FAA) earlier response, there is no regulatory requirement that mandates recurrent training for maintenance personnel. However, by regulation, a mechanic must maintain currency to exercise the privileges of his certificate and ratings. Under 14 CFR § 65.8 1 (b), "a certificated mechanic may not exercise the privileges of his certificate and rating unless he understands the current instructions of the manufacturer, and the maintenance manuals, for the specific operation concerned." Section 65.83 states that "a certificated mechanic may not exercise the privileges o/" his certificate and rating unless, within the preceding 24 months - (b) he has, for at least 6 months (1) served as a mechanic under the is certificate and rating, (2) technically supervised other mechanics, (3) supervised, in an executive capacity, the maintenance or alteration of aircraft; or (4) been engaged in any combination of paragraph (b) ( I), (2), or (3) of this section . However, we do agree with the Board that it is important for maintenance personnel to be kept up- to-date with current best practices in order to continue to maintain proficiency and obtain the highest degree of safety. Information in the form of publications, which as safety alerts for operators, information for operators, special airworthiness information bulletins (SA IBs), best practice guides, and collaboration on industry trade publications, is available to maintenance providers on a wide variety of pertinent topics. In the case of the pilot community, initial flight training followed by regular flight reviews address special emphasis areas. The flexibility of topics addressed in these areas allows the examiner/instructor to highlight items based on individual need and the most current safety topics. Therefore, the FAA believes the issuance of SAIB CE- IO-I I, Electrical: Fire Hazard in Resetting Circuit Breakers (C/Bs), Advisory Circular (AC) 120-80, In -Flight Fires (both previously provided), and the special emphasis areas in the practical test and flight reviews adequately address the issues pertaining to circuit breakers, inspection and maintenance of electrical systems, and aging wiring. At this time, we have no way of estimating the number of lives that could be saved or the number of future accidents that could be prevented if recurrent training on circuit breakers was required for pilots and maintenance personnel. Therefore, the FAA believes providing information regarding circuit breaker information via SAIB CE-10-1 1, AC 120-80, and best practices adequately addresses the concerns of the Board. I believe that the FAA has effectively addressed these recommendations, and I consider our actions complete.

From: NTSB
To: FAA
Date: 11/29/2010
Response: The FAA described a number of actions that it has taken in response to these recommendations, including (1) issuing special airworthiness information bulletin (SAIB) CE-10-11, "Electrical: Fire Hazard in Resetting Circuit Breakers (C/Bs);" (2) publishing a technical forum dedicated to aircraft wiring in two issues of Nuts and Bolts-a Newsletter Written by Mechanics for Mechanics and summaries of several advisory circulars issued to address airplane wiring; and (3) distributing copies of the SAIB via e-mail to over 300,000 pilots, instructors, and maintenance personnel. Although the issuance of the SAIB and the other publications are valuable and the distribution of information to the large number of pilots, instructors, and mechanics is particularly commendable, these actions are not fully responsive to the recommendations. The NTSB emphasizes that we have recommended a requirement for initial and recurrent training for GA pilots and maintenance personnel. Once several years have passed, a one-time publication of this information is unlikely to prevent a repeat of the chain of events that caused the accident pron1pting these recommendations. Pilots and mechanics will continually enter the field of aviation in the future, and some who received the information, without the reinforcement of recurrent training, will forget what they have learned. We also believe it is unlikely that all GA pilots and mechanics will notice the postings on the FAA's website. The actions the FAA has taken are effective first steps in responding to Safety Recommendations A-09-13 and -15, but they are not sufficient for the NTSB to close these recomn1endations. Accordingly, pending the issuance of a requirement for the recommended initial and recurrent training, Safety Recommendations A-09-13 and -15 are classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/7/2010
Response: Letter Mail Controlled 6/22/2010 2:54:09 PM MC# 2100211 - From J. Randolph Babbitt, Administrator: The Federal Aviation Administration recently issued a special airworthiness information bulletin, (SAIB) CE-IO-II, Electrical: Fire Hazard in Resetting Circuit Breakers (C/Bs), which advises pilots, owners, maintenance personnel, and operators of an airworthiness concern of all Title 14 Code of Federal Regulations (14 CFR) part 23/Civil Air Regulations (CAR 3) airplanes (enclosure I). The bulletin advises pilots to review circuit breaker resetting (tripping) procedures in Advisory Circular (AC) 120-80, In-Flight Fires, and to include this bulletin in initial and recurrent training and flight reviews. Although recurrent training is not required for airmen holding a mechanic certificate, this SAIB advises maintenance personnel to: (l) conduct an 2 electrical load analysis or make electrical measurements that account for all electrical loads when installing additional electrical devises; (2) review standard wiring practices; and (3) replace wires that show evidence ofdamage. The FAA Safety Team (FAASTeam) published two issues of Nuts and Bolts -a Newsletter Written by Mechanics/or Mechanics, Issue 08-02 (June 30, 2008) (enclosure 2), and Issue 09-01 (March 31, 2009) (enclosure 3). This publication is distributed to the maintenance community. These issues contain the tech forum that is dedicated to aircraft wiring, parts 1 and 2, and provide a summary of several ACs that have been issued to address airplane wiring. Additionally, the FAASTeam sent the SAIB, via e-mail, to pilots, instructors, and maintenance personnel (totaling 305,598 users on FAASafety.gov). The SAIB is also listed on FAASafety.gov as a notice that can be reviewed by users ofthe site. The FAA also published an article entitled "In-flight Electrical Fires" in the FAA Aviation News (September/October 2009) (enclosure 4). We believe the issuance of SAIB CE-l 0-11 and the enclosed publications satisfactorily address the issues pertaining to circuit breakers, inspection and maintenance ofelectrical systems, and aging wiring. I believe that the FAA has effectively addressed these safety recommendations, and I consider our actions complete.

From: NTSB
To: FAA
Date: 3/9/2010
Response: The FAA replied that 14 Code of Federal Regulations Part 61 requires pilots to have knowledge of aircraft systems contained in an approved flight manual, as well as related ACs, including electrical system operations in normal, abnormal, and emergency conditions. However, the FAA indicated that, because biennial or recurrent training is not required for maintenance personnel, it is not in a position to require that either the contents of the SAFO or best practices in electrical systems be included in biennial or recurrent training for mechanics. The FAA believes that the recommended SAFO is sufficient to satisfy the recommendations as they relate to maintenance personnel. To emphasize the specific regulations pertaining to circuit breaker policy contained in AC 120-80, the FAA plans to publish the information regarding initial and biennial training and the resetting of tripped circuit breakers via FAA Safety Team media and FAA Aviation News. The FAA will also request the assistance of various industry and pilot groups such the Aircraft Owners and Pilot’s Association and the National Business Aviation Association to distribute this information. The NTSB disagrees with the FAA that the recommended SAFO is sufficient to satisfy these recommendations for maintenance personnel. First, although the NTSB acknowledges that mechanics are not required to receive recurrent training, all mechanics must work with an FAA-approved authorized inspector (IA). IAs are required to receive recurrent training, which enables them to make sure that work is performed in accordance with the aircraft’s maintenance manual. Thus, requiring the contents of the SAFO as part of the recurrent training for IAs would help to ensure that work performed by mechanics complied with the guidance. Second, although pilots are required to receive initial and recurrent training, the FAA is not taking any action to require that the information in the SAFO is included in initial and recurrent training for pilots. Finally, the FAA is not planning to require that the information in the SAFO be required as part of initial training for mechanics. A SAFO does not constitute an acceptable alternative to a requirement to include the recommended information in initial and recurrent training for pilots and mechanics (through recurrent training for IAs). Accordingly, pending the FAA’s taking the recommended action, Safety Recommendation A-09-13 is classified OPEN -- UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/4/2009
Response: Letter Mail Controlled 5/12/2009 12:11:59 PM MC# 2090293: - From Lynne A. Osmus, Acting Administrator: FAA Comment. The Federal Aviation Administration will issue a safety alert for operators (SAFO) that will inform pilots and maintenance personnel of the guidance contained in Advisory Circular (AC) 120-80. The SAFO will (1) provide guidance on circuit breakers and highlight, more specifically, the policy on resetting tripped circuit breakers; (2) stress the most current “best practices” regarding inspection and maintenance of electrical systems, circuit breakers, and aging wiring; (3) reiterate the need to consult with the approved operating manual for aircraft-specific requirements pertaining to the electrical system and circuit breaker actions; and (4) focus on the need to review the information included in 14 CFR parts 61, 91, and associated Acs during initial training for both pilots and maintenance personnel and biennial training for pilots. The requirements of 14 CFR part 61 require pilots to have knowledge of aircraft systems contained in an approved flight manual as well as related Acs. Aircraft specific systems knowledge includes electrical system operations in normal, abnormal and emergency conditions. However, biennial training is not required for airmen holding a mechanic certificate. The FAA believes a SAFO per Safety Recommendation A-09-12 is sufficient to address the maintenance issues of the recommendation. The FAA also understands the need to emphasize the specific regulations pertaining to, as well as the information contained in, AC 120-80. The FAA intends to publish the information regarding initial and biennial training, and resetting tripped circuit breakers using FAA Safety Team media and FAA Aviation News, as well as coordinate with various industry and pilot groups (Aircraft Owners and Pilot’s Association, National Business Aviation Association, Inc.). We anticipate issuing this SAFO by December 2009.