NTSB · Safety Recommendation
Safety Recommendation A-04-027
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Develop specific standards to ensure any detection device used in general aviation aircraft quickly and distinctly alerts the user to the presence of carbon monoxide (CO) in the cockpit before the CO reaches a level that would impair a pilots ability to safely operate an 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 FAA indicated in its response that Technical Standard Order (TSO) C48, “Carbon Monoxide Detector Instruments,” had been updated in May 2009 to include the most recent version of Society of Automotive Engineers Aviation Standard (AS) 412, “Carbon Monoxide Detector Instruments.” This action satisfies Safety Recommendation A-04-27, which is classified CLOSED—ACCEPTABLE ACTION.
January 20, 2011 · Recipient Response · FAA
CC# 201100035: - From J. Randolph Babbitt, Administrator: On May 6, 2009, the FAA published an updated version of Technical Standard Order (ISO) C-48, Carbon Monoxide Detector Instruments (enclosure 5), that included information in the latest version of the Society of Automotive Engineers International's Aerospace Standard 412B.
June 11, 2009 · NTSB Correspondence · FAA
The FAA indicated in its response that it was in the process of updating Technical Standard Order (TSO) C48, Carbon Monoxide Detector Instruments, which currently incorporates the original version of Society of Automotive Engineers (SAE) Aviation Standard (AS) 412, Carbon Monoxide Detector Instruments. Updating TSO C48 to incorporate the information in the latest version of AS 412 (AS 412B) will meet the intent of these recommendations. Pending completion of that action, Safety Recommendation A-04-27 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: Technical Standard Order (TSO) C-48, Carbon Monoxide Detector Instruments, establishes the performance standards for carbon monoxide detector instruments. The FAA is updating the TSO by adopting the current version of the Society of Automotive Engineers Aviation Standard AS4 12, Rev B, Carbon Monoxide Detector Instruments. Enclosed is a copy of TSO C-48 and AS412, Rev B (Enclosure 3) for the Board’s information.
Under the research grant described in Safety Recommendation A-04-26, Wichita State University was tasked to perform research and testing to determine the most effective method to select the CO detector and its placement in a typical GA aircraft so that it quickly alerts the pilot if the presence of CO exceeds the 5 23.83 1 requirement of 50 ppm. This research includes installation of electrochemical sensor-based detectors with data logging capability in a fleet of Cessna Model 172 aircraft. Potential detector locations will be based on parameters such as: early detection, visibility, and accessibility.
The results of this research will be published in the final project report to be completed in December 2008 and will be used to develop a revision to the TSO. 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.