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Safety Recommendation Details

Safety Recommendation A-14-113
Details
Synopsis: On January 7, 2013, about 1021 eastern standard time, smoke was discovered by cleaning personnel in the aft cabin of a Japan Airlines (JAL) Boeing 787-8, JA829J, which was parked at a gate at General Edward Lawrence Logan International Airport (BOS), Boston, Massachusetts. About the same time, a maintenance manager in the cockpit observed that the auxiliary power unit (APU) had automatically shut down. Shortly afterward, a mechanic opened the aft electronic equipment bay and found heavy smoke coming from the lid of the APU battery case and a fire with two distinct flames at the electrical connector on the front of the case. None of the 183 passengers and 11 crewmembers were aboard the airplane at the time, and none of the maintenance or cleaning personnel aboard the airplane was injured. Aircraft rescue and firefighting personnel responded, and one firefighter received minor injuries. The airplane had arrived from Narita International Airport, Narita, Japan, as a regularly scheduled passenger flight operated as JAL flight 008 and conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 129.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Develop or revise processes to establish more effective oversight of production approval holders and their suppliers (including subtier suppliers) to ensure that they adhere to established manufacturing industry standards.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Boston, MA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA13IA037
Accident Reports: ​Auxiliary Power Unit Battery Fire Japan Airlines Boeing 787-8, JA829J
Report #: AIR-14-01
Accident Date: 1/7/2013
Issue Date: 12/1/2014
Date Closed: 2/4/2019
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Hazmat

Safety Recommendation History
From: NTSB
To: FAA
Date: 2/4/2019
Response: On May 25, 2017, you informed us that, on March 6, 2017, you issued Order 8120.23A, “Certificate Management of Production Approval Holders,” which updated risk assessment and oversight practices for managing the certificates of all PAHs and their suppliers. You also wrote that you had implemented specific codification standards for the Federal Aviation Administration (FAA) Aircraft Certification Audit Information System to allow auditors to document and record compliance failures. Further, we note that, on October 1, 2015, you issued a final rule, “Changes to Production Certificates and Approvals,” effective March 29, 2016, revising Title 14 Code of Federal Regulations Part 21 to require that all PAHs establish quality system processes to ensure supplier products conform to PAH requirements, and that suppliers use a comprehensive process to report any nonconforming items they identify—including those produced by subtier suppliers—to the PAH. You determined that these actions satisfied the recommendation and you planned no further action. On November 3, 2017, we replied that, although these actions were responsive and could ultimately satisfy the recommendation, we still had some detailed technical questions and wanted to meet with FAA staff to discuss them. Our staffs met on April 18, 2018, and again on August 7, 2018, and your staff also recently sent us a detailed reply addressing our concerns. Our questions focused on the following: 1. How does Order 8120.23A address “industry standards” regarding a manufactured item? 2. How does Order 8120.23A address and treat first article inspection (FAI), in which the designer of the part gets to inspect a manufactured item before production starts to ensure that the manufactured item complies with the design? 3. How does Order 8120.23A affect the way an upper-tier supplier performs an FAI of a manufacturer at a lower tier in the supply chain? 4. How does Order 8120.23A determine what is an “established manufacturing method?” 5. If a part is manufactured outside of the United States (the battery on the incident airplane was manufactured in Japan), is the manufacturing oversight provided by the aviation authority in the state of manufacture? Are manufacturing oversight standards those of the country of manufacture, or US standards? How does Order 8120.23A apply to a foreign manufacturer? Paragraph 3-54 of Order 8120.23A contains guidance that satisfies our concerns in items 1 through 4 regarding FAIs. With regard to item 3, we note that the rules and guidance in the order apply to all suppliers at every tier in the supply chain, rather than only at the PAH level. In response to item 5, your staff told us that, when bilateral partnerships of authority between two nations have different standards, the partner uses the FAA’s forms, requirements, and systems to perform oversight on your behalf. You believe that, as a result, there is no difference in the safety oversight of foreign-component manufacturers compared to US-component manufacturers. We further note that section 3-9 of the order requires PAHs to redo the risk assessment they submit to you when any of a number of changes occur, including quality system changes, staff turnover, reductions in workforce, changes to lower-tier suppliers, increases in international suppliers, and changes in production locations. The order also reclassifies lithium ion batteries from “category 2” (meaning failure would not prevent safe flight) to “category 1” (meaning failure can prevent safe flight and landing upon failing). Based on the information provided by your staff, and our review of Order 8120.23A and the March 29, 2016, final rule revising Part 21, we believe that you have satisfied Safety Recommendation A-14-113, which is classified CLOSED--ACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 11/8/2018
Response: -From Jennifer Hoffman, Aviation Safety, Acting Manager, AVP-420, Recommendations Branch: This email is the follow-up to the August 7, 2018, meeting held between the FAA and NTSB personnel to discuss Safety Recommendation A-14-113. This recommendation was issued in connection with the investigation of a January 7, 2013, fire in the lithium battery powering the APU on a Japan Airlines Boeing 787 that occurred while the airplane was parked at a gate at Boston’s Logan Airport. In that meeting, the FAA agreed to provide an email in which we provide specific references that address the NTSB’s concerns. Based on this email, the NTSB staff agreed to review this information and indicate if; 1) there are issues not included in what we address, of 2) if the document sections cited do not fully address the NTSB’s concerns. This email provides the NTSB the evidence of actions taken to address A-14-113, after the recommendation was published. Attachment 1 outlines the background and the actions taken to require production approval holders to control suppliers at all tiers. Attachment 2 outlines the policy changes we made to support the regulatory changes in attachment 1. We believe this information addresses the NTSB’s recommendation and satisfies the safety issues identified by the recommendation. As also discussed at our August meeting, the FAA confirms that the NTSB may use this material to initiate a letter classifying A-14-113. Thank you, and please let me know if further clarification is needed.

From: NTSB
To: FAA
Date: 11/3/2017
Response: We note that, on March 6, 2017, you issued Order 8120.23A, “Certificate Management of Production Approval Holders,” which updates risk assessment and oversight practices for managing the certificates of all PAHs and their suppliers, and implements specific codification standards for your Aircraft Certification Audit Information System to allow auditors to document and record compliance failures with improved accuracy and precision. We also note that Title 14 Code of Federal Regulations Part 21 has been revised to require that all PAHs establish quality system processes to ensure supplier products conform to PAH requirements, and that suppliers use a comprehensive process to report any nonconforming items they identify to the PAH, including those produced by subtier suppliers. Although we believe that these actions are responsive and could ultimately satisfy the intent of Safety Recommendation A-14-113, we have requested a meeting with your staff to discuss questions we have regarding the items that you have implemented, and how they would address the issues that were identified during this investigation. Pending the results of this meeting, Safety Recommendation A-14-113 remains classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/25/2017
Response: -From Michael P. Huerta, Administrator: In our previous letter to the Board dated February 24. 2015. we noted that the Federal Aviation Administration’s (FAA) Airman Certification Service modified FAA Order 8120.23. Certificate Management of Production Approval Holders. to address this safety recommendation. On March 6. 2017, the FA/\. issued Order 8120.23A. to implement the updated risk assessment and oversight practices for certificate management o f all production approval holders and suppliers, effective April I 0. 2017. This order is available at: http://wvvw.faa.gov/documentLibrary/media/Ordcr/F AA_ Order_ 8 l 20 _23A.pdf. This revision also implements use of noncompliance codes for the Aircraft Certification Audit Information System. which we described in our previous response as allowing auditors to document and record noncompliances with improved accuracy and precision. These codes will assist in tracking production approval holders· (PAHs) compliance with their supplier quality control system and reporting process in accordance with the requirements outlined in Title 14, Code or Federal Regulations §21.13 7. On October I, 2015, the FAA updated these requirements with a final rule, Changes to Production Certificates and Approvals, effective March 29, 2016. This final rule is available at: https://www.gpo.gov/fdsys/pkg/FR-20 l 5-10-0 I /pdf/2015-24950.pdf. Prior to issuing Order 8 l 20.23A. the FAA established early implementation or a new process for oversight at 23 PAHs and their critical suppliers through memorandum AIR I 00-I 6- l 40-DM09. issued April 15, 2016. The FAA also invoked other specific components or Order 8 I 20.23A by issuing memorandum AlR-1 00- 16-140-DMlS on September29. 2016. This included the use or specific noncompliance codes relative to applicable areas of part 21 and the use of a modified noncompliance record and production approval/cc11ificate management activity report. Both memorandums expired with the issuance of Order 8120.23/\. We determined that these initiatives will create an improved oversight system that directs the FAA 's oversight to the areas of greatest risk in the P AH and supplier system. I believe that the FAA has effectively addressed this safety recommendation and consider our actions complete.

From: NTSB
To: FAA
Date: 4/16/2015
Response: We note that you have modified FAA Order 8120.23, “Certificate Management of Production Approval Holders” to address this recommendation. We also note that you are currently developing specific codification standards for your Aircraft Certification Audit Information System (ACAIS) to allow auditors to document and record failures to comply with improved accuracy and precision, and that you are revising Title 14 Code of Federal Regulations Part 21 to require that all PAHs establish quality system processes to ensure a supplier product conforms to PAH requirements. We further note that this rulemaking proposes that a comprehensive supplier-reporting process be used to report back to the PAH on all nonconforming items identified at any PAH’s supplier or sub-tier supplier. Pending implementation of the codification standards for ACAIS, and completion of the Part 21 rulemaking revisions, Safety Recommendation A-14-113 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 2/24/2015
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) agrees with this recommendation. The FAA has already completed some modifications and has several additional activities underway in this area to include the following: 1. The FAA's Aircraft Certification Service (AIR) modified FAA Order 8 120.23, Certificate Management of Production Approval Holders. to: a. Mandate an increased focus on verifying that supplier control is exercised by all production approval holders (PAH); b. Emphasize the emerging need for rigorous supplier oversight with verification and accountability; and c. Streamline the method by which the auditor will document and record non-compliances pursuant to Title 14, Code of Federal Regulations Part 21 (part 21) known as the approved quality system, whenever such departures are discovered during audit activities at PAH facilities and their suppliers. 2. AIR has recently deployed an enhanced automation tool, the Aircraft Certification Audit Information System (ACAIS), to support implementation of certificate management policies. 3. AIR is currently developing specific codification standards for ACAIS that would allow auditors to document and record non-compliances with improved accuracy and precision while maintaining consistency to specific requirements pursuant to part 21. 4. The FAA also has an active rulemaking effort that has proposed modification of part 21 to require that all PAH establish quality system processes that would ensure a supplier product conforms to PAH requirements. The rulemaking also proposes that a comprehensive supplier-reporting process is adopted and used to report back to the PAH on all nonconforming product, articles, or processes identified at any PAI-l's supplier or sub-tier supplier. The net effect of these initiatives would be an improved oversight system that directs FAA oversight to the areas of greatest risk in the PAH's system.