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Safety Recommendation Details

Safety Recommendation A-94-067
Details
Synopsis: ON JANUARY 7, 1994, A JETSTREAM J4101, N304UE, OPERATED BY ATLANTIC COAST AIRLINES OF STERLING, VIRGINIA, AS UNITED EXPRESS FLIGHT 6291, WAS ON A SCHEUDLED COMMUTER FLIGHT FROM DULLES INTERNATIONAL AIRPORT TO PORT COLUMBUS INTERNATIONAL AIRPORT, IN GAHANNA, OHIO. AT 2321 EASTERN STANDARD TIME, WHILE ON AIR INSTRUMENT LANDING SYSTEM (ILS) APPROACH TO RUNWAY 28L, THE AIRPLANE STRUCK A CONCRETE BLOCK BUILDING THAT WAS ABOUT 1.2 MILES EAST OF THE RUNWAY. THE PILOT, CO-PILOT, FLIGHT ATTENDANT, AND TWO PASSENGERS WERE FATALLY INJURED, AND THE THREE OTHER PASSENGERS, A HUSBAND AND WIFE AND THEIR 5-YEAR-OLD DAUGHTER, SUSTAINED MINOR INJURIES. THE AIRPLANE WAS DESTROYED BY POSTCRASH FIRE.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: IMMEDIATELY NOTIFY ALL OPERATORS OF THE SAFETY BOARD'S FINDING, INCLUDING THE U.S. DEPARTMENT OF DEFENSE AND FOREIGN GOVERNMENTS, AND REQUIRE ALL OPERATORS WHOSE AIRCRAFT HAVE THE AFFECTED PACIFIC SCIENTIFIC SAFETY BELT BUCKLES TO INFORM PASSENGERS AND CREWMEMBERS ABOUT THE NEED TO ALIGN THE BUCKLE INSERT TO ASSURE EASY RELEASE OF THE SAFETY BELTS. (URGENT)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: COLUMBUS, OH, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA94MA027
Accident Reports: Stall and Loss of Control on Final Approach, Atlantic Coast Airlines, Inc./ United Express Flight 6291 Jetstream 4101, N304UE
Report #: AAR-94-07
Accident Date: 1/7/1994
Issue Date: 3/14/1994
Date Closed: 11/1/1994
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 11/1/1994
Response: (CLOSED IN GREENSHEET) SUBSEQUENT CONVERSATIONS WITH THE FAA THAT IT INTENDS TO TAKE NO FURTHER ACTION ON THIS RECOMMENDATION. THEREFORE, THE BOARD NOW CLASSIFIES A-94-67 "CLOSED--UNACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 10/20/1994
Response: ON 10/7/94, THE FAA ISSUED AIRWORTHINESS DIRECTIVE 94-21-06 APPLICABLE TO CERTAIN PACIFIC SCIENTIFIC LAP BELT ASSEMBLIES & RESTRAINT SYSTEMS. THIS AD REQUIRES REMOVAL OF CERTAIN LAP BELT ASSEMBLIES & RESTRAINT SYSTEMS & REPLACEMENT WITH NEW DESIGN ASSEMBLIES IN ACCORDANCE WITH PACIFIC SCIENTIFIC SERVICE BULLETIN NO. 1108435-25-01 DATED 4/28/94. I HAVE ENCLOSED A COPY OF THE AD FOR THE BOARD'S INFO. I BELIEVE THAT THIS AD ADDRESSES RECOMMENDATIONS, AND I CONSIDER THE FAA'S ACTION TO BE COMPLETED.

From: NTSB
To: FAA
Date: 9/1/1994
Response: THE BOARD NOTES THAT THE FAA BELIEVES THAT THE INTENT OF THIS RECOMMENDATION IS SATISFIED BY SERVICE BULLETIN 1108435-25-01, ISSUED BY THE PACIFIC SCIENTIFIC COMPANY ON 4/28/94, WHICH NOTIFIES OPERATORS OF DEFICIENCIES WITH THE BUCKLES & INFORMS THEM OF A FORTHCOMING AIRWORTHINESS DIRECTIVE TO MANDATE REPLACEMENT OF THE BUCKLES. HOWEVER, NEITHER THE SB NOR THE FAA HAVE ADDRESSED THE NEED FOR OPERATORS TO WARN PASSENGERS OF THE POSSIBILITY OF IN-SERVICE BUCKLES NOT OPERATING PROPERLY. THE INTENT OF THE RECOMMENDATION CAN ONLY BE MET BY REQUIRING OPERATORS TO INFORM CREWMEMBERS & PASSENGERS OF THE NEED TO ALIGN THE BUCKLE INSERT TO ASSURE THAT THE SEATBELT WILL RELEASE. THE BOARD BELIEVES THAT THE FAA SHOULD RECONSIDER ITS POSITION, & CLASSIFIES A-94-67 "OPEN--UNACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 6/6/1994
Response: PACIFIC SCIENTIFIC HAS ISSUED A SERVICE BULLETIN THAT WAS SENT TO APPROPRIATE OPERATORS & IS PROVIDING REDESIGNED REPLACEMENT BUCKLES TO OPERATORS WITH THE AFFECTED EQUIPMENT. THE DESIGN CHANGES TO THE SAFETY BELT BUCKLES WERE DEVELOPED BY THE MANUFACTURER, IN COOPERATION WITH FAA ENGINEERS & THE CIVIL AEROMEDICAL INSTITUTE. THE MANUFACTURER IS AGGRESSIVELY PURSUING THE REPLACEMENT OF AN AIRWORTHINESS DIRECTIVE TO REQUIRE MANDATORY REPLACEMENT OF THE BUCKLES WITHIN 90 DAYS. IF THE FAA ISSUES AN AIRWORTHINESS DIRECTIVE IT WILL BE SENT TO ALL OPERATORS OF AFFECTED AIRCRAFT. IN THE MEANTIME, THE FAA BELIEVES THE MANUFACTURERS NOTIFICATION TO ALL OPERATORS IS SUFFICIENT INTERIM ACTION.