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Safety Recommendation Details

Safety Recommendation A-16-004
Details
Synopsis: On March 11, 2016, the National Transportation Safety Board (NTSB) adopted our safety recommendation report concerning a June 5, 2015, incident in which United Express flight 4776, a Bombardier DHC-8-202 airplane, experienced an in-flight fire at the right windshield terminal block while on approach to Bradley International Airport, Windsor Locks, Connecticut.
Recommendation: TO BOMBARDIER, INC.: Add an emergency procedure checklist and revise training materials for all Bombardier DHC-8 airplanes that specifically instruct flight crews, as a memory item, to immediately turn off windshield heat in the event of windshield arcing, smoke, fire, or overheating.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Aviation
Location: Windsor Locks, CT, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: ENG15IA024
Accident Reports: Safety Recommendation Report: Preventing Windshield Arcing, Smoke, and Fire on Bombardier DHC-8 Airplanes
Report #: ASR-16-001
Accident Date: 6/5/2015
Issue Date: 4/12/2016
Date Closed: 4/20/2018
Addressee(s) and Addressee Status: Bombardier, Inc. (Closed - Acceptable Alternate Action)
Keyword(s):

Safety Recommendation History
From: Bombardier, Inc.
To: NTSB
Date: 6/12/2018
Response: -From David Fisher, Director, Bombardier Commercial Aircraft, ASIO (Air Safety Investigation Office): (editorial note: this text was italicized in the original letter and is a quote from the NTSB's letter) A-16-4 “Add an emergency procedure checklist and revise training materials for all Bombardier DHC-8 airplanes that specifically instruct flight crews, as a memory item, to immediately turn off windshield heat in the event of windshield arcing, smoke, fire, or overheating. We are aware that you do not include memory items in your airplane flight manuals (AFMs); we note, however, that you have revised section 3, Emergency Section, 3.4.2 “Known Source of Smoke and Fire,” of the AFM for all DHC-8 series airplanes to include the following: “If an electrical source of fire, smoke, or fumes is positively identified, remove power to source if possible.” We are also aware that you do not publish training materials for your airplanes and that each operator is responsible for providing training per its operation specifications. Although you did not include the recommended checklist as a memory item or revise training materials for all Bombardier DHC-8 airplanes, we believe that your revisions to the AFM will improve how flight crews respond to windshield arcing, smoke, fire, or overheating, and is therefore an acceptable alternate solution. Accordingly, Safety Recommendation A-16-4 is classified “Closed—Acceptable Alternate Action.”

From: NTSB
To: Bombardier, Inc.
Date: 4/20/2018
Response: We are aware that you do not include memory items in your airplane flight manuals (AFMs); we note, however, that you have revised section 3, Emergency Section, 3.4.2 “Known Source of Smoke and Fire,” of the AFM for all DHC-8 series airplanes to include the following: “If an electrical source of fire, smoke, or fumes is positively identified, remove power to source if possible.” We are also aware that you do not publish training materials for your airplanes and that each operator is responsible for providing training per its operation specifications. Although you did not include the recommended checklist as a memory item or revise training materials for all Bombardier DHC-8 airplanes, we believe that your revisions to the AFM will improve how flight crews respond to windshield arcing, smoke, fire, or overheating, and is therefore an acceptable alternate solution. Accordingly, Safety Recommendation A-16-4 is classified CLOSED--ACCEPTABLE ALTERNATE ACTION.

From: Bombardier, Inc.
To: NTSB
Date: 12/14/2017
Response: -From David Fisher, Manager, Air Safety Investigations Office (ASIO): The DHC-8 Series Aircraft Flight Manuals (AFM) were revised to add procedures to address this issue, Section 3, Emergency Section, 3.4.2 “Known Source of Smoke and Fire”. Revised AFM Section 3.4.2 below. 3.4.2 Known Source of Fire or Smoke If an electrical source of fire, smoke or fumes is positively identified, remove power to source if possible.

From: NTSB
To: Bombardier, Inc.
Date: 10/4/2017
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. We normally expect actions to address our recommendations to be completed within 3 to 5 years, and we have yet to hear from you regarding your progress toward addressing these recommendations. We would appreciate receiving a response within 90 days indicating any actions you have taken or plan to take to implement these recommendations; until then, they will retain their current classification of OPEN—AWAIT RESPONSE. For additional background information about these safety recommendations, please refer to Safety Recommendation Report 16-01, Preventing Windshield Arcing, Smoke, and Fire on Bombardier DHC-8 Airplanes. Please update us at correspondence@ntsb.gov regarding your actions to address Safety Recommendations A-16-3 through -8, and do not submit both an electronic and a hard copy of the same response.