Safety Recommendation A-04-068

We previously informed you that your July 21, 2005, issuance of Special Airworthiness Information Bulletin (SAIB) SW-05-70 and your October 25, 2005, issuance of Safety Alert for Operators (SAFO) 05005 would constitute an acceptable alternative to requiring the recommended changes, provided that you confirmed with operators that the specified actions had been taken. Through the use of the FAA Safety Performance Analysis System–National Program Tracking and Reporting System, you have done so. Accordingly, Safety Recommendation A 04 68 is classified CLOSED—ACCEPTABLE ALTERNATE ACTION.

-From Michael P. Huerta, Administrator: In the Federal Aviation Administration• s (FAA) October 1 0. 20 I 0, letter to the Board, we stated that we had issued Notice 8900.57. Part 135 Helicopter Training Program and Manual Revisions (copy previously provided). This notice included a data collection component, which we have completed. We found that of 131 FAA Safety Performance Analysis System - National Program Tracking and Reporting System records surveyed. 22 were subject to this recommendation. Of these 22, 100 percent were determined satisfactory. This represents a majority of the subject fleet.

I believe that the FAA has effectively addressed this recommendation and consider our actions complete.

The NTSB has previously informed the FAA that its July 21, 2005, issuance of Special Airworthiness Information Bulletin (SAlB) SW-05-70 and October 25, 2005, issuance of Safety Alert for Operators (SAFO) 05005 would constitute an acceptable alternative to the recommended action of requiring these changes to pilot training, provided that after the guidance were issued, the FAA confil1ned with the operators that the recommended and encouraged actions had been taken. FAA Notice 8900.57, issued November 25, 2008, directs that all affected Part 135 air carriers shall amend their pilot training programs to incorporate the recommended training/procedures cited in the SAIB and SAPO.

The notice also directs affected FAA principal operations inspectors (POI) as follows: (2) By February 1, 2009, POIs, after confirming that the operator for which they have oversight has made the necessary initial and recurrent pilot training program and applicable manual revisions, shall: • Open a PTRS [Program Tracking and Reporting Subsystem] record using code 1030; • Enter "FADEC8" in the "National Use" field (without quotes); and • Close the PTRS record when the inspection is completed.

The NTSB commends the FAA for issuing this notice, which directs FAA inspectors to follow through on guidance that the FAA had issued in response to several NTSB recommendations and to document the degree to which this guidance has been implemented by operators. We believe that this action is consistent with fundamental principles of safety management systems. Although the notice directed POIs to complete their review by February 1, 2009, the FAA has not yet finished its data collection efforts. The NTSB looks forward to reviewing the results of these efforts once they have been completed.

Pending our receipt and review of that information, Safety Recommendation A-04-68 remains classified OPEN – ACCEPTABLE ALTERNATE RESPONSE.

CC# 201000391: - From J. Randolph Babbitt, Administrator: As noted in the Federal Aviation Administration's letter dated August 17, 2007, we previously issued Special Airworthiness Information Bulletin (SAIB) SW-05-70 that discusses FADEC and Safety Alert for Operators 05005, Bell 407 with Rolls-Royce 250 series IV engine and FADEC (copies previously provided). Additionally, on November 25, 2008, the FAA issued Notice 8900.57, Part 135 Helicopter Training Program and Manual Revisions (enclosed).

The notice stated, in part, that in accordance with 14 CFR § 135.325(d), all part 135 air carriers operating Bell 407 helicopters equipped with the Rolls-Royce Model 250 series IV engine and FADEC shall amend their pilot training programs to incorporate the recommended training/procedures cited in SAIB SW-05-70. We are finalizing data collection efforts to determine that all part 135 air carriers operating Bell 407 helicopters, equipped with the Rolls-Royce Model 250 series IV engine and FADEC, have met the above guidance. Once our data collection effort is complete, we will provide the results.

I will keep the Board informed of the FAA's progress on this safety recommendation, and I will provide an update by September 2011.

On July 21, 2005, the FAA issued Special Airworthiness Information Bulletin (SAIB) SW-05-70, which discusses the FADEC and its characteristics during automatic transition from automatic mode to manual mode. The SAIB also contains recommendations for operations and training for pilots regarding this issue. On October 25, 2005, the FAA issued Safety Alert for Operators (SAFO) 05005, Bell 407 with Rolls Royce 250 series IV engine and FADEC, which alerts operators to the content of SAIB SW-05-70 and encourages them to implement the operations and training recommended in the SAIB.

On March 24, 2005, the FAA informed the Board that it planned to take these actions. On October 7, 2005, the Board replied that issuing this guidance would be an acceptable alternative to the recommended action of requiring these changes to pilot training, provided that after the guidance was issued, the FAA confirmed with the operators that the recommended and encouraged actions had been taken. Pending issuance of the guidance, and a report that demonstrated that the recommended action had been taken, Safety Recommendation A-04-68 was classified Open Acceptable Alternate Response.

The FAA has completed the review of the emergency procedure training for pilots and issued guidance on this subject. However, the FAA has not reported any information that confirms that operators have made the training revisions. More than 2 years have passed since the SAFO and SAIB were issued, which is sufficient time for the training revisions to have been implemented and for the FAA to have surveyed the operators to confirm that the guidance has been effective. Pending results of a survey of the affected operators that shows that the training revisions have been made, Safety Recommendation A-04-68 remains classified OPEN -- ACCEPTABLE ALTERNATE RESPONSE.

Letter Mail Controlled 8/27/2007 3:52:42 PM MC# 2070434: - From Marion C. Blakey, Administrator: On July 21, 2005, the Federal Aviation Administration issued Special Airworthiness Information Bulletin (SAIB) SW-05-70 to discuss the FADEC and its characteristics during automatic transition from automatic mode to manual mode. The SAIB also contains recommendations for operations and effective training for pilots using this equipment. On October 25, 2005, the FAA issued Safety Alert for Operators (SAFO) 05005, Bell 407 with Rolls Royce 250 series IV engine and FADEC.

The SAFO alerts operators of helicopters equipped with the Rolls-Royce Model 250 series IV engine of the content of SAIB SW-05-70 and encourages directors of operations, training managers, and pilots involved in operations of the Bell 407 with Rolls Royce 250 series IV engine and FADEC to implement operations and training as recommended in the SAIB. I have enclosed a copy of the SAFO and the SAIB for the Board's information. I believe that the FAA has satisfactorily responded to this safety recommendation, and I look forward to your response.

The FAA stated that it will issue a safety alert for operators of helicopters equipped with the Rolls-Royce Model 250 series IV engine to alert them to the problem of inappropriate pilot response to an in-flight failure of the FADEC. The FAA indicated that it will also encourage operators to revise their emergency procedures to caution pilots against this inappropriate response and to emphasize the importance of adhering to standard operating procedures.

The FAA's planned action is an acceptable alternative to the recommended action; however, the Safety Board requests that FAA inspectors for these operators follow up and check their operator training programs to ensure that the recommended and encouraged actions have been taken. At some suitable time after this alert has been issued, the Board requests that the FAA supply information from the Program Tracking and Reporting System (PTRS) that demonstrates that operators of helicopters with Rolls-Royce 250 series IV engines have implemented the appropriate training and procedures.

Pending issuance of the safety alert for operators and a report from PTRS that demonstrates that the recommended action has been taken, Safety Recommendation A-04-68 is classified OPEN -- ACCEPTABLE ALTERNATE RESPONSE.

Letter Mail Controlled 3/30/2005 10:51:13 AM MC# 2050138: - From Marion C. Blakey, Administrator: The Federal Aviation Administration will issue a Safety Alert for Operators alerting operators of helicopters equipped with the Rolls-Royce Model 250 series IV engine of this particular hazard. The FAA will encourage operators to revise their emergency procedures contained in their pilots' operating manuals and training programs to caution pilots against this propensity and to emphasize the importance of adhering to standard operating procedures as specified in those manuals. It is anticipated that the safety alert will be issued by May31, 2005.

I will provide the Board with a copy of the safety alert as soon as it is issued.

Letter Mail Controlled 2/1/2005 3:15:53 PM MC# 2050036. *This letter is NOT from the FAA, but from Rolls-Royce, and is directly pertinent to implementation of the recommendations*: - From Barry N. Rohm, Engineering Director, Product Assurance: On December 15,2004, your office released a five-page letter regarding Safety Recommendations A-04-68 and A-04-69, These recommendations and the associated information within your letter pertain to an incident involving the Rolls-Royce Model 250-C47B engine installed in a Bell 407 helicopter (N491 PH) operated by Petroleum Helicopters, Inc. (PHI).

This incident was initiated by a capacitor short in the Electronic Control Unit (ECU) -15 volt power supply, which rendered the ECU inoperative. The inoperative ECU transferred control of the engine to the backup hydromechanical system. This system requires the pilot to manually control the engine speed, torque and temperature. In this particular incident, the pilot did not believe that the engine was properly responding to his control inputs and consequently elected to perform an autorotation into the Gulf of Mexico. The autorotation was successful and the pilot and passengers were subsequently retrieved.

The purpose of this letter is to clarify some information contained in your December 15, 2004 letter and provide additional context regarding some of the conclusions. In addition, Rolls-Royce would like to acknowledge some of your concerns, which are contained within A-04.68 and A-04-69. Lastly, Rolls-Royce would like to raise concern over recent trends regarding NTSB recommendations associated with the Rolls-Royce Model 250 engine and request improvement in coordination between the NTSB, FAA and industry.

On December 15,2004, your office released a five-page letter regarding Safety Recommendations A-04-68 and A-04-69, These recommendations and the associated information within your letter pertain to an incident involving the Rolls-Royce Model 250-C47B engine installed in a Bell 407 helicopter (N491 PH) operated by Petroleum Helicopters, Inc. (PHI). This incident was initiated by a capacitor short in the Electronic Control Unit (ECU) -15 volt power supply, which rendered the ECU inoperative. The inoperative ECU transferred control of the engine to the backup hydromechanical system. This system requires the pilot to manually control the engine speed, torque and temperature.

In this particular incident, the pilot did not believe that the engine was properly responding to his control inputs and consequently elected to perform an autorotation into the Gulf of Mexico. The autorotation was successful and the pilot and passengers were subsequently retrieved. The purpose of this letter is to clarify some information contained in your December 15, 2004 letter and provide additional context regarding some of the conclusions. In addition, Rolls-Royce would like to acknowledge some of your concerns, which are contained within A-04.68 and A-04-69.