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Safety Recommendation Details

Safety Recommendation A-88-097
Details
Synopsis: ON MARCH 4, 1987, FISCHER BROS. AVIATION, INC., DOING BUSINESS AS NORTHWEST AIRLINK, FLIGHT 2268, A CONSTRUCCIONES AERONAUTICAS, S.A. (CASA) C-212-CC, N160FB, CRASHED JUST INSIDE THE THRESHOLD OF RUNWAY 21R AT THE DETROIT METROPOLITAN WAYNE COUNTY AIRPORT IN ROMULUS, MICHIGAN. NINE OF THE 19 PERSONS ON BOARD WERE KILLED. THE AIRPLANE WAS DESTROYED BY IMPACT FORCES AND POSTCRASH FIRE. ON MAY 8, 1987, EXECUTIVE AIR CHARTER, INC., DOING BUSINESS AS AMERICAN EAGLE, FLIGHT 5452, A CASA C-212-CC, CRASHED SHORT OF RUNWAY 9 WHILE ON A VISUAL APPROACH TO THE AIRPORT AT MAYAGUEZ, PUERTO RICO, IN VISUAL METEOROLOGICAL CONDITIONS. BOTH CREWMEMBERS WERE KILLED AND THE FOUR PASSENGERS SUSTAINED MINOR INJURIES. THE AIRPLANE WAS DESTROYED BY IMPACT FORCES AND POSTCRASH FIRE.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: CONDUCT A SPECIAL SURVEILLANCE INSPECTION OF APPROVED HARTZELL PROPELLER OVERHAUL FACILITIES AND OF OTHER PROPELLER MANUFACTURER OVERHAUL FACILITIES AS SERVICE DIFFICULTY HISTORICAL DATA AND EXPERIENCE DICTATE TO DETERMINE THAT THE PROPER QUALITY CONTROL ORGANIZATION AND PROCEDURES ARE IN PLACE AND ARE BEING FOLLOWED.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: ROMULUS, MI, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA87MA022
Accident Reports: Fischer Bros. Aviation, Inc. dba NW Airlink, Flight 2268 Construcciones Aeronautics, S.A. (CASA) C-212-CC, N160FB
Report #: AAR-88-08
Accident Date: 3/4/1987
Issue Date: 10/17/1988
Date Closed: 8/15/1990
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 8/15/1990
Response: In Safety Recommendation A-88-97 the FAA was asked to conduct a special surveillance inspection of approved Hartzell Propeller overhaul facilities and other propeller manufacturer overhaul facilities, as service difficulty historical data and experience dictate, to determine that the proper quality control organization and procedures are in place and are being followed. We note that the FAA has conducted an inspection of Hartzell Propeller certificated repair stations and has issued expanded guidance for the conduct of in-depth inspections of Part 145 repair stations. The Safety Board has reviewed the documents provided by the FAA pertaining to instructions to inspectors for repair stations and is satisfied that the intent of this recommendation has been fully accomplished. Safety Recommendation A-88-97 is classified as "Closed--Acceptable Action."

From: FAA
To: NTSB
Date: 4/10/1990
Response: "--ON MARCH, 1989, THE FAA ISSUED EXPANDED GUIDANCE FOR THE CONDUCT OF INDEPTH INSPECTIONS OF PART 145 REPAIR STATIONS. THIS DOCUMENT, WHICH WAS A BASIS FOR THE RECENT NASIP INSPECTION OF THE HARTZELL PROPELLER, INC., REPAIR FACILITY, PROVIDES DETAILED INSTRUCTIONS TO INSPECTORS FOR REPAIR STATION INSPECTIONS.--'

From: NTSB
To: FAA
Date: 1/9/1990
Response: Safety Recommendation A-88-97 concerns special surveillance inspections of Hartzell and other propeller overhaul facilities. The Safety Board notes the FAA statement that Service Difficulty Reports (SDR) and other information is regularly used for inspection purposes. However, as stated in the Safety Board accident report that prompted this safety recommendation (NTSB/AAR-88/08): The Safety Board regards the installation of incorrect parts as a serious problem, and evidently, this was not an isolated case. ... The Board attributed the failure of the propeller manufacturer's service facility to install the correct parts as an oversight on the part of an assembly worker and a failure of management to establish a sound quality control system to identify and verify the correct parts for use with replacement assemblies. The weakness in the repair station's quality control system should have been discovered in FAA's certification and surveillance of the facility. The Safety Board found that "regularly scheduled surveillance" was inadequate more than once. Therefore, the Safety Board cannot accept the FAA position that "regularly scheduled surveillance ... addresses this safety recommendation completely." The Safety Board would like to know the outcome of the "special emphasis inspection" mentioned in the FAA letter of January 12, 1989, and what other measures have been enacted to insure that this cause for error will not recur. Pending further information, Safety Recommendation A-88-97 is classified as "Open-- Unacceptable Action."

From: FAA
To: NTSB
Date: 9/15/1989
Response: IN RESPONSE TO THE SAFETY BOARD'S RECENT REQUEST, THE FAA INSPECTORS ALWAYS USE THE INFORMATION DERIVED FROM THE SDR TO ASSIST THEM IN REGULARLY SCHEDULED SURVEILLANCE OR COMPLETE INSPECTIONS.

From: NTSB
To: FAA
Date: 5/19/1989
Response: Safety Recommendation A-88-97 concerns special surveillance inspections of Hartzell and other propeller overhaul facilities. The Safety Board notes that the FAA has scheduled a special inspection of the Hartzell facility. The Safety Board would like to know specifically what actions the FAA has taken or will take to review the service difficulty history and experience of other manufacturers, as recommended. Pending these actions, Safety Recommendation A-88-97 is classified as "Open-- Acceptable Action."

From: FAA
To: NTSB
Date: 1/12/1989
Response: THE FAA CURRENTLY CONDUCTS ROUTINE SURVEILLANCE OF REPAIR STATIONS TO ENSURE THAT PROPER PROCEDURES ARE FOLLOWED. IN ADDITION TO THE ROUTINE SURVEILLANCE, HARTZELL PROPELLER, INC., REPAIR STATION NO. 4389, IS SCHEDULED FOR A SPECIAL EMPHASIS INSPECTION DURING THE THIRD QUARTER OF FISCAL YEAR 1989. I PLAN NO FURTHER ACTION ON THIS SAFETY RECOMMENDATION.