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Safety Recommendation Details

Safety Recommendation A-96-142
Details
Synopsis: ON 8/21/95, ABOUT 1253 EASTERN DAYLIGHT TIME, AN EMBRAER EMB-120, N256AS, OPERATED BY ATLANTIC SOUTHEAST AIRLINES (ASA) AS FLIGHT 529, CRASHED ON APPROACH TO THE WEST GEORGIA REGIONAL AIRPORT, CARROLLTON, GEORGIA. THE FLIGHTCREW WAS ATTEMPTING TO MAKE AN EMERGENCY LANDING FOLLOWING THE IN-FLIGHT SEPARATION OF A PROPELLER BLADE. THE CAPTAIN AND SEVEN PASSENGERS WERE KILLED, AND THE AIRPLANE WAS DESTROYED BY IMPACT FORCES AND A POSTCRASH FIRE. FLIGHT 529 WAS BEING CONDUCTED UNDER THE PROVISIONS OF TITLE 14 CODE OF FEDERAL REGULATIONS PART 135 AS A DOMESTIC, SCHEDULED PASSENGER SERVICE FLIGHT FROM ATLANTA, GEORGIA, TO GULFPORT, MISSISSIPPI. THE NTSB'S INVESTIGATION OF THIS ACCIDENT IS ONGOING.
Recommendation: THE NTSB RECOMMENDS THAT THE FAA: REQUIRE HAMILTON STANDARD TO REVIEW AND EVALUATE THE ADEQUACY OF ITS TOOLS, TRAINING, AND PROCEDURES FOR PERFORMING PROPELLER BLEND REPAIRS, AND ENSURE THAT THOSE BLEND REPAIRS ARE BEING PERFORMED PROPERLY.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Exceeds Recommended Action
Mode: Aviation
Location: CARROLLTON, GA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA95MA054
Accident Reports: In-flight Loss of Propeller Blade Forced Landing, and Collision with Terrain Atlantic Southeast Airlines, Inc., Flight 529 Embraer EMB-120RT, N256AS
Report #: AAR-96-06
Accident Date: 8/21/1995
Issue Date: 12/20/1996
Date Closed: 4/22/1998
Addressee(s) and Addressee Status: FAA (Closed - Exceeds Recommended Action)
Keyword(s): Maintenance, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 4/22/1998
Response: BASED ON THE FAA'S ACTIONS, THE SAFETY BOARD CLASSIFIES A-96-142 "CLOSED--EXCEEDS RECOMMENDED ACTION."

From: FAA
To: NTSB
Date: 8/14/1997
Response: The Federal Aviation Administration (FAA) and Hamilton Standard developed an action plan to address the issue outlined in this safety recommendation. Subsequently, Hamilton Standard conducted Special Supplemental Audits of all Hamilton Standard repair facilities. The audits focused on compliance with propeller component maintenance manual procedures, including conditions and use of tooling, personnel training, and documentation control. All corrective actions have been implemented. The repair facilities, which do blend repairs of propeller components, were reviewed during the audits and will be reviewed during future audits. As a result of this review, the blending repair for the propeller blade taper bore has been eliminated from the Component Maintenance Manuals and can no longer be used. Additional requirements are being developed and will be implemented during the remainder of the year. These procedures will require recurring Special Supplemental Audits of all Hamilton Standard repair facilities at least once a year. The Special Supplemental Audits will be required in addition to the annual self-audit required by the present quality systems program. The Special Supplemental Audits will be performed by the customer support quality organization and will continue to review all areas of repair facility activity that affect aviation components that are returned to service, including but not limited to the following areas: Quality System Document and Data Control Control of Customer-Supplied Hardware Produce Identification and Traceability Process Control Inspection and Testing Control of Inspection, Measuring, and Test Equipment Inspection and Test Status Control of Nonconforming Product Corrective and Preventative Action Handling, Storage, and Packaging, Preservation and Delivery Control of Quality Records Internal Quality Audits Training Additionally, in December 1996, Hamilton Standard implemented the Safety Parts Program, which requires review of maintenance and repair procedures for all flight-critical parts. As part of this program, maintenance documentation is being reviewed and changed, if necessary, to ensure the adequacy of tools, training, and procedures for all critical propeller component repairs. This will ensure that repairs can be done properly and meet the design intent. The Safety Parts Program is described in detail in the response to Safety Recommendation A-96-146. I consider the FAA's action to be completed on this safety recommendation, and I plan no further action.

From: NTSB
To: FAA
Date: 5/1/1997
Response: THE FAA STATED IT HAD MET WITH REPRESENTATIVES OF HAMILTON STANDARD FROM FEBRUARY 3 THROUGH FEBRUARY 14, 1997, TO DISCUSS THE BOARD'S RECOMMENDATIONS, TO SUMMARIZE THOSE ACTIONS THAT MAY HAVE ALREADY BEEN ACCOMPLISHED, TO EVALUATE THOSE ACTIONS THAT NEED FURTHER EVALUATION, AND TO DEVELOP AN ACTION PLAN TO OUTLINE THE ACTIONS THAT NEED TO BE TAKEN ADDRESS THESE RECOMMENDATIONS. THE FAA ANTICIPATES THAT THE ACTION PLAN WILL BE COMPLETED BY MAY 1997. BASED ON THIS INFO, THE BOARD CLASSIFIES A-96-142, -144, -145, & -146 "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 3/3/1997
Response: THE FAA AGREES WITH THIS RECOMMENDATION AND IS WORKING WITH HAMILTON STANDARD TO DEVELOP AN ACTION PLAN TO ADDRESS THIS SAFETY ISSUE. THE FAA MET WITH HAMILTON STANDARD TO FEBRUARY 3 THROUGH 14, 1997, TO DISCUSS THIS RECOMMENDATION, SUMMARIZED ACTIONS THAT MAY HAVE ALREADY BEEN ACCOMPLISHED, EVALUATE ACTIONS THAT NEED FURTHER ACTION, AND TO DEVELOP AN ACTION PLAN OUTLINE THE ACTIONS THAT NEED TO BE TAKEN TO ADDRESS THIS RECOMMENDATION. THE FAA ANTICIPATES THE ACTION PLAN WILL BE COMPLETED BY MAY 1997.