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Safety Recommendation Details

Safety Recommendation A-94-069
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: AMEND TSO-C22F TO INCORPORATE PROCEDURES WHICH PLACE MATERIAL REPRESENTATIVE OF SOFT ABDOMINAL TISSUE BETWEEN THE TEST APPARATUS AND THE RELEASE BUCKLE TO ENSURE THAT SAFETY BELTS CAN BE RELEASED WHEN SUBJECTED TO LOADS SPECIFIED IN THE TSO.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: COLUMBUS, OH, United States
Is Reiterated: Yes
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: 4/13/1999
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 4/13/1999
Response: THE BOARD UNDERSTANDS THAT THE SAE S-9 COMMITTEE, WHICH IS RESPONSIBLE FOR ISSUES RELATING TO SEAT RESTRAINTS, REORGANIZED IN 1997. IN TELEPHONE CONVERSATIONS WITH BOTH FAA STAFF AND MEMBERS OF THE SAE S-9 COMMITTEE IN SEPTEMBER 1998, IT WAS INDICATED THAT THEY DO NOT INTEND TO CHANGE THE TSO OR THE SAE STANDARD TO REQUIRE THE MANDATORY USE OF A MATERIAL REPRESENTATIVE OF SOFT BODY TISSUE BETWEEN THE TEST APPARATUS AND THE RELEASE BUCKLE. BASED ON SURVIVOR TESTIMONY AND EXAMINATION OF THE SAME TYPE OF SAFETY BELT BUCKLES FOUND ON THE ACCIDENT AIRPLANE, THE BOARD BELIEVES THAT SEATBELT RELEASE MECHANISMS THAT ARE NOT TESTED WITH MATERIAL REPRESENTATIVE OF SOFT BODY TISSUE COULD POSSIBLY FAIL TO RELEASE AFTER BEING EXPOSED TO ACCIDENT FORCES. BECAUSE THE FAA'S ACTIONS DO NOT MEET THE INTENT OF A-94-69, IT IS CLASSIFIED "CLOSED--UNACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 4/30/1997
Response: THE FAA HAS REVIEWED THIS RECOMMENDATION AND BELIEVES THAT THE INTENT OF THIS RECOMMENDATION IS ALREADY MET IN TSO C22G, WHICH INCORPORATES BY REFERENCE THE SEAT BELT REQUIREMENTS OF THE SOCIETY OF AUTOMOTIVE ENGINEERS (SAE) AEROSPACE STANDARD (AS) 8043. THE BODY BLOCK USED IN AS 8043 PROVIDES CLOSED CELL NON-RESILIENT FOAM REPRESENTATIVE OF SOFT TISSUE IN THE AREA OF THE SEAT BELT. ALL NEW SEAT BELT APPLICATIONS MUST COMPLY WITH THE REQUIREMENTS OF TSO C22G. I BELIEVE THAT THESE CURRENT STANDARDS ADEQUATELY ADDRESS THIS SAFETY CONCERN. THE SAE S-9 COMMITTEE, WHICH IS RESPONSIBLE FOR ISSUES RELATING TO SEAT RESTRAINTS, HAS UNDERGONE A REORGANIZATION IN THE PAST YEAR. A NEW SUBGROUP WAS FORMED IN FEBRUARY 1997 AND ITS FIRST MEETING IS SCHEDULED MAY 5/20/97. ACCORDING TO SAE, THE EVALUATION SHOULD BE COMPLETED BY JUNE 1997. IF IT IS DETERMINED THAT A REVISION TO TSO C22G IS NEEDED, THE FAA WILL INITIATE APPROPRIATE ACTION.

From: NTSB
To: FAA
Date: 6/7/1995
Response: THE BOARD IS PLEASED THAT THE FAA HAS ASKED THE SOCIETY OF AUTOMOTIVE ENGINEERS TO REEVALUATE THE BODY BLOCK DESIGN OF AEROSPACE STANDARD 8043, & LOOKS FORWARD TO REVIEWING THE PROPOSED AMENDMENTS TO THE CURRENT TSO. BASED ON THE FAA'S ACTION, THE BOARD CLASSIFIES A-94-69 "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 2/28/1995
Response: THE FAA HAS ASKED THE SOCIETY OF AEROSPACE ENGINEER (SAE) TO REEVALUATE THE BODY BLOCK DESIGN OF AEROSPACE STANDARD 8043. IT IS ANTICIPATED THAT SAE WILL COMPLETE THE EVALUATION BY DECEMBER 1995. BASED ON THE RESULT OF THE EVALUATION, TECHNICAL STANDARD ORDER C22G WILL BE AMENDED AS APPROPRIATE. I WILL KEEP THE BOARD APPRISED OF THE FAA'S PROGRESS ON THIS RECOMMENDATION.

From: NTSB
To: FAA
Date: 10/6/1994
Response: From the accident report of the stall and loss of control on final approach Atlantic Coast Airlines, Inc./ United Express flight 6291, Jetstream 4101, N304UE in Columbus, Ohio on January 7, 1994. The Board adopted this report on 10/6/1994. Also, as a result of this investigation, the Safety Board reiterated safety recommendations: A-93-36 and A-94-69.

From: NTSB
To: FAA
Date: 9/1/1994
Response: THE BOARD IS AWARE THAT APPROXIMATELY 1 YEAR AGO THE FAA ISSUED TECHNICAL STANDARD ORDER C22G (TSO-C22G) TO SUPERSEDE & IMPROVE THE SEATBELT REQUIREMENTS OF TSO-C22F. TSO-C22G INCORPORATES BY REFERENCE THE SEATBELT REQUIREMENTS OF THE SOCIETY OF AUTOMOTIVE ENGINEERS AEROSPACE STANDARD 8043, & ALLOWS NONRESILIENT FOAM RESPRESENTATIVE OF SOFT TISSUE TO BE APPLIED TO CURVED SURFACES OF THE TEST BLOCK WHEN IN CONTACT WITH THE SEATBELT WEBBING. THIS DOES NOT ADEQUATLEY ADDRESS THE CONCERNS OF THE BOARD. IN FIGURE 3 OF AS 8043, THE DIAGRAM OF THE TEST FIXTURE ON THE LEFT SHOWS A CUTOUT IN THE TEST BLOCK FOR THE LAPBELT BUCKLE. THIS CUTOUT, WHEN THE LAPBELT IS UNDER LOAD, ALLOWS THE BUCKLE TO PIVOT &, IN THE CASE OF THE PACIFIC SCIENTIFIC LAPBELTS, ALLOWS THE BUCKLE TO RELEASE. HOWEVER, AS STATED IN THE RECOMMENDATION LETTER, WHEN A PIECE OF FOAM REPRESENTATIVE OF SOFT TISSUE WAS PLACED BETWEEN THE BUCKLE & THE TEST BLOCK, THE BUCKLE WAS NOT ALLOWED TO PIVOT, & AS A RESULT, THE LAPBELT FAILED TO RELEASE. THE BOARD IS CONCERNED THAT NEITHER TSO C22G NOR AS 8043 REQUIRE THAT FOAM BE PLACED BETWEEN THE TEST BLOCK & THE BUCKLE. ON THE CONTRARY AS 8043 STATES THAT MANUFACTURERS MAY PLACE FOAM AROUND CURVED SURFACES OF THE TEST BLOCK THAT ARE IN CONTACT WITH THE LAPBELT WEBBING. SINCE THESE ACTIONS DO NOT AMEND TSO-C22 S RECOMMENDED, THE BOARD CLASSIFIES A-94-69 "OPEN--UNACCEPTABLE RESPONSE" & ASKS THE FAA TO RECONSIDER ITS POSITION.

From: FAA
To: NTSB
Date: 6/6/1994
Response: TECHNICAL STANDARD ORDER C22F REVISED OVER A YEAR AGO TO ADDRESS THE CONCERNS EXPRESSED IN THIS RECOMMENDATION. CURRENTLY, TSO-C22G INCORPORATED BY REFERENCE THE SEAT BELT REQUIREMENTS OF THE SOCIETY OF AUTOMOTIVE ENGINEERS AEROSPACE STANDARD 8043. THE BODY BLOCK USED IN AS 8043 PROVIDES CLOSED CELL NONRESILIENT FOAM REPRESENTIATIVE OF SOFT TISSUE IN THE AREA OF THE SEAT BELT. AS REQUIRED BY 14 CFR 21.605, ALL NEW SEAT BELT APPLICANTS MUST COMPLY WITH THE REQUIREMENTS OF TSO-C22G.