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Safety Recommendation Details

Safety Recommendation A-98-103
Details
Synopsis: On January 9, 1997, an Empresa Brasileira de Aeronautica, S/A (Embraer) EMB-120RT, operated by COMAIR Airlines, Inc., crashed during a rapid descent after an uncommanded roll excursion near Monroe, Michigan. The flight was a scheduled, domestic passenger flight from the Cincinnati/Northern Kentucky International Airport, Covington, Kentucky, to Detroit Metropolitan/Wayne County Airport, Detroit, Michigan. The flight departed Covington with 2 flightcrew, 1 flight attendant, and 26 passengers on board. There were no survivors. The airplane was destroyed by ground impact forces and a postaccident fire. IMC prevailed at the time of the accident, and the flight was operating on an IFR flight plan.The probable cause of this accident was the FAA's failure to establish adequate aircraft certification standardds for flight in icing conditions.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Ensure that flight standards personnel at all level (from aircraft evaluation groups to certificate management offices) are informed about all manufacturer operational bulletins and airplane flight manual revisions, including the background and justification for the revision.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: MONROE, MI, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA97MA017
Accident Reports: In-Flight Icing Encounter and Uncontrolled Collision with Terrain, Comair Flight 3272, Embraer EMB-120RT, N265CA
Report #: AAR-98-04
Accident Date: 1/9/1997
Issue Date: 11/30/1998
Date Closed: 3/23/2000
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 4/11/2000
Response: THE SAFETY BOARD BELIEVES THAT IT IS NOT THE OPERATOR'S DUTY TO PROVIDE POI'S WITH THE APPROPRIATE DOCUMENTS FOR AFM REVISIONS, RATHER THE POI'S SHOULD BE UP-TO-DATE ON THEIR ASSIGNED CARRIERS' AIRCRAFT, WHICH INCLUDES HAVING THE MOST CURRENT UPDATES OF APPLICABLE MANUALS AND INSTRUCTIONS. RELYING ON OPERATORS TO PROVIDE POI'S WITH SUCH DOCUMENTATION INTERFERES WITH THE OFFICIAL PERFORMANCE OF THEIR DUTIES AS REGULATORY OFFICIALS. ALTHOUGH THE SAFETY BOARD AGREES THAT IT IS A POI'S DUTY TO EVALUATE OPERATORS' COMPLIANCE WITH FAA REGULATIONS, THE BOARD ALSO BELIEVES THAT POI'S SHOULD HAVE A SYSTEM OF EVALUATION STANDARDS THAT DOES NOT RELY ON OPERATORS' INITIATIVE. THE SAFETY BOARD IS ENCOURAGED BY THE CREATION OF A USE-FRIENDLY DATABASE AND ITS USE BY POI'S IN THEIR SURVEILLANCE ACTIVITIES AND OTHER FLIGHT STANDARDS PERSONNEL IN THE PERFORMANCE OF THEIR DUTIES. IT IS THE SAFETY BOARD'S UNDERSTANDING OF HBAT 99-16A, HBAW 99-14A, AND HBGA 99-20A THAT FAA PERSONNEL WILL INDEPENDENTLY BE RESPONSIBLE FOR UPDATING THIS DATABASE AND WILL NOT RELY ON CARRIERS TO SUBMIT THIS INFORMATION. THE BULLETIN DESCRIBES THE USE OF THE DATABASE AND THE MEASURES THAT THE FAA PLANS TO DEVELOP TO ASSIST IN MONITORING IMPLEMENTATION OF AFM REVISIONS AND MANUFACTURER'S OPERATIONAL BULLETINS. HOWEVER, SEVERAL ITEMS OF CONCERN REMAIN; THEREFORE, WE REQUEST THAT THE FAA CLARIFY THE FOLLOWING MATTERS: (1) WILL THE DATABASE INCLUDE MANUFACTURERS' OPERATIONAL BULLETINS AS WELL AS AFM'S? RETENTION OF OPERATIONAL BULLETINS IN THE DATABASE IS INCLUDED UNDER THE HEADING "PURPOSE AND RECORDS" IN THE DATABASE SECTIONS OF HBAT 99-16A, HBAW 99-14A, AND HBGA 99-20A. HOWEVER, IN SECTION 4B, "DATABASE USE DURING SURVEILLANCE," INSPECTORS ARE INSTRUCTED TO USE THE DATABASE FOR SURVEILLANCE AND COMPARE THE DATABASE TO "OPERATOR'S AFM(S), MANUAL(S), AND TRAINING PROGRAM(S)." MANUFACTURERS' OPERATIONAL BULLETINS ARE NOT INCLUDED IN THIS LIST. (2) HBAT 99-16A, HBAW 99-14A, AND HBGA 99-20A, AS WRITTEN, DESCRIBE THE INCLUSION OF INFORMATION AND ITS USE DURING SURVEILLANCE. HOWEVER, THERE IS NO SYSTEM TO MAKE FLIGHT STANDARDS PERSONNEL, INCLUDING POI'S, AWARE OF NEW REVISIONS TO THE AFM'S OR MANUFACTURERS' OPERATIONAL BULLETINS. WAITING UNTIL THE NEXT SURVEILLANCE ROUND TO MAKE FLIGHT STANDARDS PERSONNEL AWARE OF SUCH CHANGES MAY CREATE AN EXCESSIVE PERIOD OF TIME BEFORE THE POI ENSURES THE OPERATOR'S COMPLIANCE WITH THESE REVISIONS. (3) THE DATABASE WILL CONTAIN ONLY THE NUMBER, DATE, AND NAME OF THE DOCUMENT CORRESPONDING TO EACH AFM REVISION AND EACH OPERATIONAL BULLETIN LISTED. THE DATABASE WILL NOT INCLUDE FULL TEXT INFORMATION REFLECTING THE CONTENT. THEREFORE, WHEN THE POI OR OTHER FLIGHT STANDARDS PERSONNEL USE THE DATABASE, THEY WILL BE REQUIRED TO OBTAIN COPIES OF THESE DOCUMENTS. A-98-103 SPECIFICALLY MENTIONS "INCLUDING THE BACKGROUND AND JUSTIFICATION FOR THE REVISION." EXISTING COMPUTER TECHNOLOGY SHOULD ALLOW FOR AT LEAST AN ABSTRACT, INCLUDING THE BACKGROUND AND JUSTIFICATION OF THE DOCUMENT, TO BE PLACED IN THE DATABASE. PENDING CLARIFICATION FROM THE FAA THAT MANUFACTURERS' OPERATIONAL BULLETINS IN THE DATABASE WILL BE INCLUDED IN OVERSIGHT ACTIVITIES BY THE POI, THE DEVELOPMENT OF A SYSTEM WITHIN THE FAA TO ALERT POI'S AND OTHER FLIGHT STANDARDS PERSONNEL WHEN NEW INFORMATION IS POSTED TO THE DATABASE, AND REVISION OF THE DATABASE TO INCLUDE AN ABSTRACT INCLUDING BACKGROUND AND JUSTIFICATION OF THE REVISIONS TO THE AFM'S AND OPERATIONAL BULLETINS, A-98-89 AND A-98-103 ARE CLASSIFIED AS "OPEN--ACCEPTABLE RESPONSE."

From: NTSB
To: FAA
Date: 3/23/2000
Response: THE SAFETY BOARD REVIEW OF THE DATABASE SYSTEM INDICATES THAT WHEN PROPERLY USED, IT WILL MEET THE INTENT OF OUR RECOMMENDATION. HOWEVER, THE BOARD STRONGLY URGES THE FAA TO PROVIDE OVERSIGHT TO THE SYSTEM TO ENSURE THAT ITS POTENTIAL IS FULLY UTILIZED BY ALL FLIGHT STANDARDS PERSONNEL. BASED ON THE 10/25/99, RELEASE OF JOINT FLIGHT STANDARDS HANDBOOK BULLETIN HBAT 99-16, HBAW 99-14, HBGA 99-20 AND THE RELEASE OF THE NEW DATABASE SYSTEM, A-98-103 IS CLASSIFIED "CLOSED--ACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 12/15/1999
Response: Letter Mail Controlled 02/16/2000 9:06:10 AM MC# 991501 THE FAA HAS DEVELOPED AN ELECTRONIC DATA BASE LISTING CURRENT AIRCRAFT MANUFACTURERS' OPERATIONS BULLETINS, AIRPLANE FLIGHT MANUAL (AFM) REVISIONS, AND ROTORCRAFT FLIGHT MANUAL (RFM) REVISIONS. THE DATA BASE, WHICH BECAME AVAILABLE IN NOVEMBER 1999, ADDRESSES TRANSPORT-CATEGORY AIRPLANES. SMALL AIRPLANE DATA AND ROTORCRAFT DATA WILL BE ADDED IN LATE 2000. FLIGHT STANDARDS INSPECTORS WILL USE THE DATA BASE TO EVALUATE THEIR OPERATOR'S IMPLEMENTATION SYSTEM AND TO DETERMINE IF THE OPERATOR IS RESPONDING TO AFM AND RFM REVISIONS IN COMPLIANCE WITH REGULATIONS OR OTHER FAA SAFETY POLICY. ON 10/25/99, THE FAA ISSUED JOINT FLIGHT STANDARDS HANDBOOK BULLETIN HBAT 99-16, HBAW 99-14, AND HDGA 99-20, ANNOUNCEMENT OF NEW DATABASE SYSTEM ON THE FAA INTRANET: AIRPLANE FLIGHT MANUAL REVISIONS AND AIRCRAFT MANUFACTURING OPERATIONS BULLETINS. THE BULLETIN ESTABLISHES PROCEDURES FOR PRINCIPAL INSPECTORS IN USING THE DATA BASE AS A SURVEILLANCE TOOL. I HAVE ENCLOSED A COPY OF THE BULLETIN FOR THE BOARD'S INFORMATION. I CONSIDER THE FAA'S ACTION TO BE COMPLETED ON THIS SAFETY RECOMMENDATION, AND I PLAN NO FURTHER ACTION.

From: FAA
To: NTSB
Date: 9/16/1999
Response: Letter Mail Controlled 9/22/99 9:22:50 AM MC# 991064 THE FAA AGREES WITH THE INTENT OF THIS RECOMMENDATION AND ON 5/28/99, ISSUED A JOINT FLIGHT STANDARDS HANDBOOK BULLETIN FOR AIR TRANSPORTATION (HBAT), AIRWORTHINESS (HBAW), AND GENERAL AVIATION (HBGA), FLIGHT STANDARDS POLICY - COMPANY OPERATING MANUALS AND COMPANY TRAINING PROGRAM REVISIONS FOR COMPLIANCE. THE BULLETIN DIRECTS POI'S TO ENCOURAGE EACH OPERATOR TO DEVELOP AN ACTION PLAN AND NOTIFY ITS RESPECTIVE POI IN WRITING WITHIN 15 CALENDAR DAYS OF RECEIPT WHEN A NEW AFM/RFM REVISION HAS BEEN RECEIVED. THE FAA IS ALSO DEVELOPING AN ELECTRONIC DATA BASE LISTING CURRENT AIRCRAFT MANUFACTURERS' OPERATIONS BULLETINS, AFM REVISIONS, AND RFM REVISIONS. THE DATA BASE, WHICH WILL BE AVAILABLE IN NOVEMBER 1999, WILL INITIALLY ADDRESS TRANSPORT-CATEGORY AIRPLANES. SMALL AIRPLANE DATA AND ROTORCRAFT DATA WILL BE ADDED IN LATE 2000. FLIGHT STANDARDS INSPECTORS WILL USE THE DATA BASE TO EVALUATE THEIR OPERATOR'S IMPLEMENTATION SYSTEM AND TO DETERMINE IF THE OPERATOR IS RESPONDING TO AFM AND RFM REVISIONS INCOMPLIANCE WITH REGULATIONS OR OTHER FAA SAFETY POLICY. ONCE THE DATA BASE IS AVAILABLE FOR USE, THE FAA WILL ISSUE A SEPARATE HANDBOOK BULLETIN TO ESTABLISH THE PROCEDURES FOR USE BY PRINCIPAL INSPECTORS IN USING THE DATA BASE AS A SURVEILLANCE TOOL. MS. LEACH FAXED A COPY OF HBAT 99-16A, HBAW 99-14A, AND HBGA 99-20A, ISSUED 10/27/99. THIS BULLETIN DESCRIBES THE CREATION AND USE BY ALL FAA FLIGHT STANDARDS PERSONNEL OF A DATABASE OF AIRPLANE FLIGHT MANUAL REVISIONS, AIRCRAFT MANUFACTURER OPERATIONS BULLETINS.