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Safety Recommendation Details

Safety Recommendation A-09-118
Details
Synopsis: On June 4, 2007, about 1600 central daylight time, a Cessna Citation 550, N550BP, impacted Lake Michigan shortly after departure from General Mitchell International Airport, Milwaukee, Wisconsin (MKE).1 The two pilots and four passengers were killed, and the airplane was destroyed. The airplane was being operated by Marlin Air under the provisions of 14 Code of Federal Regulations (CFR) Part 135 and departed MKE about 1557 with an intended destination of Willow Run Airport (YIP), near Ypsilanti, Michigan. At the time of the accident flight, marginal visual meteorological conditions prevailed at the surface, and instrument meteorological conditions prevailed aloft; the flight operated on an instrument flight rules flight plan.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require Cessna to replace all Citation series airplane pitch trim, autopilot, and any other circuit breakers for critical systems that a pilot might need to access during an emergency situation with easily identifiable and collared circuit breakers to aid a pilot in quickly identifying and easily pulling those circuit breakers if necessary. (A-09-118) (This recommendation supersedes Safety Recommendation A-07-54)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: Milwaukee, WI, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: CHI07MA160
Accident Reports: Loss of Control and Impact with Water, Marlin Air Cessna Citation 550, N550BP
Report #: AAR-09-06
Accident Date: 6/4/2007
Issue Date: 10/27/2009
Date Closed: 11/7/2013
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): General Aviation

Safety Recommendation History
From: NTSB
To: FAA
Date: 11/7/2013
Response: This recommendation superseded Safety Recommendation A-07-54. Since the issuance of Safety Recommendation A-07-54, the FAA has consistently opposed a requirement that circuit breakers required to be pulled as part of emergency or abnormal procedures be collared and easily identifiable. The FAA reviewed the airplane flight manuals (AFM) for Citation series airplanes and found that some emergency and abnormal procedures in the AFM call for pulling a breaker, but because disabling a system through this means is a secondary and not a time-critical function, the FAA does not have sufficient justification to require the use of collars. In our previous letter, we reiterated our belief that guidance (such as an FAA Safety Alert for Operators or a Special Airworthiness Information Bulletin) urging the appropriate use of collars is needed and that issuance of such a document might constitute an acceptable alternate response to this recommendation. In its current letter, the FAA replied that, based on its assessment of current requirements for circuit breaker marking and accessibility, the intended use of circuit breakers as secondary controls to deactivate a failed system, and the agency’s review of the Citation series aircraft design, it had concluded that additional guidance is not needed, and it plans no further action in response. Consequently, Safety Recommendation A 09-118 is classified CLOSED—UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 8/8/2013
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) reviewed Citation-series Airplane Flight Manuals (AFM) to examine circuit breaker use during emergency and abnormal procedures. While circuit breaker use is called out in a small number of procedures, disabling a system through this means is a secondary, not time-critical function. Circuit breakers are most often used to finally de-energize or render a system safe after the malfunction has been managed by some other means. For example, in the case of runaway trim suspected as contributing to this accident, the AFM states that the autopilot/trim disengage button should be depressed to manage the malfunction. Safety Recommendation A-09-118 superseded A-07-54, which was issued following an accident on July 22, 2003, involving a Cessna Citation 525 in Coupeville, Washington. Safety Recommendation A-07-54 recommended that the FAA require Cessna to replace the pitch trim circuit breaker on the Citation 525 with a collared circuit breaker to aid the pilot in quickly identifying it if necessary. During our investigation of this earlier accident, we concluded there was a non-compliant design feature. This design feature prevented the pilot from arresting the runaway trim condition using the standard AFM procedure, depressing the autopilot/trim disconnect switch on the control wheel. Therefore, we issued Airworthiness Directive (AD) 2003-21-07 for the Citation 525 airplane, which added an extension cap or collar on the pitch trim circuit breaker. Once the non-compliant design feature; corrected on these aircraft, allowing the pilot to arrest any runaway trim condition using the disconnect switch, we allowed the removal of the cap or collar. We have determined that the Citation 550 accident aircraft, which resulted in Safety Recommendation A-09-118, does not have a similar design deficiency. If the flightcrew experiences runaway trim, the AFM step directing the flightcrew to push the autopilot/trim disconnect switch is the appropriate initial action. In response to the Board's most recent letter dated January 10, 2012, we acknowledge that some operators add collars or other additional identification as an operational aid to pilots and/or maintenance personnel. When used appropriately, these means of identification can improve the ability to locate a specific circuit breaker that may be called out by in-flight, non-normal, or maintenance procedures. We considered both a Special Airworthiness Information Bulletin and a possible Safety Alert for Operators to further raise awareness of additional circuit breaker markings as suggested by the Board. Based on our assessment of current requirements for circuit breaker marking and accessibility, their intended use as secondary controls to deactivate a failed system, and our in-depth review of the Citation series aircraft design, we concluded that the issue is mitigated and that additional guidance is not needed. I believe the FAA has effectively addressed this recommendation, and I consider our actions complete.

From: NTSB
To: FAA
Date: 1/10/2012
Response: Staff from the NTSB and the FAA met to discuss this issue, and the FAA agreed that collars could improve a pilot’s ability to locate a particular circuit breaker and could be implemented at low cost. FAA staff was also aware that the airplane flight manual specifies pulling the circuit breaker during some emergency procedures. However, in its letter, the FAA states that its review did not find sufficient justification to warrant requiring the use of collars. We continue to believe that there is a need to communicate the need for collars and to urge their appropriate use through guidance such as a Safety Alert for Operators or a Special Airworthiness Information Bulletin. Although we believe that issuance of such a document may constitute an acceptable alternate response to this recommendation, the FAA has not suggested such an alternative. Consequently, pending the FAA’s taking the recommended action or an acceptable alternate action, Safety Recommendation A-09-118 remains classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/4/2011
Response: - From J. Randolph Babbitt, Administrator: We have completed our investigation of this recommendation and while we agree that collars could improve the pilot’s ability to locate a particular circuit breaker, we do not believe there is sufficient justification to warrant requiring the use of collars. We reviewed the AFM for the Cessna 550 and other Cessna model aircraft to examine the number of circuit breaker pulls required as part of the emergency procedures and the criticality of pulling the breaker within a specific procedure. Typically, there were three to four emergency procedures requiring a circuit breaker to be pulled and/or reset. The number of circuit breakers varied from a total of three to eight for all emergency procedures depending on the aircraft model. It was noted that pulling a circuit breaker was one of the final steps in a given procedure after the immediate emergency situation had been addressed. This is consistent with the design philosophy of not utilizing circuit breakers as switches. Circuit breakers should be pulled as part of a final means to disable a system. The first step in all procedures addressing uncommanded motion is to actuate the autopilot/trim disengage or disconnect switch, thus arresting the uncommanded motion. This allows the flightcrew time to locate the required circuit breaker and ultimately disable the affected system. For example, on the Cessna 550, a trim runaway can be arrested by activating and holding the autopilot/trim disengage button per AFM procedures and as trained as part of the type rating. This allows time for the circuit breaker to be located and pulled. The aircraft can then be retrimmed by use of the manual trim system. In the Cessna 550 or the 525 (after incorporation of AD 2004-14-20), it would take multiple failures before pulling a circuit breaker would be required to address an emergency situation. Therefore, there is a low criticality in the need to quickly locate a particular breaker. Additionally, the FAA reviewed other Citation models with respect to their certification requirements and found them to be compliant. The AFM review process did reveal some procedural inconsistencies in the means by which Cessna addresses pitch trim runaways. These inconsistencies have to do with the treatment of pitch trim runaways as emergency or abnormal procedures and the procedural steps themselves. We are working with Cessna to resolve these inconsistencies. We reviewed the design and certification of the circuit breaker panel and found that the circuit breaker panel design is not unique to this model airplane, nor is the use of AFM procedures requiring the selection of certain breakers under a failure condition. A review of the type certification data on the Cessna 550 found the installation of the circuit breaker panel to be in compliance with the applicable part 25 standards. Those standards would still be valid for use on similar systems under the current part 25 requirements. I will keep the Board informed of the FAA's progress and provide an updated response to this recommendation by August 2012.

From: NTSB
To: FAA
Date: 11/17/2010
Response: This recommendation superseded Safety Recommendation A-07-54. More than 2 1/2 years after that recommendation was issued, the FAA has not yet taken any action to address this safety issue. The FAA's current planned action is to review the emergency procedures for the Cessna Citation Model 550 alone, to determine the number of circuit breakers that would be involved, and to evaluate whether the installation of collars would appreciably increase safety. However, this recommendation is intended to apply to all Citation series airplanes, not only to the Model 550. Accordingly, pending the FAA's reconsideration and completion of the recommended action, Safety Recommendation A-09-118 remains classified OPEN – UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 4/28/2010
Response: Letter Mail Controlled 5/5/2010 12:17:19 PM MC# 2100167 - From J. Randolph Babbitt, Administrator: The Wichita ACO in conjunction with Cessna will review the emergency procedures for the Model 550 to determine the number of circuit breakers that would be involved. We will evaluate whether installation of collars will appreciably increase safety. Once we have completed our review we will provide our proposed course of action to the Board. I will provide an update on the progress of this safety recommendation by March 2011.