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Safety Recommendation Details

Safety Recommendation A-85-076
Details
Synopsis: ABOUT 0805 ATLANTIC STANDARD TIME ON AUGUST 2, 1984, A PILATUS BRITTEN-NORMAN MODEL BN-2A-6 ISLANDER AIRPLANE, N589SA, CRASHED SHORTLY AFTER DEPARTING THE VIEQUES AIRPORT, VIEQUES, PUERTO RICO. THE AIRPLANE, WHICH IS MANUFACTURED PRINCIPALLY IN THE UNITED KINGDOM, WAS BEING OPERATED BY VIEQUES AIR LINK, INCORPORATED, IN AN AIR TAXI OPERATION. THE PILOT AND EIGHT PASSENGERS WERE KILLED. THE NATIONAL TRANSPORTATION SAFETY BOARD'S FINDINGS IN THE ACCIDENT INDICATE THAT THE AIRPLANE'S FUEL WAS CONTAMINATED BY WATER DURING REFUELING SHORTLY BEFORE TAKEOFF AND, AS A CONSEQUENCE, THE LEFT ENGINE LOST POWER SHORTLY AFTER TAKEOFF.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REQUIRE PILATUS BRITTEN-NORMAN TO PREPARE AND DISSEMINATE A SAFETY ADVISORY RELATING TO WATER IN THE FUEL TO ALL OPERATORS OF BN-2, BN-2A, BN-2B, BN-2T, AND BN-2A MK III MODEL AIRPLANES. THE ADVISORY, IN ADDITION TO OUTLINING THE CIRCUMSTANCES RELATING TO THE VIEQUES AIR LINK ACCIDENT OF AUGUST 2, 1984, AND THE CRITICALITY OF PROPER PREFLIGHT FUEL TANK DRAINAGE PROCEDURES, SHOULD URGE OPERATORS TO INCORPORATE BRITTEN-NORMAN MODIFICATION NB/M/350 IN THEIR AIRPLANES.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: VIEQUES, PR, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA84AA033
Accident Reports: Vieques Air Link, Inc., Britten- Norman BN-2A-6 Islander, N589SA
Report #: AAR-85-08
Accident Date: 8/2/1984
Issue Date: 9/25/1984
Date Closed: 9/24/1986
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Fuel Contamination

Safety Recommendation History
From: NTSB
To: FAA
Date: 9/24/1986
Response: We have reviewed Airworthiness Alert No. 95 of June 1986, and the FAA's Action Notice A 8430.3 dated May 1, 1986. The information and instructions contained in these documents do address preflight inspection procedures for fuel contamination and emphasize the need to drain fuel tank sumps before each flight. However, in view of the reluctance of the CAA-UK, and the FAA, to urge operators to incorporate the NB/M/350 modification in their airplanes, this recommendation is classified as "Closed--Unacceptable Action."

From: FAA
To: NTSB
Date: 6/3/1986
Response: "THE FAA CONCURS, IN PART, WITH THIS RECOMMENDATION AND WILL ISSUE AN AIRWORTHINESS ALERT WARNING THAT SOME AFM'S MAY HAVE OMITTED THE CHECK FOR FUEL CONTAMINATION BY DRAINING OF FUEL SUMPS DURING THE PREFLIGHT INSPECTION. THE ALERT WILL CALL TO THE ATTENTION OF THE PILOT/OPERATORS THAT THEY SHOULD MAKE A FUEL CONTAMINATION CHECK BEFORE THE FIRST FLIGHT OF THE DAY AND AFTER EACH REFUELING AS A MATTER OF GOOD AIRMANSHIP. AN ALERT HAS BEEN PREPARED FOR PUBLICATION IN THE JUNE 1986 ISSUE OF THE FAA'S GENERAL AVIATION AIRWORTHINESS ALERTS (ADVISORY CIRCULAR 43-16). A COPY OF THE ALERT WILL BE FORWARDED TO THE BOARD WHEN PUBLISHED. IN ADDITION, AND AS NOTED IN MY RESPONSE RECOMMENDATION A-85-74, THE FAA ISSUED ACTION NOTICE A 8430.3, FAR PART 135 PREFLIGHT CHECKS INVOLVING PILATUS BRITTEN-NORMAN LTD BN-2 SERIES AIRCRAFT, DATED MAY 1, 1986. THE NOTICE REQUESTS THAT ALL FAA PRINCIPAL OPERATIONS INSPECTORS WHO PERFORM SURVEILLANCE ON OPERATORS OF BRITTEN-NORMAN BN-2 SERIES AIRCRAFT REQUIRED THAT A PREFLIGHT CHECK FOR FUEL CONTAMINATION BE MADE BEFORE THE FIRST FLIGHT OF THE DAY AND AFTER EACH REFUELING OPERATION. THEY ARE ALSO ADVISED TO REVIEW THE CONTENTS OF THIS NOTICE WITH THEIR ASSIGNED CARRIERS AND REQUIRE THAT THESE OPERATORS INCORPORATE THE IMPORTANCE OF FUEL SUMPING OF THE BN-2 AIRCRAFT IN THEIR OPERATIONS MANUAL AND AIRCREW TRAINING PROGRAM. I CONSIDER THIS ALTERNATIVE ACTION TO BE RESPONSIVE TO THIS RECOMMENDATION."

From: FAA
To: NTSB
Date: 1/13/1986
Response: The FAA's investigation relative to these recommendations is continuing. Recommendation A-85-74 is being reviewed by the FAA's Central Region Flight Standards Division for its evaluation and comments. Recommendations A-85-73, -75, and -76 have been forwarded to the FAA's Brussels, Belgium, Aircraft Certification Office for evaluation and coordination with the United Kingdom Civil Airworthiness Authority and to the manufacturer Pilatus Britten-Norman, LTD. I anticipate that the FAA's investigation will be completed by March 20, 1986, and I will advise the Board of the FAA's further actions shortly thereafter.