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General Aviation Safety
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.
THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REVIEW THE TRAINING OF AND THE SURVEILLANCE PROCEDURES FOLLOWED BY FEDERAL AVIATION ADMINISTRATION INSPECTORS AND MODIFY THEM IF NECESSARY TO PROVIDE INCREASED EMPHASIS ON THE PROVISIONS OF 14 CFR PART 135 WITH REGARD TO OCCUPANT SAFETY AND SAFETY EQUIPMENT.
Original recommendation transmittal letter:
Closed - Acceptable Action
PROVIDENCE, RI, United States
Pilgrim Airlines Flight 458, DeHavilland DHC-6-100, N127PM
Addressee(s) and Addressee Status:
FAA (Closed - Acceptable Action)
Oversight, Training and Education
Safety Recommendation History
The Board is encouraged that FAA Order 8430.lC contains new emphasis on cabin safety. We also are pleased to receive your assurance that many principal inspectors of Part 135 operations have attended cabin safety workshops during air carrier indoctrination courses. The Board notes that a new training curriculum, which will include cabin safety topics, is being developed for principal operations inspectors and that the training will be required of all principal inspectors of Part 121 and Part 135 operations. The Board further notes that the program which you described includes the development of the training curriculum and the training of all principal inspectors. We would appreciate being advised when some of the Board's staff could attend these courses. In light of the overall review and modifications to information and procedures provided FAA inspectors, the Board has placed Safety Recommendation A-82-73 in a "Closed--Acceptable Action" status.
FAA Order 8430.lC, "Inspection and Surveillance Procedures - Air Taxi Operators/Commuter Air Carriers and Commercial Operators," has been published. Enclosed for the Board's information and file is a copy of this Order. Changes contained in this Order address NTSB Recommendations A-82-70, and -73 and, more specifically, provide new or additional guidance to FAA inspectors concerning oral briefings and briefing cards, location and use of fire extinguishers, articulation by crewmembers of passenger briefings, and emphasis on cabin safety and surveillance. These changes may be found in Chapter 4, Inspection and Surveillance Procedures. We believe that the FAA has been responsive to the Board's recommendations as well as fulfilling its own responsibilities in this area.
FAA LETTER: FAA ORDER 8430.1C ENTITLED "INSPECTION AND SURVEILLANCE PROCEDURES - AIR TAXI OPERATORS/COMMUTER AIR CARRIERS AND COMMERCIAL OPERATORS" WAS EXTENSIVELY REVISED AND REISSUED ON MAY 20, 1983.
Your response indicates that the FAA has established a formal cabin safety program in its air carrier indoctrination courses. Also, that, since April of this year, a cabin safety workshop has become available to flight standards inspectors and that about 25 inspectors to date have participated in this program. You also state that the revision to Order 8430.1B will include emphasis on cabin safety surveillance. The Safety Board believes that the anticipated revision to FAA Order 8430.1B should provide a basic awareness of cabin safety and occupant survival issues to general aviation inspectors whose duties include surveillance of air taxi and commuter operators. The cabin safety workshops also appear to have merit. It is the Board's understanding that the material presented at these workshops is intended to fully acquaint inspectors regarding cabin safety issues and provide them with a cabin safety checklist to facilitate the completion of en route inspection reports. Although these workshops are aimed primarily at air carrier inspectors, they also would be appropriate for air taxi and commuter inspectors if the material and checklists were oriented towards air taxi/commuter operations. Notwithstanding these excellent steps, the Safety Board does not believe that the FAA has been responsive to Safety Recommendation A-82-73 for the following reasons: (1) Air carrier indoctrination courses are not usually attended by general aviation inspectors. Therefore, they do not benefit from the cabin safety program Data Source: NTSB Recommendations to FAA and FAA Responses FAA has instituted. (2) Of the approximately 25 field inspectors who attended the cabin safety workshop at the Civil Aeromedical Institute, only three attendees were general aviation inspectors; all others were air carrier inspection personnel. The Board also notes that these workshops are not mandatory for inspection personnel. The Safety Board is concerned that general aviation inspectors are not receiving cabin safety training comparable to that received by air carrier inspectors and that the FAA presently has no program in place to provide such training. Therefore, the Safety Board requests that the FAA reevaluate its response to Safety Recommendation A-82-73. The Board urges the FAA to consider initiating a program for training general aviation inspectors comparable to that for air carrier inspectors; that it provide its general aviation inspection personnel cabin safety information material which is oriented towards air taxi/commuter operations; and that it initiate mandatory attendance of general aviation inspectors at the cabin safety workshops provided by the Civil Aeromedical Institute. Pending FAA's further response to this recommendation, the Board has placed Safety Recommendation A-82-73 in an "Open-- Unacceptable Action" status.
FAA LETTER: WITHIN THE LAST YEAR, THE FAA HAS INITIATED A FORMAL CABIN SAFETY PROGRAM AT THE MIKE MONRONEY AERONAUTICAL CENTER. THE PROGRAM OF INSTRUCTION IS GIVEN IN BOTH THE AIR CARRIER INDOC TRINATION AND ABBREVIATED AIR CARRIER INDOCTRINATION COURSES. AS OF APRIL 16, 1982, A CABIN SAFETY WORKSHOP CONDUCTED BY THE CIVIL AEROMEDICAL INSTITUTE AT THE MIKE MONRONEY AERONAUTICAL CENTER BECAME AVAILABLE TO FLIGHT STANDARDS FIELD INSPECTORS. TO DATE, APPROXIMATELY 25 FIELD INSPECTORS HAVE PARTICIPATED IN THIS PROGRAM. THE REVISION IN PROGRESS TO ORDER 8430.1B WILL INCLUDE EMPHASIS ITEMS ON CABIN SAFETY SURVEILLANCE. THE TENTATIVE TARGET DATE FOR ISSUANCE OF THE REVISED ORDER IS DECEMBER 1982. A COPY OF AMENDED ORDER 8430.1B WILL BE FORWARDED TO THE BOARD WHEN PUBLISHED.
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