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Safety Recommendation Details

Safety Recommendation A-88-103
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: REQUIRE THE AIRCRAFT EVALUATION GROUP DURING THE TYPE CERTIFICATION PROCESS OF TURBOPROPELLER AIRPLANES TO REVIEW CAREFULLY THE DESIGN OF PROPELLER PITCH CONTROLS IN ORDER TO IDENTIFY AND ESTABLISH APPROPRIATE FLIGHTCREW TRAINING GUIDELINES AND EMPHASIS ON THE PROPER USE OF THESE CONTROLS TO PREVENT INADVERTENT OPERATION IN THE BETA MODE IN FLIGHT WHERE PROHIBITED BY THE AIRPLANE MANUFACTURER.
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: 7/23/1991
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Flightcrew, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/23/1991
Response: Safety Recommendation A-88-103 asked the FAA to carefully review the design of propeller pitch controls during the type certification process of turbopropeller airplanes in order to identify and establish appropriate flightcrew training guidelines emphasizing the proper use of these controls. We note that the FAA has issued Air Carrier Operations Bulletin (ACOB) No. 89-1, "Inadvertent Operations in Beta Mode/Turbopropeller Airplanes." Because the FAA has assured the Safety Board that all aircraft evaluation groups have received copies of this ACOB, and that these groups have been directed to carefully review the design of propeller pitch controls during the type certification process of turbopropeller airplanes, we have classified Safety Recommendation A-88-103 as "Closed--Acceptable Action."

From: FAA
To: NTSB
Date: 3/18/1991
Response: THE FAA ISSUED AIR CARRIER OPERATIONS BULLETIN (ACOB) NO. 89-1, INADVERTENT OPERATIONS IN BETA MODE/TURBOPROPELLER AIRPLANES. THE FAA PROVIDED THE SAFETY BOARD WITH A COPY OF THE ACOB ON 4/19/89. ALL AIRCRAFT EVALUATION GROUPS RECEIVED A COPY OF THE ACOB AND WERE REQUESTED TO CAREFULLY REVIEW THE DESIGN OF PROPELLER PITCH CONTROLS DURING THE TYPE CERTIFICATION PROCESS OF TURBOPROPELLER AIRPLANES.

From: NTSB
To: FAA
Date: 7/27/1989
Response: Safety Recommendation A-88-103 called upon the FAA to require aircraft evaluation groups to review the design of propeller pitch controls to identify and establish flightcrew training guidelines during the type certification process. While the Safety Board appreciates the content of air carrier operations bulletin (ACOB) on inadvertent operation in beta mode, we need further assurance by the FAA that the evaluation groups have been specifically informed of the need for careful attention to the evaluation of the design of propeller pitch controls. Pending further response, this safety recommendation will be held in an "Open--Acceptable Action" status.

From: NTSB
To: FAA
Date: 5/19/1989
Response: Regarding Safety Recommendation A-88-103, the Safety Board notes that the FAA plans to issue an ACOB to reemphasize the proper use of propeller pitch controls. Safety Recommendation A-88-103 is classified as "Open--Acceptable Action" pending receipt of the ACOB.

From: FAA
To: NTSB
Date: 4/19/1989
Response: THE FAA ISSUED ACOB NO. 89-1, INADVERTENT OPERATION IN BETA MODE/TURBOPROPELLER AIRPLANES, TO ADDRESS THESE SAFETY RECOMMENDATIONS. THIS ACOB REEMPHASIZES THE PROPER USE OF PROPELLER PITCH CONTROLS AND REQUESTS THAT PRINCIPAL OPERATIONS INSPECTORS REVIEW FLIGHT CONTROL TRAINING PROGRAMS OF TURBOPROPELLER AIRPLANE OPERATORS TO ENSURE THAT APPROPRIATE INFORMATION IS PROVIDED TO PREVENT INADVERTENT OPERATION IN THE BETA MODE IN FLIGHT.

From: FAA
To: NTSB
Date: 1/12/1989
Response: THE FAA'S AIRCRAFT EVALUATION GROUPS (AEG), IN CONJUNCTION WITH THE AIRCRAFT CERTIFICATION OFFICES, CURRENTLY EVALUATE THE DESIGN OF CONTROLS FOR COMPLIANCE WITH REGULATIONS AND INDUSTRY STANDARDS. THE AEG'S ESTABLISH TRAINING REQUIREMENTS BASED ON AN EXTENSIVE EVALUATION OF THE OPERATIONAL CHARACTERISTICS. THE FAA WILL ISSUE AN ACOB TO REEMPHASIZE PROPER USE OF PROPELLER PITCH CONTROLS. IT IS ANTICIPATED THAT THE ACOB WILL BE ISSUED IN FEBRUARY 1989. I WILL PROVIDE THE BOARD WITH A COPY OF THE ACOB AS SOON AS IT IS ISSUED.