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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.
THE NTSB RECOMMENDS THAT THE FEDERAL AVAITION ADMINISTRATION: ENHANCE FLIGHT STANDARDS PROGRAMS GUIDELINES, INCLUDING THE NATIONAL AVIATION SAFETY INSPECTION PROGRAM, TO EMPHASIZE HANDS-ON INSPECTION OF EQUIPMENT AND PROCEDURES, UNANNOUNCED AND INTERNAL AUDIT FUNCTIONS, IN ORDER TO EVALUATE THE EFFECTIVENESS OF AIR CARRIER MAINTENANCE PROGRAMS RELATED TO AIRCRAFT CONDITION, THE ADHERENCE TO APPROVED AND PRESCRIBED PROCEDURES, AND THE ABILITY OF AIR CARRIERS TO IDENTIFY AND CORRECT PROBLEMS FROM WITHIN. (Supersedes Safety Recommendation A-89-062 and A-89-063)
Original recommendation transmittal letter:
Closed - Acceptable Action
EAGLE LAKE, TX, United States
Britt Airways, Inc., d/b/a Continental Express Flight 2574 In-Flight Structural Breakup EMB-120RT, N33701
Addressee(s) and Addressee Status:
FAA (Closed - Acceptable Action)
Safety Recommendation History
THE BOARD NOTES THAT FROM JUNE 1 THROUGH DECEMBER 31, 1992, THE FAA CONDUCTED APPROXIMATELY 75,815 UNANNOUNCED SHOP VISITS AND IDENTIFIED COMMON FINDINGS. THE BOARD ACKNOWLEDGES THE POSITIVE ACTIONS THAT HAVE BEEN TAKEN BY THE FAA IN RESPONSE TO RECOMMENDATION A-92-7 AND CLASSIFIES IT "CLOSED--ACCEPTABLE ACTION."
THE FAA AGREES WITH THE INTENT OF THIS RECOMMENDATION. ON JULY 31, 1992, THE BOARD REQUESTED INFORMATION CONCERNING TYPICAL FREQUENCY OF UNANNOUNCED SHOP VISITS BY FAA INSPECTORS TO AIR CARRIER MAINTENANCE FACILITIES AND THE RESULTS OF COMMON FINDINGS. THE FOLLOWING INFORMATION SHOULD SATISFY THE SAFETY BOARD'S REQUEST. TYPICAL UNANNOUNCED INSPECTTIONS ARE: PRTS CODE 3627 AND 5627 - MAINTENANCE AND AVIONICS RAMP INSPECTIONS PRTS CODE 3628 AND 5628 - MAINTENANCE AND AVIONICS SPOT INSPECTIONS PARTS CODE 3629 AND 5629 - MAINTENANCE AND AVIONICS EN ROUTE INSPECTIONS OTHER INSPECTIONS WHICH OCCUR UNANNOUNCED (APPROXIMATELY 50 PERCENT OF THE TIME) ARE: PRTS CODE 3632 AND 5632 - MAINTENANCE AND AVIONICS SHOP/FACILITY INSPECTIONS PRTS CODE 3638 AND 5638 - MAINTENANCE AND AVIONICS FUEL FACILITY INSPECTIONS THERE WERE APPROXIMATELY 75,815 UNANNOUNCED INSPECTIONS CONDUCTED JUNE 1 THROUGH DECEMBER 31, 1992. I BELIEVE THAT THE FAA HAS COMPLETELY ADDRESSED THIS RECOMMENDATION, AND I CONSIDER THE FAA'S ACTION TO BE COMPLETED.
The FAA noted in its May 15, 1992, letter that the NASIP has been revised to include "hands-on" inspections of employee shift changes and/or interrupted work and required item sign-offs. Also, on April 8, 1992, the FAA approved an Airworthiness Inspector's Handbook Bulletin entitled "Adequacy of Communication Between Arriving and Departing Maintenance Shifts" to address this issue. The Safety Board is also aware of other actions to encourage air carriers to develop internal self-audit programs for better quality assurance. However, before final disposition of this safety recommendation, the Safety Board would like further information about the typical frequency of unannounced shop visits by FAA inspectors to air carrier maintenance facilities and the results of common findings. Pending further information, the Safety Board is classifying Safety Recommendation A-92-7 as "Open-- Acceptable Response."
The FAA agrees with the intent of this recommendation. The National Aviation Safety Inspection Program (NASIP) FAR Part 135 Airworthiness Inspection Guidelines have been revised to include "hands-on" inspections of employee shift changes and/or interrupted work and required inspection item sign offs. The two new additional inspection tasks make a total of 27 "hands-on" tasks to be conducted during a 14 CFR Part 135 operator NASIP inspection. On April 8, 1992, the FAA approved Airworthiness Inspector's Handbook Bulletin 92- XX, Adequacy of Communication Between Arriving and Departing Maintenance Shifts. The bulletin directs principal maintenance inspectors to audit the oral and written changeover procedures between arriving and departing maintenance shifts for their assigned operators and repair stations to ensure the exact status of repair work and that applicable airplane work cards depict repair work status. A copy of the handbook bulletin is enclosed for the Safety Board's information. Unannounced spot inspections, "hands-on" inspections by FAA inspectors, and the observation of quality assurance functions are integral parts of the National Program Guidelines work programs. The FAA believes that the guidance to safety inspectors places the proper emphasis on the importance of these elements in surveillance of operators. The revisions to the NASIP guidelines, the Required National Flight Standards Program Work Functions, and the Airworthiness Inspector's Handbook ensure that these elements are incorporated into national surveillance programs. The FAA does not require internal evaluation programs except for those specifically contained in the aviation regulations. The internal evaluation or self-audit programs outlined in March 1990 by former Administrator Busey were voluntary. There is no intent to require these programs for all air carriers or operators. The FAA is encouraging these internal evaluation programs through: a. Development of an internal evaluation model program guide to aid operators in the design of their own programs. b. Working with independent contractors to develop industry training seminars on quality assurance and independent evaluation. c. Developing and fielding computer-based instruction for Flight Standards inspectors on internal evaluation program key elements. d. Exploring contractor-provided seminar training for targeted flight standards inspectors to enhance their knowledge of internal evaluation issues, thus improving their ability to advise operators in program development. In summary, the FAA has accomplished additional surveillance and made inspector guidance changes based on this safety recommendation. Also, the FAA will evaluate future guidance of the NASIP, National Program Guideline notices, inspector handbooks, and orders to promote the "hands-on" philosophy of surveillance. I plan no further action on this safety recommendation.
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