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Safety Recommendation Details

Safety Recommendation A-16-007
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.: Revise the Bombardier DHC-8 Aircraft Maintenance Manual to include detailed permissible damage limits of windshields and windshield components in accordance with the PPG Aerospace Transparencies Abbreviated Component Maintenance Manual.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
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:
Addressee(s) and Addressee Status: Bombardier, Inc. (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Bombardier, Inc.
Date: 7/17/2018
Response: In our previous letter about this recommendation, we pointed out that information in the Bombardier DHC-8 AMM about permissible damage limits for scratches, delamination, and cracks was not consistent with the published information in the PPG Aerospace Transparencies ACMM. We note that you have now determined that your AMMs were dated before the latest version of PPG Aerospace Transparencies ACMM, and you plan to revise your AMMs to incorporate the information in the current ACMM. Pending completion of those revisions, Safety Recommendation A-16-7 is classified OPEN--ACCEPTABLE RESPONSE.

From: Bombardier, Inc.
To: NTSB
Date: 6/12/2018
Response: -From David Fisher, Director, Bombardier Commercial Aircraft, ASIO (Air Safety Investigation Office): A-16-7 “Revise the Bombardier DHC-8 Aircraft Maintenance Manual [AMM] to include detailed permissible damage limits of windshields and windshield components in accordance with the PPG Aerospace Transparencies Abbreviated Component Maintenance Manual [ACMM]. You reported that the Bombardier DHC-8 AMM maintenance task card was revised and now contains permissible damage limits for scratches, delamination, and cracks that are consistent with the published information in the PPG Aerospace Transparencies ACMM. However, our review of the Bombardier DHC-8 AMM, which we obtained from your staff, found that the AMM has not changed from what was published before the incident. We continue to believe that omitting information on certain types of damage and referencing a separate document for other types of damage could confuse maintenance personnel and lead to inadequate inspections of DHC-8 windshields. Therefore, pending revisions to the DHC-8 AMM that include detailed permissible damage limits for windshields and windshield components in accordance with the PPG Aerospace Transparencies ACMM, Safety Recommendation A-16-7 is classified “Open—Unacceptable Response.” Bombardier Response: There appears to be some misunderstanding of the time when the damage limitations were referenced in the relevant AMM that resulted in a delta between the CMM’s and the AMM’s The latest PPG revision of the CMM is Rev 6 - dated June 16th 2015. The latest Sierracin revision of the CMM is Rev D dated April 6th 2017 Latest Q400 AMM limits issued Mar 5 2017 Latest Q100 AMM limits issued Jan 15 2012 Latest Q200 AMM Limits issued Nov 15 2011 Latest Q300 AMM Limits issued Oct 15 2011 The relevant AMM’s will be revised to ensure alignment with the same damage limits and tolerances specified within the manufacturers CMM’s.

From: NTSB
To: Bombardier, Inc.
Date: 4/20/2018
Response: You reported that the Bombardier DHC-8 AMM maintenance task card was revised and now contains permissible damage limits for scratches, delamination, and cracks that are consistent with the published information in the PPG Aerospace Transparencies ACMM. However, our review of the Bombardier DHC-8 AMM, which we obtained from your staff, found that the AMM has not changed from what was published before the incident. We continue to believe that omitting information on certain types of damage and referencing a separate document for other types of damage could confuse maintenance personnel and lead to inadequate inspections of DHC-8 windshields. Therefore, pending revisions to the DHC-8 AMM that include detailed permissible damage limits for windshields and windshield components in accordance with the PPG Aerospace Transparencies ACMM, Safety Recommendation A-16-7 is classified OPEN--UNACCEPTABLE RESPONSE.

From: Bombardier, Inc.
To: NTSB
Date: 12/14/2017
Response: -From David Fisher, Manager, Air Safety Investigations Office (ASIO): Aircraft Maintenance Manual (AMM) - Maintenance Task Card procedure to inspect, that include detailed permissible damage limits of the Windshield components, (typical to all series 100, 200 and 300) in accordance with the PPG Aerospace Transparencies abbreviated Component Maintenance Manual (CMM).

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.