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Safety Recommendation Details

Safety Recommendation A-92-006
Details
Synopsis: ON SEPTEMBER 11, 1991, AN EMBRAER BRASILIA EMB-120 AIRPLANE, OPERATED UNDER 14 CODE OF FEDERAL REGULATIONS (CFR) PART 135 AS CONTINENTAL EXPRESS FLIGHT 2574, CRASHED NEAR EAGLE LAKE, TEXAS. THE FLIGHTCREW HAD BEGUN TO DESCEND FROM ABOUT 24,000 FEET 11 MINUTES BEFORE THE CRASH. INBOUND TO HOUSTON'S INTERCONTINENTAL AIRPORT, PASSING THROUGH 11,800 FEET, THE LEADING EDGE OF THE LEFT HORIZONTAL STABILIZER SEPARATED FROM THE AIRPLANE. PERFORMANCE EVALUATIONS HAVE THUS FAR DETERMINED THAT LOSS OF THE LEADING EDGE'S AERODYNAMIC SURFACE, COMBINED WITH THE SUDDEN INCREASE IN DRAG CAUSED BY THE EXPOSED FLAT STRUCTURAL PLANE ON THE LEFT SIDE OF THE HORIZONTAL STABILIZER, LED TO AN ALMOST IMMEDIATE STALL OF THE HORIZONTAL STABILIZER AND RAPID PITCH DOWN OF THE AIRPLANE'S NOSE. THE NEGATIVE LOADING ON THE AIRPLANE'S STRUCTURE RESULTED IN THE LEFT WING FOLDING UNDER THE FUSELAGE AND THE SUBSEQUENT BREAKUP OF THE AIRPLANE. WITNESSES SAID THAT THE AIRPLANE WAS CONSUMED BY A FIREBALL AND THAT ONLY THE WING TIPS WERE OUTSIDE THE FIREBALL. IT THEN ENTERED A FLAT SPIN UNTIL GROUND IMPACT. ALL 14 PERSONS ABOARD WERE FATALLY INJURED.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: ENHANCE FLIGHT STANDARDS SURVEILLANCE OF CONTINENTAL EXPRESS, TO INCLUDE SUFFICENT DIRECT OBSERVATION OF ACTUAL MAINTENANCE SHOP PRACTICES TO ENSURE THAT SUCH PRACTICES CONFORM TO THE CONTINENTAL EXPRESS GENERAL MAINTENANCE MANUAL AND APPLICABLE FEDERAL AVIATION REGULATIONS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: EAGLE LAKE, TX, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA91MA052
Accident Reports: Britt Airways, Inc., d/b/a Continental Express Flight 2574 In-Flight Structural Breakup EMB-120RT, N33701
Report #: AAR-92-04
Accident Date: 9/11/1991
Issue Date: 2/28/1992
Date Closed: 11/4/1993
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 11/4/1993
Response: THE BOARD NOTES THAT THE FAA HAS CONDUCTED A NUMBER OF INSPECTIONS OF CONTINENTAL EXPRESS MAINTENANCE OPERATIONS FROM JUNE 1, 1992, THROUGH JANUARY 19, 1993. THE INSPECTIONS INCLUDED THE MAIN BASE OF OPERATIONS IN HOUSTON, TEXAS, AND SUB-BASES AT ALLENTOWN, PENNSYLVANIA; DENVER COLORADO; AND CLEVELAND, OHIO. A SUMMARY OF FINDINGS INDICATE THAT CONTINENTAL EXPRESS IS OPERATING WITHIN THE ESTABLISHED MANUAL PROCEDURES AND IS IN COMPLIANCE WITH COMPANY PRACTICES AND THE FAA REGULATIONS. THE BOARD IS AWARE THAT CHANGES HAVE BEEN MADE TO THE INSPECTORS' HANDBOOK BULLETIN AND THAT INSPECTIONS OF CONTINENTAL EXPRESS ARE TYPICAL OF THOSE PERFORMED AT OTHER AIR CARRIERS. HOWEVER, IN LIGHT OF THE MAINTENANCE INCIDENT THAT OCCURRED ON DECEMBER 9, 1992, INVOLVING CONTINENTAL EXPRESS FLIGHT 2522, THE BOARD CONTINUES TO BE CONCERNED ABOUT THE ACTUAL MAINTENANCE SHOP PRACTICES AT CONTINENTAL EXPRESS AND ENCOURAGES THE FAA TO CONTINUE A CLOSE SURVEILLANCE OF THESE ACTIVITIES. BASED ON THE ASSURANCES OF THE FAA THAT THE HOUSTON FLIGHT STANDARDS DISTRICT OFFICE WILL CONTINUE TO EMPHASIZE THESE AREAS IN FUTURE SURVEILLANCE, THE BOARD CLASSIFIES RECOMMENDATION A-92-6 "CLOSED--ACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 6/23/1993
Response: THE FAA AGREES WITH THE INTENT OF THIS RECOMMENDATION. DURING AUGUST 25 THROUGH AUGUST 27, 1992, THE HOUSTON FLIGHT STANDARDS DISTRICT OFFICE (FSDO) CONDUCTED ITS ANNUAL MAIN BASE INSPECTION AT CONTINENTAL EXPRESS IN HOUSTON, TEXAS. THERE WERE SEVERAL FINDINGS AS A RESULT OF THE INSPECTION; HOWEVER, ONLY ONE RESULTED IN ENFORCEMENT ACTION. ON DECEMBER 18, 1992, THE HOUSTON FSDO REQUESED SPECIAL SUB-BASE SURVEILLANCE AT HOUSTON, TEXAS; ALLENTOWN, PENNSYLVANIA; DENVER, COLORADO; AND CLEVELAND, OHIO. THIS SPECIAL SURVEILLANCE WAS CONDUCTED JANUARY 4 THROUGH JANUARY 31, 1993. THIRTY-FOUR INSPECTIONS WERE CONDUCTED WITH NO SIGNIFICANT DISCREPANCIES REPORTED. DURING JANUARY 7, THROUGH JANUARY 14, 1993, THE HOUSTON FSDO ALSO CONDUCTED A SPECIAL INSPECTION AT CONTINENTAL EXPRESS MAIN BASE IN HOUSTON, TEXAS. THE INSPECTION COVERED ALL THREE SHIFTS WITH PARTICULAR ATTENTION TO BOTH MAINTENANCE AND INSPECTION TURNOVER PROCEDURES. ALTHOUGH THIS INSPECTION PROVIDED SEVERAL FINDINGS THAT ARE BEING CORRECTED, SHIFT TURNOVER PROCEDURES AND SHOP PRACTICES WERE BEING FOLLOWED SATISFACTORILY. INSPECTION FINDINGS INDICATE THAT CONTINENTAL EXPRESS IS OPERATING WITHIN THE ESTABLISHED MANUAL PROCEDURES AND THE FAA REGULATIONS. THE HOUSTON FSDO WILL CONTINUE TO EMPHASIZE THESE AREAS IN FUTURE SURVEILLANCE. I BELIEVE THAT THE FAA HAS COMPLETELY ADDRESSED THIS RECOMMENDATION, I CONSIDER THE FAA'S ACTION TO BE COMPLETED.

From: NTSB
To: FAA
Date: 7/31/1992
Response: In a letter of May 15, 1992, the FAA indicated its agreement with the intent of this recommendation. From March 12 through April 3, 1992, the FAA conducted several inspections of Continental Express maintenance shop practices in Houston, Denver, Cleveland, and Allentown. Special emphasis was placed on direct observation to ensure that practices conformed to the airline's General Maintenance Manual. No adverse practices were found. However, the Safety Board expects that the FAA will continue to observe actual shop practices in Continental Express maintenance facilities to ensure that personnel continue to comply with the General Maintenance Manual. The Safety Board would like to be informed of the results of subsequent inspections and will classify Safety Recommendation A-92-6 as "Open--Acceptable Response" pending further information.

From: FAA
To: NTSB
Date: 5/15/1992
Response: The FAA agrees with the intent of this recommendation. During March 12 through April 3, 1992, the FAA conducted several inspections which focused on direct observation of maintenance shop practices at Houston, Denver, Cleveland, and Allentown. Special emphasis was placed on ensuring that practices conform to the Continental Express General Maintenance Manual, that proper shift turnover procedures were followed, that proper required inspection item inspectors possess the data necessary to accomplish a thorough and complete inspection, and that mechanics were using special tools when required by aircraft/engine maintenance manuals. There have been no adverse findings to date as a result of these inspections. The FAA is presently drafting inspection summary reports. I believe that the FAA has completely addressed this safety recommendation, and I plan no further action.