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Safety Recommendation Details

Safety Recommendation A-79-101
Details
Synopsis: THE NATIONAL TRANSPORTATION SAFETY BOARD HAS COMPLETED ITS DETERMINATION OF PROBABLE CAUSE AND FINAL REPORT ON THE AMERICAN AIRLINES DC-10 ACCIDENT IN CHICAGO ON MAY 25, 1979. THE SAFETY BOARD'S ANALYSIS OF THE EVIDENCE, AND RECOMMENDATIONS SUBMITTED TO THE BOARD BY THE OTHER PARTIES WHO PARTICIPATED IN THE INVESTIGATION AND PUBLIC HEARING, HAVE IDENTIFIED SEVERAL AREAS WHICH WE BELIEVE REQUIRE THE FEDERAL AVIATION ADMINISTRATION'S EARLY ATTENTION.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: ASSURE THAT THE MAINTENANCE REVIEW BOARD FULLY CONSIDERS THE FOLLOWING ELEMENTS WHEN IT APPROVES AN AIRLINE/MANUFACTURER MAINTENANCE PROGRAM: (A) HAZARD ANALYSIS OF MAINTENANCE PROCEDURES WHICH INVOLVE REMOVAL,INSTALLATION, OR WORK IN THE VICINITY OF STRUCTURALLY SIGNIFICANT COMPONENTS IN ORDER TO IDENTIFY AND ELIMINATE THE RISK OF DAMAGE TO THOSE COMPONENTS; (B) SPECIAL INSPECTIONS OF STRUCTURALLY SIGNIFICANT COMPONENTS FOLLOWING MAINTENANCE AFFECTING THESE COMPONENTS; AND (C) THE APPROPRIATENESS OF PERMITTING "ON CONDITION" MAINTENANCE AND, IN PARTICULAR, THE VALIDITY OF SAMPLING INSPECTION AS IT RELATES TO THE DETECTION OF DAMAGE WHICH COULD RESULT FROM UNDETECTED FLAWS OR DAMAGE TO STRUCTURALLY SIGNIFICANT ELEMENTS DURING MANUFACTURE OR MAINTENANCE.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: Chicago, IL, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA79AA017
Accident Reports: American Airlines, Inc., DC-10, N110AA
Report #: AAR-79-17
Accident Date: 5/25/1979
Issue Date: 12/21/1979
Date Closed: 5/17/1983
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 5/17/1983
Response: The safety board continues to believe that actions such as thoseproposed in these recommendations are feasible and needed. Similar re- commendations are feasible and needed. Similar recommendations were included in investigative report on the matter of maintenance and airworthiness procedures concerning dc-10 aircraft operated by u.S. Air carriers submitted to the faa by mr. John m. Cyrocki under a covering letter dated june 25, 1979. Mr. Cyrocki was the investigator in charge of a group appointed by the faa to review air carrier maintenance practicesin the aftermath of the american airlines dc-10 accident. . . . the faa apparently believes that actions envisioned by the safety board and recommended by the cyrocki maintenance review management team are impractical. Since the safety board does not agree, safety recommendations a-79-101 and -102 are classified as closed--unacceptable action.

From: FAA
To: NTSB
Date: 10/5/1982
Response: FAA LETTER: WE HAVE REVIEWED NTSB COMMENTS IN YOUR LETTER DATED JUNE 8, 1982. THE RELEVANCE OF THE QUOTED STATEMENTS TO DISCUSSIONS OF SAFETY RECOMMENDATIONS A-79-101 AND -102 IS NOT CLEAR TO THE FAA. STAFF MEMBERS OF THE OFFICE OF AIRWORTHINESS WOULD BE WILLING TO MEET WITH STAFF MEMBERS OF THE NTSB TO CLARIFY THIS DISCUSSION. UNTIL THEN, THE FAA CONSIDERS THE ACTION TAKEN IN OUR JUNE 10, 1981, LETTER VALID.

From: NTSB
To: FAA
Date: 6/7/1982
Response: Your comments regarding these recommendations addressed the single central issue of permitting air carrier and repair stations to determine the adequacy of their own maintenance procedures. The faa disagreed with the safety board position that manufacturer's maintenance procedures should be the basis from which air carrier deviations are evaluated; and the faa also stated support for current industry maintenance sterring group/faa maintenance review board procedures involving the faa, manufacturer and operator. . . . based on the foregoing discussion of maintenance procedures approval, the safety board assumes that procedural reviews, to be adequate, will include consideration of installation, removal and work in the vicinity of the structurally significant items; and we fail to understand the disagreement expressed in the followup reply. We would appreciate receiving a clarification of your position and will classify these recommendations as open-- acceptable action until that time.

From: FAA
To: NTSB
Date: 6/10/1981
Response: FAA LTR: THESE RECOMMENDATIONS AND YOUR DISCUSSION OF OUR RESPONSE IMPLY A BELIEF BY THE BOARD THAT THE TRANSPORT AIRCRAFT MANUFACTURERS ARE THE MOST KNOWLEDGEABLE SOURCE ON HOW TO MAINTAIN THE AIRCRAFT; AND, THAT ANY OPERATOR'S DEVIATION FROM THE MANUFACTURERS' GUIDANCE SHOULD BE SUBJECTED TO AN EXTENSIVE HAZARD ANALYSIS PRIOR TO FAA APPROVAL. WE DO NOT AGREE. TO SUMMARIZE, WE DO NOT AGREE THAT THE MANUFACTURERS' MAINTENANCE PROCEDURAL RECOMMENDATIONS NECESSARILY PROVIDE THE BEST BASE AGAINST WHICH TO JUDGE DEVIATIONS BY THE AIR CARRIERS; THAT THE CURRENT INDUSTRY MSG AND FAA MRB PROCEDURES, INVOLVING THE FAA, THE MANUFACTURER, AND THE OPERATOR, ARE ADEQUATE; AND, WE BELIEVE THE FACT THAT ESTABLISHED PROCEDURES WERE NOT FOLLOWED WAS A SIGNIFICANT FACTOR IN THIS ACCIDENT, PERHAPS MORE THAN THE PROCEDURE ITSELF.

From: NTSB
To: FAA
Date: 6/13/1980
Response: Your reply explained that the responsibility for maintenance procedure adequacy resides with the individual air carrier and repair stations, and faa surveillance is provided by inspectors assigned to the carrier. . . . this position strengthens the case for hazard analysis of certain ssi-related maintenance procedures in certification activities. A review of manufacturer developed procedures involving removal, installation, or work in the vicinity of ssi's could provide the ability to forecast which ssi's are vulnerable to maintenance-induced damage and to prescribe to the suitable method and interval of inspection. This recommendation has been classified as open--unacceptable action until we hear from you regarding alternatives to mrb review of hazards analyses.

From: FAA
To: NTSB
Date: 3/20/1980
Response: FAA LTR: COMMENT ON A-79-101(A) AND (B): BOTH OF THESE RECOMMENDATIONS SUGGEST THAT THE MAINTENANCE REVIEW BOARD (MRB) FUNCTION BE EXPANDED TO INCLUDE HAZARD ANALYSIS OF MAINTENANCE FUNCTIONS AND SPECIAL INSPECTIONS FOLLOWING MAINTENANCE OF STRUCTURAL COMPONENTS. THUS, THE RECOMMENDATION INCORPORATES THE ASSUMPTION THAT THE MRB IS THE APPROPRIATE PLACE FOR SUCH FUNCTIONS. BOTH RECOMMENDATIONS ALSO INCORPORATE THE ASSUMPTION THAT BECAUSE THE FAA APPROVES THE OVERALL MAINTENANCE PROGRAM, IT ALSO APPROVES EACH AND EVERY MAINTENANCE PROCEDURE. SINCE THE MRB FUNCTION IS NOT TO PROVIDE THE BASIS FOR APPROVAL OF AN AIRLINE'S TOTAL MAINTENANCE PROGRAM, THERE IS NO REASON TO INCLUDE MAINTENANCE HAZARD EVALUATIONS OR SPECIAL INSPECTIONS FOLLOWING MAINTENANCE TO CRITICAL COMPONENTS. MAINTENANCE PROGRAMS FOR EACH AIRLINE ARE REVIEWED AND APPROVED BY FAA MAINTENANCE INSPECTORS ASSIGNED TO EACH CARRIER. THEY CONTINUALLY MONITOR THE PROGRAMS AND TAKE CORRECTIVE ACTION WHEN HAZARDOUS MAINTENANCE PRACTICES ARE DISCOVERED. COMMENT ON A-79-101(C): WE AGREE THAT EMPHASIS SHOULD BE PLACED ON ASSURING THAT NO DEFECTS ARE PERMITTED DURING MANUFACTURE AND THAT DAMAGE IS NOT INFLICTED DURING MAINTENANCE. "ON CONDITION" AND "SAMPLING" INSPECTION FREQUENCY AND PROCEDURES ARE TIME PROVEN TECHNIQUES FOR A PROPERLY ASSEMBLED PRODUCT OR ITEM. WE CANNOT ENVISION HOW AN MRB COULD HAVE THE INSIGHT TO FORECAST WHICH STRUCTURALLY SIGNIFICANT COMPONENTS WOULD SUFFER A MANUFACTURING DEFECT OR DAMAGE DUE TO A MAINTENANCE PRACTICE. HOWEVER, THE APPROPRIATENESS OF THE TYPE OF INSPECTION TECHNIQUES FOR STRUCTURALLY SIGNIFICANT COMPONENTS WILL BE INCLUDED IN THE AGENDA FOR THE MAINTENANCE STEERING GROUP (MSG-3), WHICH HAS BEEN CONVENED FOR THE PURPOSE OF UPDATING THE MAINTENANCE ANALYSIS LOGIC PROCESS.