NTSB · Safety Recommendation
Safety Recommendation A-04-026
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Evaluate carbon monoxide detector technology for use in general aviation aircraft.
Safety Issue and Context
On December 17, 2000, about 1821 central standard time, a Beech BE-23, N2324J, impacted hilly, wooded terrain en route from Spirit of St. Louis Airport (SUS), Chesterfield, Missouri, to Tulsa, Oklahoma.1 The commercial-rated pilot, the sole occupant of the airplane, was killed, and the airplane was destroyed. Radar data indicate that about 1 hour after its departure from SUS, the airplane’s heading and altitude became erratic. Between 1809 and 1821, the airplane descended from 8,500 feet mean sea level (msl) to 2,500 feet msl, and its flightpath was a series of irregular descending turns in an easterly direction. The last radar return was about 0.5 mile from the accident site.
Visual meteorological conditions prevailed, and no flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 flight.
Response History
July 5, 2011 · NTSB Correspondence · FAA
The NTSB notes that Wichita State University completed FAA-sponsored research on CO-related issues as they apply to general aviation products. The focus of this research was to determine the most appropriate CO detector sensor technology and to identify how detectors perform at different locations within the cabin of a typical GA aircraft (C-172). The findings of this research are reported in FAA report DOT/FAA/AR-09/49. Also, in March 2010, the FAA published SAIB CE-10-19 R1 to advise all owners and operators of the results of evaluations on various CO detectors suitable for GA aircraft.
The SAIB recommends the use of CO detectors and inspection of the engine exhaust systems (1) during 100-hour and annual inspections and (2) at inspection intervals recommended by the aircraft and engine maintenance manuals.
Because the FAA has completed its evaluation of CO detector technology for use in GA aircraft and has distributed this information to owners and operators, Safety Recommendation A-04-26 is classified CLOSED—ACCEPTABLE ACTION.
January 20, 2011 · Recipient Response · FAA
CC# 201100035: - From J. Randolph Babbitt, Administrator: FAA report DOT/FAA/AR-09/49 includes information on CO detector technology, performance of selected commercially available detectors, and how detectors may perform at different locations within the cabin. The list of CO detector performance parameters and specifications are shown in Appendix B, Section B2.2 of the report. We published a SAIB CE-IO-19 RI (enclosure 4) on March 17, 2010 to advise all owners and operators on the results of evaluations on various CO detectors suitable for general aviation aircraft.
The SAIB recommends that owners and operators use CO detectors while operating their aircraft and continue to inspect engine exhaust systems during 100-hour and annual inspections and at inspection intervals recommended by the aircraft and engine maintenance manuals.
June 11, 2009 · NTSB Correspondence · FAA
The NTSB notes that Wichita State University is currently conducting research on carbon monoxide (CO) issues as they apply to GA products under the FAA’s cooperative research grant titled Detection and Prevention of Carbon Monoxide Exposure in General Aviation Aircraft. The FAA indicated that 43 commercially available CO detectors, sampled from each of the five sensor technology types (biometric, electrochemical, spot, infrared, and semiconductor), were surveyed to determine the most appropriate sensor technology. The technical survey considered requirements for detecting accuracy, response time, false alarms, and power consumption.
The NTSB notes that electrochemical sensor based CO detectors were found to be most suitable for use in the GA environment.
The FAA indicated that a list of performance parameters and specifications have been developed and categorized into four tiers that indicate how critical each performance parameter is within the GA environment. The NTSB notes that once completed, the list can assist users in selecting the CO detector best suited for their aircraft.
The FAA’s actions are responsive to the recommendation. Pending completion of the recommended action, Safety Recommendation A-04-26 remains classified OPEN -- ACCEPTABLE RESPONSE.
May 15, 2008 · Recipient Response · FAA
Letter Mail Controlled 5/28/2008 10:53:40 AM MC# 2080270: - From Robert A. Sturgell, Acting Administrator: (A-04-26): The FAA tasked Wichita State University to conduct research that focuses on the carbon monoxide issues as they apply to general aviation products and that research is ongoing. Enclosed is a copy of the Project Statement of Work (Enclosure 2). Under this cooperative research grant Detection and Prevention of Carbon Monoxide Exposure in General Aviation Aircraft, researchers created a database by surveying technical information on 43 CO detectors commercially available from two dozen manufacturers.
CO detectors can be grouped into five sensor technology types: biomimetic, electrochemical, spot, infrared, and semiconductor. Each type of sensor technology has advantages and limitations. Considering the requirements for detecting accuracy, response time, false alarms, and power consumption, electrochemical sensor-based carbon monoxide detectors appear to be the most suitable for use in general aviation environment. Based on the technical information provided by the manufacturers, the researchers developed a list of performance parameters and specifications and categorized them into four different groups: Tier 1 : imperative performance parameters within a general aviation environment;
Tier 2: useful performance parameters within a general aviation environment; Tier 3: not necessarily useful performance parameters within a general aviation environment; and Tier 4: miscellaneous parameters Users will be able to use the database of commercially available detectors and the categorized list of performance parameters to assist them in selecting CO detectors best suited for their aircraft. This database and the list of parameters will be included as an appendix in the final project report scheduled to be completed in December 2008. I will keep the Board informed of the FAA’s progress on this safety recommendation.
April 7, 2005 · NTSB Correspondence · FAA
The Safety Board obtained and reviewed a copy of AS-412B, and believes that it contains much of the information these recommendations discuss. Updating TSO C48 to incorporate the information in the latest version of AS-412B will meet the intent of these recommendations. Pending completion of that action, Safety Recommendations A-04-26 and -27 are classified OPEN -- ACCEPTABLE RESPONSE.
September 9, 2004 · Recipient Response · FAA
Letter Mail Controlled 9/16/2004 1:07:32 PM MC# 2040566 - From Marion C. Blakey, Administrator: Technical Standard Order (TSO) C48 for Carbon Monoxide Detector Instruments was issued on October 15, 1957. The FAA will examine the possibility of having the FAA William J. Hughes Technical Center conduct research into developing carbon monoxide detection technology. The FAA will contact instrument and aircraft manufacturers to determine if and how carbon monoxide detectors are being installed and used in general aviation aircraft. Once this information is obtained, the FAA will determine a course of action.
The FAA will also review TSO-C48 to evaluate the need to update the TSO to meet current technology. I will keep the Board informed of the FAA's progress on this safety recommendation.