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Safety Recommendation Details

Safety Recommendation A-90-171
Details
Synopsis: ON JULY 19, 1989, AT 1516, A DC-10-10, N1819U, OPERATED BY UNITED AIRLINES (UAL) AS FLIGHT 232, EXPERIENCED A CATASTROPHIC FAILURE OF THE NO. 2 TAIL-MOUNTED ENGINE DURING CRUISE FLIGHT. THE SEPARATION, FRAGMENTATION AND FORCEFUL DISCHARGE OF STAGE 1 FAN ROTOR ASSEMBLY PARTS FROM THE NO. 2 ENGINE LED TO THE LOSS OF THE THREE HYDRAULIC SYSTEMS THAT POWERED THE AIRPLANE'S FLIGHT CONTROLS. THE FLIGHTCREW EXPERIENCED SEVERE DIFFICULTIES CONTROLLING THE AIRPLANE, WHICH SUBSEQUENTLY CRASHED DURING AN ATTEMPTED LANDING AT SIOUX GATEWAY AIRPORT, IOWA. THERE WERE 285 PASSENGERS AND 11 CREWMEMBERS ONBOARD. ONE FLIGHT ATTENDANT AND 110 PASSENGERS WERE FATALLY INJURED.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: CONDUCT A COMPREHENSIVE EVALUATION OF AIRCRAFT AND ENGINE MANUFACTURERS' RECORDKEEPING AND INTERNAL AUDIT PROCEDURES TO EVALUATE THE NEED TO KEEP LONG-TERM RECORDS AND TO ENSURE THAT QUALITY ASSURANCE VERIFICATION AND TRACEABILITY OF CRITICAL AIRPLANE PARTS CAN BE ACCOMPLISHED WHEN NECESSARY AT ALL MANUFACTURNING FACILITIES.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: SIOUX CITY, IA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA89MA063
Accident Reports: United Airlines Flight 232 McDonnell Douglas DC-10-10‚Äč
Report #: AAR-90-06
Accident Date: 7/19/1989
Issue Date: 12/14/1990
Date Closed: 7/7/1993
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/7/1993
Response: THE BOARD NOTES THAT THE FAA ISSUED NOTICE N8120.13, VERIFICATION OF COMPLETENESS, ACCURACY, & TRACEABILITY OF MANUFACTURING & QUALITY RECORDS. THIS NOTICE REQUIRED CERTAIN FAA FIELD OFFICES TO CONDUCT A REVIEW & EVALUATION OF THE RECORDKEEPING PRACTICES & PROCEDURES OF ALL MANUFACTURERS OF AIRPLANES, HELICOPTERS, ENGINES, & PROPELLERS. THE RESULTS OF THE REVIEW COVERED FOUR TYPES OF PRODUCTION APPROVALS ISSUED BY THE AIRCRAFT CERTIFICATION SERVICE & INDICATED THAT ALL PRODUCTION APPROVAL HOLDERS WERE IN COMPLIANCE. MANY OF THEM RETAIN RECORDS FOR MORE THAN 2 YEARS & HAVE AN INTERNAL AUDIT PROGRAM. THE FAA CONCLUDED THAT THE CURRENT REGULATION IS INSUFFICIENT. THE FAA IS CONSIDERING A REGULATORY REVISION TO INCREASE THE RECORD RETENTION REQUIREMENTS & TO REQUIRE THAT ALL PRODUCTION APPROVAL HOLDERS ESTABLISH & MAINTAIN AN INTERNAL AUDIT PROGRAM. BASED ON THIS INFO, THE BOARD CLASSIFIES A-90-171 "CLOSED--ACCEPTABLE ACTION." HOWEVER, THE BOARD REQUESTS THAT THE FAA KEEP US INFORMED OF ANY REGULATORY REVISION CONCERNING THIS ISSUE.

From: FAA
To: NTSB
Date: 3/24/1993
Response: THE FAA AGREES WITH THIS RECOMMENDATION. ON APRIL 9, 1991, THE FAA ISSUED NOTICE N8121.13 VERIFICATION OF COMPLETENESS, ACCURACY, AND TRACEABILITY OF MANUFACTURING AND QUALITY RECORDS. THIS NOTICE REQUIRED CERTAIN FAA FIELD OFFICES TO CONDUCT A REVIEW AND EVALUATION OF THE RECORDKEEPING PRACTICES AND PROCEDURES FOR ALL MANUFACTURERS OF AIRPLANES, HELICOPTERS, ENGINES AND PROPELLERS. THE RESULTS OF THE REVIEW WERE ANALYZED TO DETERMINE THE ADEQUACY OF CURRENT FEDERAL AVIATION REGULATIONS.

From: NTSB
To: FAA
Date: 10/9/1991
Response:

From: FAA
To: NTSB
Date: 3/8/1991
Response: