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Safety Recommendation Details

Safety Recommendation A-98-104
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: Revise its current EMB-120 flight data recorder (FDR) system inspection procedure to include a FDR readout and evaluation of parameter values from normal operations to ensure a more accurate assessment of the operating status of the flight control position sensors on board the airplane.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate 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: 10/21/2004
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 10/21/2004
Response: The Safety Board notes that, in December 2002, the FAA issued a supplemental type certificate (STC) to Chippewa Aerospace that authorized the replacement of the potentiometer rudder and control column position sensors for the FDR system with rotary variable transformers. The FAA reported via e-mail on August 3, 2004, that a survey of EMB-120 commercial operators indicated that 74 of 88 airplanes have or will soon have upgraded sensors installed. The FAA reports that the 2 operators of the remaining 14 airplanes are following the manufacturer's recommended maintenance program for the potentiometers to avoid the installation costs and because of the uncertain future plans for their EMB-120 airplanes. The Safety Board appreciates the FAA's efforts to follow up on this issue. The approval of upgraded sensors appears to be an improvement in technology that will enhance the reliability of the signals provided to the FDR. The improved sensors eliminate the need for revision of the FDR system inspection procedures. It is unfortunate that two Part 135 operators are not installing the improved sensors. However, the Board believes that the actions completed, which have resulted in the majority of EMB-120 series airplanes that remain in service being equipped with the improved sensors, accomplishes the objective of these safety recommendations in an acceptable alternate manner. Accordingly, Safety Recommendation A-98-104 is classified "Closed--Acceptable Alternate Action." The development and STC approval of the rotary variable transformers have improved the design and reliability of the EMB-120 FDR system. Therefore, Safety Recommendation A-96-33 is classified "Closed--Acceptable Action."

From: FAA
To: NTSB
Date: 8/3/2004
Response: rcvd via email Here is an update on the activities for Safety Rec A-98-104. I have been performing an informal survey of EMB-120 operators for replacement of potentiometers for the FDR system. I have sent e-mails to the Part 91 operators for their input but none of them have replied. The 135 operators have been in touch and here is the information. Skywest,, as you know, operates 74 EMB-120s. They are in the process if installing the STC for the upgraded sensors. Ameriflight - They have a varied fleet but operate only 7 EMB-120 aircraft. The air carrier is aware of the STC but does not want to made the initial up front cost associated with the installation of the STC. They will continue with the EMB-120 recommended maintenance program. Great Lakes - They operate 7 EMB-120 aircraft. They are aware of the STC but are not sure how long they will continue to operate EMB-120 aircraft. They do not want to make an investment in an aircraft that they may discontinue to operate. They will continue with the EMB-120 recommended maintenance program.

From: NTSB
To: FAA
Date: 1/3/2002
Response: The Safety Board is disappointed by the FAA's response. The Board continues to encounter problems with EMB-120 FDR flight control position data. The Board's investigation of a serious incident on March 19, 2001, involving Comair flight 5054, an EMB-120, has been hampered by problems with the FDR data that are similar to the problems 4 years ago that prompted this recommendation. In the March 19, 2001, incident, the pilot reported experiencing an upset event and a loss of altitude after encountering icing conditions. The aircraft was substantially damaged, which resulted in an emergency diversion to West Palm Beach, Florida. In the letter that transmitted this recommendation to the FAA, the Board noted that it had "observed anomalous FDR-recorded values for flight control parameters on seven of eight Embraer EMB-120 FDRs it has reviewed." Having repeatedly found anomalous flight control position data recorded by EMB-120 FDRs, the Board disagrees with the FAA's finding that these FDR systems function appropriately. Consequently, the level of safety intended by this recommendation has not been reached. The Safety Board concludes that the FAA's action taken in response to this recommendation has not satisfied the intent of the recommendation. Pending completion of the recommended action, Safety Recommendation A-98-104 is classified "Open--Unacceptable Response."

From: FAA
To: NTSB
Date: 8/2/2001
Response: Letter Mail Controlled 08/10/2001 1:11:47 PM MC# 2010634: The FAA completed its review of flight data recorder system inspection procedures for the EMB-120 aircraft and found that the potentiometers function appropriately and will identify failure modes when the FDR system is maintained in accordance with Advisory Circular (AC) 20-141, Airworthiness and Operational Approval of Digital Flight Data Recorders. The review found that operators are performing maintenance in accordance with AC 20-141 and that the level of safety intended by this safety recommendation has been reached. I believe that the FAA has met the full intent of this safety recommendation, and I consider the FAA's action to be completed.

From: NTSB
To: FAA
Date: 1/12/2001
Response: THE SAFETY BOARD BELIEVES THE FAA IS TAKING THE ACTION RECOMMENDED. AFTER THE CONCLUSION OF THE FAA'S REVIEW, THE BOARD WOULD APPRECIATE LEARNING THE NATURE AND TYPES OF MAINTENANCE PROBLEMS FOUND AND THE REVISIONS IMPLEMENTED. PENDING COMPLETION OF THE FAA'S REVIEW AND THE BOARD'S RECEIPT OF A REPORT SUMMARIZING THE PROBLEMS FOUND AND THE RESULTING MAINTENANCE SYSTEM IMPROVEMENTS, A-98-104 REMAINS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 7/7/2000
Response: Letter Mail Controlled 07/12/2000 9:46:00 AM MC# 2000878 IN FEBRUARY 1999, THE FAA TOLD THE BOARD THAT IT WOULD REVIEW THE EMB-120 FLIGHT DATA RECORDER (FDR) SYSTEM INSPECTION PROCEDURES TO DETERMINE IF CHANGES WERE REQUIRED TO ADDRESS THE ISSUES RAISED BY THE BOARD. THE FAA TOLD THE BOARD THAT IT WOULD INCLUDE THE BOARD'S FINDINGS OF THE WESTAIR EMB-120 INCIDENT AS PART OF ITS REVIEW. THE REVIEW OF FDR SYSTEM INSPECTION PROCEDURES FOR THE EMB-120 AIRCRAFT IS ONGOING. THE FAA HAS BEEN SHARING ITS FINDINGS OVER SEVERAL INSPECTION INTERVALS WITH THE PRINCIPAL AVIONICS INSPECTOR ASSIGNED TO COMAIR, AND ADJUSTMENTS TO THE MAINTENANCE PROGRAM WERE MADE TO ADDRESS SHORTCOMINGS IN PERFORMANCE OF THE RECORDERS ON THE EMB-120. THE FAA ANTICIPATES COMPLETING ITS REVIEW BY DECEMBER 2000. UPON COMPLETION OF THE REVIEW, THE FAA WILL ASSESS WHAT ADDITIONAL ACTIONS NEED TO BE TAKEN. ALTHOUGH THIS REVIEW IS ONGOING, IT IS IMPORTANT TO NOTE THAT THE FAA HAS MADE SIGNIFICANT CHANGES TO INDUSTRY PROCEDURES AFFECTING FDR MAINTENANCE AND INSPECTION PROCEDURES. THESE INITIATIVES ARE DOCUMENTED, IN PART, IN THE FAA'S RESPONSE TO A-98-53 THROUGH -56, WHICH RESULTED FROM THE FINE AIR DC-8-61 ACCIDENT IN MIAMI, FL ON 8/7/97. SOME OF THE ACTIONS ALREADY IN PLACE ARE SPECIALIZED FDR SYSTEMS TRAINING FOR AVIONICS INSPECTORS; FLIGHT STANDARDS HANDBOOK BULLETIN FOR AIRWORTHINESS 97-13B, DIGITAL FLIGHT DATA RECORDER MAINTENANCE, ISSUED 12/15/97; AND THE DEVELOPMENT OF A NEW ADVISORY CIRCULAR (AC) ADDRESSING THE CONTINUED AIRWORTHINESS OF FDR'S. IN ADDITION, THE FAA ISSUED AC 20-141, AIRWORTHINESS AND OPERATIONAL APPROVAL OF DIGITAL FLIGHT DATA RECORDER SYSTEMS, ON 10/5/99. THE AC ADDRESSES THE CONTINUED AIRWORTHINESS OF DIGITAL FLIGHT DATA RECORDERS (DFDR) AND PROVIDES GUIDANCE ON THE DESIGN, INSTALLATION, AND CONTINUED AIRWORTHINESS OF DFDR SYSTEMS. THE AC INCORPORATES THE INFORMATION REGARDING THE INSTALLATION AND MAINTENANCE OF DFDR'S AND FLIGHT DATA ACQUISITION UNITS CONTAINED IN NOTICE N8110.65, POLICY AND GUIDANCE FOR THE CERTIFICATION AND CONTINUED AIRWORTHINESS OF DIGITAL FLIGHT DATA RECORDER SYSTEMS. THE NOTICE REFERENCES THE APPROPRIATE REGULATORY REQUIREMENTS AND CONTAINS THE UNIVERSAL DOCUMENTATION FORMAT FOR EACH DFDR AIRCRAFT CONFIGURATION AND INSTALLATION. THE UNIVERSAL FORMAT DEVELOPED BY AERONAUTICAL RADIO, INC., AND THE BOARD'S PROPOSED FDR CONFIGURATION DOCUMENTED STANDARD WERE USED AS BASELINE DOCUMENTS FOR THE NOTICE. THE AC REFERENCES THE INFORMATION IN THE NOTICE. I HAVE ENCLOSED A COPY OF THE AC FOR THE BOARD'S INFORMATION. I WILL KEEP THE BOARD INFORMED OF THE FAA'S ACTION ON THIS RECOMENDATON.

From: NTSB
To: FAA
Date: 3/9/2000
Response: THE SAFETY BOARD ENCOURAGES RAPID REVIEW AND ACTION ON THIS ISSUE. FDR'S ARE AN ESSENTIAL PART OF ACCIDENT PREVENTION, AND ACCURACY OF THESE SYSTEMS IS CRUCIAL TO FLIGHT SAFETY. PENDING COMPLETION OF THE FAA'S REVIEW, A-98-104 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 2/26/1999
Response: THE FAA WILL REVIEW THE EMB-120 FLIGHT DATA RECORDER (FDR) SYSTEM INSPECTION PROCEDURES TO DETERMINE IF CHANGES ARE REQUIRED TO ADDRESS THE ISSUES RAISED BY THE BOARD. THE BOARD'S FINDINGS IN THE WESTAIR EMB-120 INCIDENT WILL ESPECIALLY BE EXAMINED AS PART OF THIS EVALUATION. THE FAA HAS MADE SIGNIFICANT CHANGES TO INDUSTRY PROCEDURES AFFECTING FDR MAINTENANCE AND INSPECTION PROCEDURES. THESE INITIATIVES ARE DOCUMENTED, IN PART, IN FAA RESPONSE TO A-98-53 THROUGH -56, WHICH RESULTED FROM THE FINE AIR DC-8-61 ACCIDENT IN MIAMI, FL ON 8/7/97. SOME OF THE ACTIONS ALREADY IN PLACE TO ADDRESS THIS ISSUE ARE SPECIALIZED FDR SYSTEMS TRAINING FOR AVIONICS INSPECTORS; FLIGHT STANDARDS HANDBOOK BULLETIN FOR AIRWORTHINESS 97-13B, DIGITAL FLIGHT DATA RECORDER MAINTENANCE, ISSUED 12/15/97; AND THE DEVELOPMENT OF A NEW ADVISORY CIRCULAR ADDRESSING THE CONTINUED AIRWORTHINESS OF FDR'S. I WILL KEEP THE BOARD INFORMED OF THE FAA'S PROGRESS ON THIS SAFETY RECOMMENDATION.