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Safety Recommendation Details

Safety Recommendation A-10-118
Details
Synopsis: On December 20, 2008, about 1818 mountain standard time, Continental Airlines flight 1404, a Boeing 737-500, N18611, departed the left side of runway 34R during takeoff from Denver International Airport (DEN), Denver, Colorado. A postcrash fire ensued. The captain and 5 of the 110 passengers were seriously injured; the first officer, 2 cabin crewmembers, and 38 passengers received minor injuries; and 1 cabin crewmember and 67 passengers (3 of whom were lap-held children) were uninjured. The airplane was substantially damaged. The scheduled, domestic passenger flight, operated under the provisions of 14 Code of Federal Regulations (CFR) Part 121, was departing DEN and was destined for George Bush Intercontinental Airport, Houston, Texas. At the time of the accident, visual meteorological conditions prevailed, with strong and gusty winds out of the west. The flight operated on an instrument flight rules flight plan.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require that operators of transport-category airplanes that use galley latches or latch plates secured solely by adhesives that may degrade over time modify the latches to include mechanical fasteners.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Aviation
Location: Denver, CO, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA09MA021
Accident Reports: Runway Side Excursion During Attempted Takeoff in Strong and Gusty Crosswind Conditions Continental Airlines Flight 1404, Boeing 737-500, NN18611
Report #: AAR-10-04
Accident Date: 12/20/2008
Issue Date: 7/29/2010
Date Closed: 9/6/2013
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s): Aircraft Design

Safety Recommendation History
From: NTSB
To: FAA
Date: 9/6/2013
Response: We are encouraged that the FAA has issued Special Airworthiness Bulletin NM 12 11 and Safety Alert for Operators 12006, which recommend that operators comply with the guidance contained in Service Bulletin 25-30-0426, published by B/E Aerospace. Although neither document constitutes the recommended requirement, we note that the affected airline with B/E Aerospace galleys installed is taking remedial action to address the issue. We believe that these actions constitute an acceptable alternate means of addressing Safety Recommendation A 10 118; accordingly, it is classified CLOSED—ACCEPTABLE ALTERNATE ACTION.

From: FAA
To: NTSB
Date: 4/22/2013
Response: -From Michael P. Huerta, Administrator: As noted in our last letter dated November 21,2011, the Federal Aviation Administration (FAA) conducted an investigation of the issue and determined the B/E Aerospace galleys installed on 48 additional Boeing 737s were affected. We conducted a risk analysis of the potential implications and concluded that the risk imposed by the subject latch does not meet the criteria for issuing an airworthiness directive. We determined that a Special Airworthiness Information Bulletin (SAIB) and a Safety Alert for Operators (SAFO) would be sufficient to address possible safety concerns. We issued SAIB NM-12-ll (enclosed) on January 10, 2012, and SAFO 12006 (enclosed) on October 15, 2012. Both the SAIB and the SAFO recommend that owners and operators of Boeing 737 model airplanes equipped with BIE Aerospace galleys comply with BIE Aerospace Service Bulletin 25-30-0426, Revision B, dated October 3, 2011. Service Bulletin 25-30-0426 recommends replacement of the latch attachment method. The FAA notes that the affected airline with the BIE Aerospace galleys installed is taking remedial action to address the issue. We recognize that SAIBs or SAFOs are not mandatory and are intended as an information and advisory system. They encourage the implementation of new approaches or make the affected parties aware of a potential issue with the means to mitigate the associated risk. The typical distribution for an SAIB or a SAFO includes all known aircraft owners/operators, FAA Flight Standards Field Offices, and manufacturers. I believe that the SAIB and SAFO effectively address this safety recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 3/6/2012
Response: The FAA indicated that 48 additional B-737 aircraft have been identified as having the same galley latch adhesive as that used on the accident aircraft. The FAA also indicated its determination that displacement of the box retained by the galley latch would not preclude safe evacuation and, therefore, any displacement does not meet the FAA’s criteria for issuance of an AD. Instead, the FAA indicated that it plans to issue a special airworthiness bulletin (SAIB) and a safety alert for operators (SAFO) to recommend that operators comply with the guidance contained in B/E Aerospace–published Service Bulletin (SB) 25-30-0426. Although neither an SAIB nor a SAFO constitutes the recommended requirement, we believe that, if the FAA can verify that all operators have complied with the guidance, this action would constitute an acceptable alternate means of meeting the intent of the recommendation. Accordingly, pending FAA confirmation that all operators of these airplanes have complied with the SB, Safety Recommendation A-10-118 is classified OPEN—ACCEPTABLE ALTERNATE RESPONSE.

From: NTSB
To: FAA
Date: 12/16/2011
Response: The FAA indicated that it is reviewing the design, process specifications, and testing used during its manufacture and certification to discover the root cause of the galley latch’s failure before determining the agency’s future course of action. Accordingly, pending completion of the recommended action, Safety Recommendation A-10-118 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 11/21/2011
Response: -From J. Randolph Babbitt, Administrator: The FAA conducted an investigation and identified 48 additional B-737 aircraft with the same galley latch adhesive issue found in the Board's investigation. We conducted a quantitative risk analysis of the potential safety implications and concluded that displacement of the box retained by the subject latch would not preclude safe evacuation. Based on our analyses, the criteria for issuance of an Airworthiness Directive were not met. Instead, we determined that a Special Airworthiness Information Bulletin (SAIB) and a Safety Alert for Operators are appropriate to address the issue. We plan to issue an SAIB recommending replacement of the latch attachment per manufacturer's instructions in BIE Aerospace SB 25-30-0426 dated September 30, 2009. I will keep the board informed of the FAA's progress on these safety recommendations and provide an updated response by December 2012.

From: FAA
To: NTSB
Date: 10/14/2010
Response: CC#201000393: - From J. Randolph Babbitt, Administrator: The FAA agrees that galley latches and restraints must be reliable. The applicable transport airplane certification regulation, 14 CFR 25.601, requires that: "The airplane may not have design features or details that experience has shown to be hazardous or unreliable. The suitability of each questionable design detail and part must be established by tests." We are reviewing the design, process specifications, and testing used to manufacture and certify this galley to establish a root cause for the failure and to develop an appropriate course of action. I will keep the Board informed of the FAA's progress and provide an updated response on the remaining recommendations by December 2011.