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Safety Recommendation Details

Safety Recommendation A-79-102
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: REQUIRE THAT AIR CARRIER MAINTENANCE FACILITIES AND OTHER DESIGNATED REPAIR STATIONS: (A) MAKE A HAZARD ANALYSIS EVALUATION OF PROPOSED MAINTENANCE PROCEDURES WHICH DEVIATE FROM THOSE IN THE MANUFACTURER'S MAINTENANCE MANUAL AND WHICH INVOLVE REMOVAL, INSTALLATION, OR WORK IN THE VICINITY OF STRUCTURALLY SIGNIFICANT COMPONENTS; AND (B) SUBMIT PROPOSED PROCEDURES AND ANALYSIS TO THE APPROPRIATE REPRESENTATIVE OF THE ADMINISTRATOR, FAA, FOR APPROVAL.
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: 1/11/2000
Response: Notation 7215: The National Transportation Safety Board has reviewed the Federal Aviation Administration's (FAA) notice of proposed rulemaking (NPRM), "Part 145 Review: Repair Stations," which was published in the Federal Register, Volume 64, No. 118, on June 21, 1999. The FAA proposes to update and revise the regulations for repair stations. According to the NPRM, this action is necessary because many portions of the current repair station regulations do not reflect changes in repair station business practices and aircraft maintenance practices, or advances in aircraft technology. In general, the Safety Board agrees with the FAA that to ensure that the regulations are appropriate for today's repair station industry, Part 145 should be extensively revised. Where possible, the Safety Board's specific comments are organized by sections to correspond with sections in the NRPM. However, in some instances, the Board's comments extend across several sections of the NPRM. Manufacturers' Maintenance Facilities The FAA proposes to eliminate the "limited" ratings for manufacturers and to require that these facilities obtain the appropriate repair station certification. These ratings had previously been granted to allow manufacturers to perfoml maintenance on articles manufactured by them. However, manufacturers' systems for inspection, recordkeeping, and quality control vary considerably from those used by repair stations. Because maintenance practices and aircraft technologies have evolved since the establishment of limited ratings for manufacturers, the FAA has detern1ined that all repair facilities' systems for inspection, recordkeeping, and quality control should be consistent, and that the issuance of limited ratings for manufacturers is no longer appropriate. The Safety Board concurs with this proposed revision to Part 145. Deviation Authority The FAA proposes to include deviation authority to provide flexibility to operations subject to Part 145 that may be safely or satisfactorily conducted as an alternative means of compliance with portions of Part 145. The FAA further indicates that if deviation authority is granted, the FAA would require that operations be conducted to certain conditions and limitations and these would be placed in the Operations Specifications. Without specific criteria, or examples of the types of conditions or limitations'that would be imposed, the Safety Board questions the practicality of this section of the proposed rule or how consistency in granting deviation authority can be assured. Further, the Safety Board questions the basis for the FAA's contention that limited deviations would be sought and that letters of deviation authority would likely be limited in scope. The Safety Board does not support the inclusion of deviation authority, as currently written, in the final rule. Ratings and Classes The FAA proposes to revise the ratings and classes that can be issued to certificated repair stations. In response to the FAA's request for comments as to whether ratings and classes should be prescribed in a separate regulation, the Safety Board believes that the proposed system of ratings and classes can be appropriately prescribed in the proposed revisions to Part 145. The Safety Board supports the proposed revisions to ratings and classes, and specifically the establishment of a new rating for computer systems to account for the technological developments and advances in aircraft design and manufacturing. However, the Safety Board has expressed concerns in the past about how ratings and classes are applied, the interpretation of those ratings by the FAA, and, as a result, repair stations performing maintenance that exceeds the authority of their rating. The proposed ratings and classes provide no better guidance to certificate holders and FAA inspectors than the current ratings and classes in terms of what ratings are required for specific repair station work. In its report of the uncontained engine failure/fire of ValuJet Airlines flight 597 in Atlanta, Georgia, on June 8,1995, the Safety Board concluded that the Operations Specifications of the repair station that performed maintenance on the failed engine could reasonably have been read to indicate that the repair station did not have authority under Part 145 to overhaul the type of engine that it did overhaul and that ultimately failed. The Safety Board asked the FAA in Safety Recommendation A-96-78 to review the air agency certificates and repair station Operations Specifications of all repair stations and ensure that the language used in the Operations Specifications clearly indicates the extent of the repair station's authority. In response to this recommendation, the FAA issued Flight Standards Information Bulletin for Airworthiness 97-17A, "Certificate and Operations Specifications Evaluation of Limited Specialized Services Rated Repair Station." The bulletin directed principal inspectors to review the Operations Specifications and certificate to determine if the Operations Specifications were appropriate for the rating that had been issued. The review found that 53 repair stations were operating beyond their certificate privileges, 134 repair station Operations Specifications were reissued, 16 repair stations were recertified, and 108 repair stations received rating changes. Although the discrepancies uncovered by this review were corrected, the findings suggest a lack of consistency in how ratings are applied. The Safety Board suggests that given the proposed revisions to ratings, the opportunity exists for the FAA to provide better guidance to certificate holders and inspectors regarding what ratings are required for specific repair station work. Using the organizational structure of Appendix A: Job Functions, the FAA could prepare a master list of the maintenance capabilities, by make and model of part or article, on which those functions can be performed. Such a list, published as an advisory circular and as a supplement to FAA Handbook 8300.10, would ensure a more consistent application of ratings to maintenance operations. It would also serve as a reference for the FAA certificate holding district offices (CHDO), which will continually be evaluating changes to capability lists. An example that illustrates the Board's concern in this area is the maintenance of flight data recorders (FDRs). Most repair stations perfornling maintenance on FDRs currently work under a "limited rating for specialized service." The Safety Board's experience with FDRs indicates that some of these maintenance facilities do not possess the necessary special testing equipment and software to properly maintain the FDRs. Specific guidance is not provided in the proposed regulations as currently written. The Safety Board urges the FAA to include "inspect, test, and validate flight data recorders" in Appendix A: Job Functions. A repair station should also be required to list flight data recording equipment, by make and model, in its capability list. Further, principal maintenance inspectors should be provided better guidance concerning the rating appropriate for maintenance, preventive maintenance, or alteration of FDRs. Repair Station Manual, Quality Assurance, and Capability List In general, the Safety Board concurs with the proposed revisions to these sections that require repair stations to (1) maintain an approved repair station manual that covers all of the repair station's technical operations, (2) establish quality assurance systems to ensure that maintenance, preventive maintenance, or alterations (including the maintenance and alterations performed by a repair station's contractors) are consistently performed in accordance with all applicable requirements, and (3) maintain a capability list that would specify all articles on which the repair station is capable of performing work. Under the proposal, prior to working on an article, a repair station would be required to conduct a self-evaluation, described in the quality assurance system, which is to be included in the repair station manual, to ensure that the repair station has the required facilities, equipment, materials, technical data, processes, housing, and training personnel in place to properly perform the work on the article. After the self-evaluation, the article would be added to the repair station's capability list and, based on procedures in the repair station manual, the repair station would be required to infonn the FAA CHDO of the revision to the capability list. The Safety Board agrees with the intent of these proposals; however, the Board suggests that better guidance, in the fonn of a master capability list, as an example, and specific material and equipment requirements listed in Appendix A: Job Functions, would aid the certificate holder during the self-evaluation and aid the FAA CHDO in its oversight of the repair station activities. Repair Station Manual, Quality Assurance, and Capability List In general, the Safety Board concurs with the proposed revisions to these sections that require repair stations to (1) maintain an approved repair station manual that covers all of the repair station's technical operations, (2) establish quality assurance systems to ensure that maintenance, preventive maintenance, or alterations (including the maintenance and alterations performed by a repair station's contractors) are consistently performed in accordance with all applicable requirements, and (3) maintain a capability list that would specify all articles on which the repair station is capable of performing work. Under the proposal, prior to working on an article, a repair station would be required to conduct a self-evaluation, described in the quality assurance system, which is to be included in the repair station manual, to ensure that the repair station has the required facilities, equipment, materials, technical data, processes, housing, and training personnel in place to properly perform the work on the article. After the self-evaluation, the article would be added to the repair station's capability list and, based on procedures in the repair station manual, the repair station would be required to inform the FAA CHDO of the revision to the capability list. The Safety Board agrees with the intent of these proposals; however, the Board suggests that better guidance, in the form of a master capability list, as an example, and specific material and equipment requirements listed in Appendix A: Job Functions, would aid the certificate holder during the self-evaluation and aid the FAA CHDO in its oversight of the repair station activities. Contract Maintenance The FAA proposes to continue permitting repair stations to contract out maintenance and alteration of components of a type-certificated product as is currently permitted. However, the proposal would permit any repair station to contract out such work on any article for which it is rated (other than a complete type-certificated product) provided certain conditions are met, including equipment and material requirements and a listing in the repair station manual of those functions that a repair station would be permitted to contract to an outside facility. With respect to contracting to noncertificated sources, under the proposal, contracting would not be restricted to type certificate holders. The Safety Board concurs with these proposals so long as the conditions outlined in the NPRM remain in the final rule; that is, the certificated repair station would be required to supervise or otherwise remain directly in charge of a shop that performs maintenance, preventive maintenance, or alterations; and the certificated repair station would be required to verify by test and/or inspection that the job function has been satisfactorily performed by the noncertificated person before the certificated repair station approves the article for return to service. The Safety Board emphasizes that while we concur with the conditions for contract maintenance arrangements, the air carriers ultimately are responsible for the safety of their operations and the airworthiness of their airplanes" Likewise, the FAA continues to have oversight responsibility of Part 145 activities regardless of the contractual arrangements between repair facilities. Training Program The FAA's training program proposal would require that each repair station establish and maintain a documented training program for all employees who perform work under the repair station's ratings and classes. The training program would be required to be described in the repair station manual and would be required to consist of initial and recurrent training for aviation maintenance personnel, be based on each individual's assignment, and ensure that each individual is capable of performing the assigned task. Although the Safety Board is pleased that the proposed training program establishes the basis for recurrent training at repair stations, the proposed rule does not contain specific requirements for the length and content of the training. The Board is concerned that the details and requirements for content and delivery of recurrent training will be dependent on FAA advisory material, which is not enforceable. In contrast, the Board notes that minimum standards addressing the duration and content of recurrent training exist in regulations governing pilots, flight attendants, ground personnel involved in deicing operations, operators of security screening equipment, airport fire and rescue personnel, and supervisory personnel administering a certificate holder's drug test program. The Safety Board believes that the currency of job-specific skills and knowledge is no less essential for mechanics and that a reasonable quantity of recurrent training should be specified in the final rule. Recordkeeping The proposed training program establishes the basis for recurrent training at repair stations, the 2 proposed rule does not contain specific requirements for the length and content of the training. 3 The Board is concerned that the details and requirements for content and delivery of recurrent 4 training will be dependent on FAA advisory material, which is not enforceable. In contrast, the 5 Board notes that minimum standards addressing the duration and content of recurrent training 6 exist in regulations governing pilots, flight attendants, ground personnel involved in deicing 7 operations, operators of security screening equipment, airport fire and rescue personnel, and supervisory personnel administering a certificate holder's drug test program. The Safety Board believes that the currency of job-specific skills and knowledge is no less essential for mechanics and that a reasonable quantity of recurrent training should be specified in the final rule. Recordkeeping The FAA's proposed revisions in this section would require a repair station's records and reports to include the make, model, identification number, and serial number (when applicable) of the aircraft, airframe, aircraft engine, propeller, appliance, or component part of the article worked on, and copy of the maintenance release. The repair station would continue to be required to retain records for 2 years, with the record retention period based on the date the article was returned to service as opposed to the date that maintenance was performed. The Safety Board concurs with the proposed revisions in this section, and based on the FAA's intent to eliminate the distinction between domestic and foreign repair stations, it is the Board's understanding that the foreign repair stations would be subject to the same recordkeeping requirements outlined in the proposed revisions. Safety Recommendation A-96-79, issued as a result of the ValuJet Atlanta accident, specifically addressed this issue by asking the FAA to revise 14 CFR Part 145 to require facilities operating under Subpart C: Foreign Repair Stations to adhere to the same recordkeeping as domestic repair stations. The proposed rule, if implemented, would satisfy the intent of the Board's Safety Recommendation A-96-79, which is currently classified "Open-Acceptable Response." Foreign Repair Stations In its analysis of Part 145, the FAA concluded that, with few exceptions, no basic distinction exists between the regulations governing domestic or foreign repair stations. Based on that conclusion, the proposed rule removes the separate subpart on foreign repair stations that currently exists in the regulations. The Safety Board agrees that the requirements for safe aircraft maintenance should not depend on the business location of the repair station. A high level of technical skill, calibrated equipment, airworthy parts, and quality work processes are necessary for any repair station to conduct aviation maintenance. However, the procedures for ensuring regulatory compliance may be affected by the foreign location of a repair facility. Currently, FAA principal maintenance inspectors conduct certification and inspection of foreign repair stations. The proposed rule would also allow the FAA Administrator to base certification and inspection of foreign repair stations on bilateral aviation safety agreements (BASAs) according to maintenance implementation procedures (MIPs) between the United States and the national aviation authority of foreign countries. Under these international agreements, Part 145 certificates can be issued to foreign repair stations based on the national aviation authority demonstrating that the repair station complies with Part 145. Advisory Circular (AC) 145-7 addresses the issuance of repair stations' certificates to maintenance organizations approved by the Joint Aviation Authorities (JAA). There are nearly 300 FAA-certified foreign repair stations in more than 60 countries that work on U.S. transport category aircraft. BASAs currently exist with 12 countries, and in another 4 countries, agreements have been proposed but have not been executed with implementation procedures. MIPs currently exist with just Ireland and Germany. For western European countries, where safety records are nearly identical to those in the United States, it may be acceptable to rely on a foreign aviation authority's determination that a repair station complies with Part 145. However, the Safety Board is concerned that there will be many locations where economic incentives and available labor are conducive to repair station business but the country's inspection and safety oversight practices may not meet U.S. standards. The FAA currently assigns about 50 maintenance inspectors to foreign repair stations, and reliance on the findings of foreign authorities pursuant to BASAs would free up some portion of those resources for domestic oversight. However, under BASAs, the MIPs must be evaluated and monitored by those same FAA inspectors. It would appear that the FAA is focusing on a resource solution rather than a safety solution, and that overall, the resource savings would not appear to be substantial. Surveillance is one of the FAA's primary means for ensuring that repair stations continually meet the aviation regulations. The Safety Board is concerned that an inspection structure based on many different foreign governments performing compliance inspections in accordance with bilateral agreements has a risk for inconsistency and reduced assurances of safety. The Safety Board believes that the same level of oversight should be applied to foreign repair stations and domestic repair stations, and that maintenance repair work on U.S. flag carriers should be under the direct oversight of FAA maintenance inspectors. The Safety Board does not agree that the proposed rule places foreign and domestic repair stations under similar safety regulations because the proposed process for ensuring compliance with the regulations could differ from country to country and may not always be adequate. We appreciate the opportunity to comment on this important rulemaking activity and urge the FAA to proceed on this rulemaking as quickly as possible.

From: NTSB
To: FAA
Date: 5/17/1983
Response: The Safety Board continues to believe that actions such as those proposed in these recommendations 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. Cyrocki, the investigator in charge of a group appointed by the FAA to review air carrier maintenance practices in 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 carriers and repair stations to determine the adequacy of their own maintenance procedures. The FAA disagreed with the Safety Board position that manufacturers's maintenance procedures should be the basis from which air carrier deviations are evaluated; and the FAA also stated support for current industry Maintenance Steering Group (MSG)/FAA Maintenance Review Board procedures involving the FAA, manufacturer and operator. . . . based on the foregoing discussion of maintenance procedure 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 FAA 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 SUB JECTED 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 THS ACCIDENT, PERHAPS MORE THAN THE PROCEDURE ITSELF.

From: NTSB
To: FAA
Date: 6/13/1980
Response: Your response states that the responsibility for maintenance procedures resides with the air carrier and repair stations. This includesthe responsibility to assure the adequacy of maintenance programs and procedural changes. It was this type of cursory surveillance activity which allowed the variant spherical bearing replacement procedure to be practiced by air carriers. This safety recommendation is intended to assure a proper review of maintenance procedures differing from those developed by the manufacturer for removal, installation, or work in the vicinity of structurally significant items. This recommendation has been classified as Open-- Unacceptable Action. We request reconsideration of this recommendation to intensify surveillance and review manufacturer recommendations.

From: FAA
To: NTSB
Date: 3/20/1980
Response: FAA LTR: COMMENT ON A-79-102(A): SUCH A REQUIREMENT IS ALREADY IMPOSED BY THE STATUTORY PROVISION OF THE FEDERAL AVIATION ACT OF 1958. SPECIFICALLY, SECTION 605(A), AND FAR 121.363 AND 135.413 PLACE RESPONSIBILITY DIRECTLY UPON THE CARRIERS FOR MAINTAINING THEIR AIRCRAFT IN AN AIRWORTHY CONDITION. ADDITIONALLY, FAR 121.373 AND 135.431 REQUIRE CARRIERS TO PERFORM CONTINUING ANALYSIS OF THEIR MAINTENANCE PROGRAMS FOR ADEQUACY. IN PROPER EXERCISE OF THAT RESPONSIBILITY, IT IS INCUMBENT UPON AIR CARRIERS AND REPAIR STATIONS DOING WORK FOR A CARRIER TO ANALYZE THEIR MAINTENANCE PRACTICES FOR POSSIBLE HAZARD TO STRUCTURE. COMMENT ON A-79-102(B): PRESENT REGULATION FAR 121.369(B) (1) REQUIRES THAT THE CARRIER SET FORTH ITS MAINTENANCE PROCEDURES IN A MANUAL. FAR 121.137 REQUIRES THAT THE MANUAL AND CHANGES BE PROVIDED TO THE FAA. THIS PROCESS DOES NOT SIGNIFY FAA APPROVAL OF EACH AND EVERY MAINTENANCE PRACTICE, OR PROCEDURE, BUT IS ONE WHICH IS DESIGNED TO ENSURE THAT A CARRIER HAS CLEARLY SET FORTH ITS MAINTENANCE PROCEDURES. IT IS THE DUTY OF THE CARRIER TO ENSURE THAT THESE PROCEDURES, AS PART OF SEVERAL ASPECTS OF ITS MAINTENANCE PROGRAM, ARE APPROPRIATE TO MAINTAINING THE HIGHEST POSSIBLE DEGREE OF SAFETY.