Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation A-09-014
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 aircraft manufacturers and those responsible for postmanufacture modifications to improve existing guidance, or create new guidance, regarding which circuit breakers pilots should and should not attempt to reset before or during flight and to disseminate the resultant guidance to airplane mechanics, pilots, and owners.
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: 9/22/2011
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s): Maintenance, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 9/22/2011
Response: On January 24, 2010, the FAA revised Special Airworthiness Information Bulletin (SAIB) CE-10-111R1, which provides guidance for pilots, owners, maintenance personnel, and operators of all non-transport category airplanes regarding (1) how circuit breakers should be reset, (2) that circuit breakers essential for safe flight should be marked, and (3) that only marked circuit breakers should be reset. The FAA also stated that, although an airworthiness directive (AD) would require manufacturers to make design changes (including changes to service documents) for existing aircraft, the agency does not yet have sufficient evidence of an unsafe condition to justify the issuance of an AD. On December 3, 2010, to clarify and emphasize the means of compliance with Title 14 Code of Federal Regulations Part 23.1357, the FAA issued policy memorandum PS-ACE100-2010-001 regarding placement of critical circuit breakers and identifying what circuit breakers may be reset. Part 23.1357 currently requires manufacturers and aircraft modifiers to design electrical systems such that devices designed to protect circuits that are essential for safe flight must be located and identified so that they can be readily reset in flight. The policy memorandum is available to aircraft certification offices, aircraft manufacturers, and those performing modifications on aircraft. On January 31, 2011, the NTSB stated that, although adoption of the policy memorandum constituted an acceptable solution for newly certificated airplanes, we were unclear as to how post-manufacture modifications would be required to incorporate the intent of the policy memorandum. For example, if a radio or other electrical device were installed through the use of Major Modification and Alteration Form 337, how would additional items necessary for implementing the FAA’s policy memorandum be brought to the attention of modifiers? In the same letter, we asked that the FAA submit additional information describing its plan to address the application of the policy memorandum to the large number of existing aircraft. The FAA indicated in its current letter that, in answer to this question, it had distributed SAIB CE-10-11R1 via e-mail to 305,598 pilots, instructors, and maintenance personnel and had published multiple articles in various trade magazines alerting readers to the hazards associated with in-flight electrical fires and damaged wiring. Accordingly, the FAA considers its actions in response to this recommendation to be complete. The NTSB carefully considered whether the FAA’s actions fully satisfy this recommendation. The policy memorandum will address new airplane designs and will also likely address new equipment and modifications that are subject to supplemental type certificates. We remain concerned with the situation described above, in which a piece of electrical equipment is installed on an existing aircraft and a Form 337 is used to show compliance with applicable regulations. The issuance of the policy memorandum and the distribution of the SAIB to over 300,000 pilots, owners, and mechanics may not adequately address the safety concern several years from now, once the distribution has been forgotten. At the same time, we recognize that the actions taken by the FAA constitute all that the FAA believes it can currently accomplish. We also acknowledge the difficulty the FAA would have in justifying the issuance of a large number of ADs, in the absence of a documented, widespread safety problem. In recognition of the actions completed by the FAA in response to Safety Recommendation A-09-14, the recommendation is classified CLOSED—ACCEPTABLE ALTERNATE ACTION. We will continue to consider this issue in future accident investigations, and, if we find further evidence of a safety problem that would substantiate the FAA’s issuing an AD, we will bring this to your attention.

From: FAA
To: NTSB
Date: 6/1/2011
Response: CC# 201100233: - From J. Randolph Babbitt, Administrator: In our August 24, 2010 letter we stated that we published a revision to Special Airworthiness Information Bulletin (SAIB) CE-10-11R1 on January 14, 2010. We also stated that per 14 CFR 21.99, when the Federal Aviation Administration (FAA) takes airworthiness directive (AD) action, it can require manufacturers to make design changes, including changes to service documents, for existing aircraft. However in this situation, based on existing data, there is no unsafe condition warranting an AD; therefore, we do not intend on requiring action by manufacturers to address service documents for existing aircraft models. However, we committed to issue a policy memorandum for aircraft manufacturers and modifiers clarify and emphasize appropriate and acceptable means of compliance to § 23.1357. On December 3, 2010, we issued policy memorandum PS-ACE100-2010-001 (enclosed) regarding placement of critical circuit breakers and identifying what circuit breakers may be reset. The policy memorandum was made available to aircraft certification offices, aircraft manufacturers, those performing modifications on aircraft. The Board issued on January 31, 2011, a letter requesting the FAA to submit additional information describing its plan to address existing aircraft. The FAA Safety Team has supplied SAIB CE-10-11R1 via email to 305,598 pilots, instructors, and maintenance personnel. In addition, FAA Flight Standards issued multiple articles in various trade magazines alerting readers to the hazards associated with in-flight electrical fires and damaged wiring. Details of these articles were provided in previous responses to Safety Recommendations A-09-13 and A-09-15. I continue to believe that when combined, the guidance provided to the operating community tough the SAIB and the policy memorandum address the intent of the Board's safety recommendation. I believe that the FAA has effectively addressed this safety recommendation, and I consider our actions complete.

From: NTSB
To: FAA
Date: 1/31/2011
Response: The NTSB notes that the FAA’s revised Special Airworthiness Information Bulletin (SAIB) CE-10-111R1, which was published on January 14, 2010, provides guidance for pilots, owners, maintenance personnel, and operators of all non-transport category airplanes (1) describing how circuit breakers should be reset, (2) indicating that circuit breakers essential for safe flight should be marked, and (3) indicating that only marked circuit breakers should be reset. We also note that the FAA plans to facilitate implementation of the SAIB recommendations for all newly certificated airplanes through the development of a policy memorandum for aircraft manufacturers and modifiers that will provide appropriate means for complying with the requirements stipulated in 14 Code of Federal Regulations Part 23.1357. Although the NTSB considers adoption of the policy memorandum to constitute an acceptable solution for newly certificated airplanes, we are unclear as to how postmanufacture modifications will be required to incorporate the intent of the policy memorandum. Therefore, we request that the FAA submit additional information describing its plan to address the large number of existing aircraft. For instance, if a radio or other electrical device were installed through use of Major Modification and Alteration Form 337, how would additional items necessary for implementing the FAA’s policy memorandum be brought to the attention of modifiers? Pending our receipt and review of this additional information and the FAA’s issuance of a policy memorandum that addresses newly certificated airplanes and postmanufacture modifications, Safety Recommendation A-09-14 remains classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/24/2010
Response: CC# 201000337: - From J. Randolph Babbitt, Administrator: On January 14, 2010, the Federal Aviation Administration published a revision to Special Airworthiness Information Bulletin (SAIB) CE-10-1I1Rl (enclosed) for distribution to pilots, owners, maintenance personnel, and operators of all non-transport category airplanes. The revised bulletin recommends circuit breakers (CBs) essential for safe flight be marked and that only marked CBs be reset in flight. The bulletin provides further guidance that essential CBs be reset only once in flight and only under the following conditions: 1. No sooner than one minute after the circuit trips; 2. Only when there is no remaining smoke or burning smell; and 3. Only if the affected system or equipment is needed for the current type of flying. The bulletin explains how to determine which systems are essential in different types of flying and identifies the pilot and maintenance personnel training requirements related to circuit breakers. Title 14, Code of Federal Regulations (14 CFR) § 23.1357 requires manufacturers and aircraft modifiers to design electrical systems such that circuit protective devices for circuits essential for safe flight must be located and identified so that they can be readily reset in flight. We are currently developing a policy memorandum for aircraft manufacturers and modifiers to clarify and emphasize appropriate and acceptable means of compliance to this requirement that will facilitate effective implementation of the SAIB recommendations. This addresses newly certificated airplanes. We expect to issue this policy by December 31, 2010. The FAA does not intend to require action by manufacturers to address service documents for existing aircraft models. Based on existing data, there is no unsafe condition warranting Airworthiness Directive (AD) action in this case. Per 14 CFR 21.99, when the FAA takes AD action, it can require manufacturers to make design changes, including changes to service documents, for existing aircraft. However, in this situation, the FAA is not taking AD action and the SAIB addresses the intent of this recommendation. A review of the part 23 airplane fleet accident history revealed no other accidents from cockpit fire due to the resetting of a circuit breaker following the detection of smoke or a burning smell. We also note that in addition to the requirements of § 23.1357, § 23.1361 contains requirements for a master switch that can shut off electrical power to a fire, and § 23.851 requires that a fire extinguisher be installed in the pilot compartment and located within easy access of the pilot while seated. Taken together, we believe the part 23 requirements provide a robust and reasonable level of design safety in the area of electrical fire protection. When combined with the guidance provided to the operating community through the SAIB and the proposed policy memorandum, we believe our actions address the intent of the Board's safety recommendation. I will keep the Board informed of the FAA's progress on this safety recommendation and provide an updated response by February 2011.

From: NTSB
To: FAA
Date: 3/9/2010
Response: The FAA replied that it will issue new guidance on how circuit breakers may be reset by pilots and will publish this guidance in a policy memorandum that will be made available to aircraft manufacturers, mechanics, pilots, and those performing modifications on aircraft. Next, the FAA plans to work with manufacturers to incorporate aircraft-specific guidance into their existing model maintenance manuals, airplane flight manuals, and other service documents. For new aircraft designs and modifications to aircraft electrical systems, the FAA will ensure that the manufacturers and modifiers identify and provide pilots and mechanics information on which circuit breakers may be reset during flight. Pending (1) issuance of the policy memorandum; (2) revisions by manufacturers and modifiers to incorporate aircraft specific guidance into all existing model maintenance manuals, airplane flight manuals, and other service documents; and (3) revisions to the certification process for new aircraft designs and modifications to require information to pilots and maintenance crews on which circuit breakers may be reset during flight, Safety Recommendation A-09-14 is classified OPEN -- ACCEPTABLE 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 FAA will address this recommendation by considering new FAA guidance on how circuit breakers may be reset by pilots, and publish this guidance in a policy memorandum. This policy memorandum would be made available to aircraft manufacturers, mechanics, pilots, and those performing modifications on aircraft. Next, we will work with manufacturers on the best methods to incorporate aircraft specific guidance into their existing model maintenance manuals, airplane flight manuals, and other service documents. We will also consider potential actions related to new aircraft designs and those performing modifications to aircraft electrical systems to identify and provide pilots and mechanics information on which circuit breakers may be reset during flight. I will provide the Board with a status update on this recommendation by December 2009.