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Safety Recommendation Details

Safety Recommendation A-17-003
Details
Synopsis: On June 7, 2013, about 0925 coordinated universal time, an EMB-145LR, registration B-3052, operating as China Eastern Airlines flight MU2947, departed the left side of runway 18L onto taxiway A2 while landing at Hongqiao International Airport, Shanghai, China, in moderate rain. The flight originated from Huai’an Lianshui Airport, Jiangsu, China. The 25 crewmembers and 44 passengers were uninjured, and the nose landing gear sustained minor damage.2 After this incident, the nosewheel steering manifold assembly and electrohydraulic servo valve (EHSV) were tested by the components’ manufacturers (Parker Aerospace and Woodward HRT, respectively) according to their returned component acceptance test protocols, which are the same tests that newly manufactured components would undergo before delivery.
Recommendation: TO EMBRAER (EMPRESSA BRASILEIRA DE AERONAUTICA, S.A.): Issue an operations bulletin informing your operators that the use of binder brackets to hold chart binders is not approved by Embraer and could cause a hazardous condition if a binder becomes dislodged from the bracket.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Aviation
Location: Shanghai, China
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA13WA123
Accident Reports:
Report #: ASR-17-02
Accident Date: 6/7/2013
Issue Date: 2/2/2017
Date Closed: 8/31/2017
Addressee(s) and Addressee Status: Embraer (Empressa Brasileira de Aeronautica, S.A.) (Closed - Acceptable Alternate Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Embraer (Empressa Brasileira de Aeronautica, S.A.)
Date: 8/31/2017
Response: Our goal in issuing this recommendation was to ensure that pilots and operators of Embraer aircraft are aware of the potential danger of using binder brackets to hold chart binders. We note that, as an alternative to the recommended action of issuing an operational bulletin, Embraer has completed several actions that you believe better satisfy the recommendation. Embraer has taken the following actions: • Included articles addressing the potential dangers of using binder brackets in Embraer aircraft in its operational newsletter and in technical updates. The format of these publications permits a more detailed description of the occurrence, investigation, and findings, and includes pictures to aid understanding. These free documents reach pilots directly, as opposed to operational bulletins, which are more formal and whose distribution is limited. • Issued Embraer Field Report GFS-006-17 on March 14, 2017, to advise ERJ-145 family operators not to install or use binder brackets that are not approved by the appropriate aviation authority. • Highlighted this topic at the Embraer operators’ safety meeting in Fort Lauderdale, Florida, on March 29–30, 2017, and in a flight operations forum at the Embraer operators’ conference in Rio de Janeiro, Brazil, on April 11¬–12, 2017. Embraer’s actions are an effective alternative to satisfy Safety Recommendation A-17-3, which is classified CLOSED—ACCEPTABLE ALTERNATE ACTION.

From: Embraer (Empressa Brasileira de Aeronautica, S.A.)
To: NTSB
Date: 5/4/2017
Response: -From Mauro Kern, Executive Vice President, Operation and Chief Operating Officer: Embraer recognizes the value of recommendations issued by the national investigation authorities with the objective to promote continuous improvement to the safety of the aviation system worldwide. In the effort to provide the response to the recommendations A-17-2 and A-17-3, Embraer had been working in cooperation with Parker, Woodward HAT and the Brazilian authorities (CENIPA and ANAC). The result of this work was already consolidated in terms of describing the actions considered as adequate to address the issues listed in the report ASR-17-02. Recently however, Embraer was informed by CENIPA that they, as the Brazilian Investigation Authority, would like to send the detailed response to the recommendations A-17-2 and A-17-3 directly to NTSB. We have already provided our proposal and a formal response from the CENIPA to the NTSB is expected soon. Embraer reaffirms its commitment to advise CENIPA's accredited representatives and, in this way, continuously provide assistance to the investigations conducted by the NTSB.

From: Embraer (Empressa Brasileira de Aeronautica, S.A.)
To: NTSB
Date: 5/3/2017
Response: -From Major General Fredico Alberto Marcondes Felipe, Chief of CENIPA and Roberto Fernandex Alves, Colonel: This letter is from the Ministry of Defense, Command of Aeronautics, Aeronautical Accident Investigation and Prevention Center (CENIPA) of Brazil: Embraer answer to NTSB Safety Recommendation A-17-3: • Embraer understands that, normally, operational Bulletins modifies or introduces a procedure that will be reflected or introduced in a later revision of the approved flight manuals, which is not applicable for this case. • For that reason, Embraer intends to address this issue in articles to be included in the next edition of the "Operational Newsletter" (ONL) and "Technical Updates". The main goal of these publications from the Embraer Flight Operations Engineering and Support for commercial and executive jets, respectively, is to strengthen the communication channel between Embraer and its operators. They include information about operational publication evolutions, products developed, improvements to aircraft systems and related subjects. • The format of these publications permit a more detailed description of the occurrence, investigation, findings and even the inclusion of pictures for a better understanding. Also their free distribution process permits them to reach the pilots directly, and not through a formal "top-down" process, as occurs with Operational Bulletins. • Besides that, on March 14th, 2017 Embraer issued the Embraer Release of Field Report (ERFR) GFS-006-17 to advise ERJ-145 family operators to neither install nor use binder brackets which were not approved by the competent aviation authority. The ERFR is a publication by Embraer Air Safety department to its operator's Safety Officers. • Additionally, Embraer highlighted this topic in the Embraer Operators Safety Meeting (EOSM) held in Fort Lauderdale, Florida on March 29th and 30th, 2017 and in flight operations forum of the Embraer Operators Conference (EOC) in Rio de Janeiro, Brazil on April 11th and 12th, 2017. The EOC is a global event held in a different region of the world each year and its presentations are available to all Embraer operators through the Fly Embraer website. • Finally, this topic will be included in the operational safety visits to the operators, which usually occurs by operator request. During these meetings, Embraer discuss the latest OB/ONL, present the findings from closed investigations and share the best safety practices with our customers. After analysing the Embraer response and its corrective actions implemented, the Brazilian Civil Aviation Authority (ANAC) and the Brazilian Accident Investigations Authority (CENIP A) have considered both recommendations (A-17-2 & A-17-3) accomplished.

From: NTSB
To: Embraer (Empressa Brasileira de Aeronautica, S.A.)
Date: 2/1/2017
Response: On January 26, 2017, we adopted our safety recommendation report concerning uncommanded nosewheel steering anomalies during landing in Embraer EMB-145 regional jets. Additional information may be found in the safety recommendation report, which can be accessed at our website (www.ntsb.gov) under report number ASR-17-02. As a result, we issued five new recommendations, including three to the Federal Aviation Administration and the following two recommendations to Embraer.