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Safety Recommendation Details

Safety Recommendation A-96-146
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, IF NECESSARY, REVISE ITS POLICIES AND PROCEDURES REGARDING 1) INTERNAL COMMUNICATION AND DOCUMENTATION OF ENGINEERING DECISIONS, AND 2) INVOLVEMENT OF THE DESIGNATED ENGINEERING REPRESENTATIVE (DER) AND FAA, AND TO ENSURE THAT THERE IS PROPER COMMUNICATION, BOTH INTERNALLY AND WITH THE FAA, REGARDING ALL SIGNIFICANT ENGINEERING DECISIONS.
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):

Safety Recommendation History
From: NTSB
To: FAA
Date: 4/22/1998
Response: BASED ON THE FAA'S ACTIONS, THE SAFETY BOARD CLASSIFIES SAFETY RECOMMENDATION A-96-146 "CLOSED--EXCEEDS RECOMMENDED ACTION."

From: FAA
To: NTSB
Date: 8/14/1997
Response: In December 1996, Hamilton Standard implemented its Safety Parts Program. The program, in effect, has revised procedures affecting all portions of the company, including remote facilities, with respect to changes and procedures that require involvement of the designated engineering representative (DER) and the FAA. This program ensures that all personnel are made aware on a continuing basis of those parts and processes that require Hamilton Standard DER and FAA approval for change and makes it clear that no deviation from the approved procedures is acceptable. The objective is achieved through a process of clear identification of parts and processes subject to this control, strict requirements for review of all requests for change, and training of all personnel involved. The Hamilton Standard Safety Parts Program formally establishes the definition of an unsafe condition related to the use of Hamilton Standard parts and defines flight safety parts as those parts that can cause an unsafe condition if they do not function properly. The program also defines the safety characteristics as features (dimensions and procedures) associated with flight safety parts. The flight safety characteristics are to be clearly identified in all manufacturing and maintenance documentation in each figure and next to all processes that affect these features. All processes that affect identified flight safety characteristics are "frozen" and require review of all proposed changes by a board of experts and management. Full consensus of the board is required before any changes affecting a flight safety characteristic are submitted to the FAA for approval. The Safety Parts Program also requires the training of all employees who will work with flight safety parts. All new employees are trained on the program as part of the entry program. The training provides familiarization with the safety parts program and its intent and includes the definition of a flight safety characteristic and "frozen" process. The training stresses that the consequence of failure to follow identified "frozen" manufacturing or repair procedures can cause an unsafe condition during operation of some Hamilton Standard products. Employees are also instructed that deviation from these procedures is unacceptable unless it has been approved through the safety program process and by the FAA after proper submittal of data by the Hamilton Standard DER to the FAA. I consider the FAA's action to be completed on this safety recommendation.

From: NTSB
To: FAA
Date: 5/1/1997
Response: THE FAA STATES 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, AND -146 "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 3/3/1997
Response: THE FAA AGREES WITH THIS RECOMMENDATION & IS WORKING WITH HAMILTON STANDARD TO DEVELOP AN ACTION PLAN TO ADDRESS THIS SAFETY ISSUE. THE FAA MET WITH HAMILTON ON FEBRUARY 3 THROUGH 14, 1997, TO DISCUSS THIS RECOMMENDATION, SUMMARIZE 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 COMPLETED BY MAY 1997.