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Safety Recommendation Details

Safety Recommendation A-82-072
Details
Synopsis: ON FEBRUARY 21, 1982 AT 1533 E.S.T., PILGRIM AIRLINES FLIGHT 458, A SCHEDULED COMMUTER PASSENGER FLIGHT, MADE AN EMERGENCY LANDING ON THE NORTHWEST BRANCH OF THE SCITUATE RESERVOIR NEAR PROVIDENCE, RHODE ISLAND, AFTER A FIRE ERUPTED IN THE COCKPIT WHILE THE AIRCRAFT WAS EN ROUTE UNDER INSTRUMENT CONDITIONS BETWEEN GROTON, CONNECTICUT, AND BOSTON, MASSACHUSETTS, AT 4,000 FEET. THE FIRE, WHICH SPREAD FROM THE COCKPIT TO THE CABIN IN FLIGHT, DESTROYED THE AIRCRAFT AFTER IMPACT. THE CAPTAIN AND FIRST OFFICER WERE SERIOUSLY INJURED. ONE PASSENGER WAS KILLED, EIGHT PASSENGERS HAD SERIOUS INJURIES, AND ONE PASSENGER SUSTAINED MINOR INJURIES.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: AMEND 14 CFR 135.155 TO MAKE THE REQUIREMENTS REGARDING THE ACCESSIBILITY AND LOCATION OF FIRE EXTINQUISHERS IN PASSENGER COMPARTMENTS OF AIRCRAFT IN COMMUTER SERVICE AT LEAST AS STRINGENT AS THE REQUIREMENTS IN 14 CFR 91.193 (C)(4).
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Aviation
Location: PROVIDENCE, RI, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA82AA016
Accident Reports: Pilgrim Airlines Flight 458, DeHavilland DHC-6-100, N127PM
Report #: AAR-82-07
Accident Date: 2/21/1982
Issue Date: 7/27/1982
Date Closed: 10/26/1987
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 10/26/1987
Response: We are pleased to receive a copy of the FAA's Order 8430.1D. We note that Chapter 7, section 149 adequately addresses the Safety Board's concern expressed in this recommendation. Safety Recommendation A-82-72 is now classified as "Closed-- Acceptable Alternate Action."

From: FAA
To: NTSB
Date: 9/10/1987
Response: ON OCTOBER 12, 1984, AN ADVANCE COPY OF FAA ORDER 8430.1D WAS PROVIDED TO THE BOARD. CHAPTER 7, SECTION 149 (PAGE 181) ADDRESSES THE ACCESSIBILITY AND LOCATION OF SAFETY EQUIPMENT. I CONSIDER THE FAA'S ACTION TO BE COMPLETED ON THIS RECOMMENDATION. I TRUST THAT THIS ACTION WILL MEET THE BOARD'S APPROVAL.

From: NTSB
To: FAA
Date: 11/22/1983
Response: The Board is pleased to learn that Change 1 will be issued to FAA Order 8430.lC to require air taxi and commuter operators to identify storage locations of fire extinguishers which are located in less than obvious locations in passenger compartments. Your letter also states that Change 1 will emphasize to principal inspectors that the term "conveniently located," as used in Part 135.155(c) in reference to fire extinguishers, implies that the fire extinguishers also are to be "accessible" for use in an emergency. The Board believes that these instructions to principal inspectors will reinforce to both inspectors and operators the importance of the need for quick access to fire extinguishers by crew and passengers. Although Change 1 to FAA Order 8430.lC will attempt to clarify and to make synonymous the words "convenient" and "accessible", the Board believes it preferable that Part 135.155(c) be amended to use the word "accessible" instead of the current word "convenient." As discussed in the Board's letter of May 24, 1983, we still believe that Part 91.139(c)(4) is far more specific than Part 135.155(c) with regard to the accessibility of fire extinguishers and that amending Part 135.155(c) is preferable in the long term to preclude operators from misinterpreting the intent of the regulations. Furthermore, an operator not having access to FAA Order 8430.lC will be unaware that FAA inspectors will be interpreting the words "convenient" and "accessible" synonymously. We again urge the FAA to reconsider this recommendation. Although we have expressed concern about the wording of FAA Order 8430.lC, and have suggested that a change in 14 CFR 135 would be a more effective solution, we have accepted the order as a means to provide the information needed. The Safety Board has placed Safety Recommendation A-82-72 in an "Open--Acceptable Alternate Action" status pending issuance of Change 1 to FAA Order 8430.1C and the FAA's further consideration of this recommendation.

From: FAA
To: NTSB
Date: 7/14/1983
Response: FAA LETTER: IN RESPONSE TO RECOMMENDATION A-82-72, THE FAA BELIEVES THAT THE REGULATORY REQUIREMENTS IN 14 CFR 135 ARE ADEQUATE IN ADDRESSING THE LOCATION AND USE OF FIRE EXTINGUISHERS. HOWEVER, CHANGE 1 TO ORDER 8430.1C IS CURRENTLY BEING DRAFTED. THIS CHANGE WILL INCLUDE DIRECTIONS TO PRINCIPAL INSPECTORS TO REQUIRE OPERATORS TO IDENTIFY STORAGE LOCATIONS OF FIRE EXTINGUISHERS WHEN THEIR LOCATIONS ARE LESS THAN OBVIOUS. IN ADDITION, THIS CHANGE WILL EMPHASIZE TO THE PRINCIPAL INSPECTORS THAT THE WORDS "CONVENIENTLY LOCATED" IN PART 135.155(C) ALSO INFER THE EXTINGUISHERS ARE ACCESSIBLE.

From: NTSB
To: FAA
Date: 5/24/1983
Response: Your response indicates that an amendment to Part 135.155 is not appropriate since it and Part 135.117 adequately provide for the "convenient" location of fire extinguishers and the briefing of passengers on the location and use of fire extinguishers. The Board does not agree for the following reasons: The requirements of Parts 135.117 and 155 notwithstanding, Part 91.193(c)(4) is specific in requiring that hand fire extinguishers must be readily accessible and, unless the locations of the fire extinguishers are obvious, their stowage locations are to be properly identified. The Board believes, and the Pilgrim Airlines accident vividly reinforces our belief, that passengers must be able to rapidly locate cabin fire extinguishers. Placards which identify the location of fire extinguishers in Part 135 aircraft will provide instant visual cues during emergency situations of where extinguishers can be found without having passengers refer to a briefing card or requiring them to remember the location of an extinguisher as described in the pretakeoff briefing. This can be especially critical in Part 135 aircraft in which there usually is no flight attendant trained in emergency procedures and who knows the location of emergency equipment. The Board notes that one passenger onboard the Pilgrim Airlines aircraft was a flightcrew member of a major U.S. air carrier. Although he had made this trip several times, had read the briefing card previously, and had heard the pretakeoff briefing, he was unaware that a fire extinguisher was located beneath the rearmost row of cabin seats. Based on the FAA's premise that the pretakeoff briefing and the safety cards are adequate, it would have been reasonable to expect this passenger to remember where the fire extinguisher was located even though the safety card did not show its location. However, this passenger, although he had been exposed to several oral briefings, was not able to recall that a fire extinguisher was in the rear cabin. He did recall that there was an extinguisher in the cockpit. The Board believes that a requirement to mark the location of hand fire Data Source: NTSB Recommendations to FAA and FAA Responses extinguishers would not pose unreasonable maintenance, logistics, or economic burdens upon Part 135 operators. The second issue addressed in this recommendation was the accessibility of hand fire extinguishers. Part 91.193(c)(4) states that hand fire extinguishers must be readily accessible. Part 135.155(c) states "At least one hand fire extinguisher must be conveniently located...." It is evident that there is a disparity in the requirements. A fire extinguisher, or indeed any item intended for use in an emergency, can be installed in a "convenient" cabin location which may well be inaccessible or otherwise extremely difficult to reach in an emergency. In the Pilgrim Airlines accident, the cabin fire extinguisher was stowed against the rear cabin bulkhead and beneath the rear row of seats. Post accident investigation revealed that the extinguisher could be reached only after (1) the seat occupant vacated the seat; (2) the seat was folded against the bulkhead; and (3) a person knelt on the floor to release the extinguisher from its stowage clips. These steps are difficult enough for a trained person to perform, but they might be almost impossible for a passenger to perform in a stressful environment; i.e., when smoke, fire, or low light levels are present. The Board believes that the FAA should reconsider its evaluation of this recommendation. Pending such reconsideration, Safety Recommendation A-82-72 will be held in an "Open-Unacceptable Action" status.

From: FAA
To: NTSB
Date: 10/18/1982
Response: FAA LETTER: THE FAA HAS DETERMINED THAT AN AMENDMENT TO SECTION 135.155 IS NOT APPROPRIATE. THE "CONVENIENTLY LOCATED" REQUIREMENT IN SECTION 135.155 FOR FIRE EXTINGUISHERS, AND SUPPLEMENT THE ORAL BRIEFING BY PRINTED BRIEFING CARDS, EXCEED THE REQUIREMENTS OF SECTION 91.193 (C)(4). WE PLAN NO FURTHER ACTION ON THIS RECOMMENDATION.