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  3. NTSB A-06-036
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NTSB · Safety Recommendation

Safety Recommendation A-06-036

Recommendation

TO THE FEDERAL AVIATION ADMINISTRATION: Compile a list of safety-critical systems derived from the safety assessment process for each type certification project, and place in the official type certification project file the documentation for the rationale, analysis methods, failure scenarios, supporting evidence, and associated issue papers used to identify and assess safety-critical systems.

Safety Issue and Context

Certification of systems that are critical to safety of flight has been an issue in several National Transportation Safety Board accident investigations of transport-category airplanes. In 1999, the Safety Board expressed concern about the Federal Aviation Administration's (FAA) certification process during its investigation of the rudder actuator in USAir flight 427. In 2000, the Board suggested the need for a directed examination of the certification process in the investigation of the center wing fuel tank in TWA flight 800.

Subsequent investigations of the horizontal stabilizer jackscrew in Alaska Airlines flight 26 1 and the rudder system in American Airlines flight 5874 also raised questions about the certification process used by the FAA to determine compliance with airworthiness standards. These four accidents resulted in 715 fatalities and accounted for 60 percent of the air carrier fatalities that occurred from 1994-2001 . In each of these accidents, the Board identified a safety-critical system that suffered a catastrophic failure, and issued certification-related recommendations to address system-specific design, operational, or maintenance issue.

Response History

November 2, 2015 · NTSB Correspondence · FAA

We reviewed the existing FAA regulations, advisory material, and processes that you discussed in your letter including the requirements contained in Title 14 Code of Federal Regulations Part 25.1309, which requires the development of system safety assessments (SSA) that identify safety critical systems, describes the failure conditions associated with these systems, and classifies the hazards associated with failure conditions as catastrophic, hazardous, or major.

On December 9, 2014, we said that the procedures used under FAA Order 8110.4C, “Type Certification,” to retain the information in the SSA satisfy the part of this recommendation concerning the availability of the information in the type certification project file. We agree with you that current regulations, advisory material, and processes identify safety-critical systems during certification; therefore, Safety Recommendation A-06-36 is classified CLOSED—ACCEPTABLE ACTION.

September 2, 2015 · Recipient Response · FAA

-From Michael P. Huerta, Administrator: In our October 28, 2013, response, we conveyed our plan to resume issuance of a Key Safety Information (KSI) advisory circular (AC) for Title 14, Code of Federal Regulations (14 CFR) Part 25 products after several years on hold, while we considered the benefits of application to a broader group of type certificated products. Upon further review, we believe the objectives of this recommendation are met using our current certification regulations, advisory material, and processes; some were developed or have evolved since 2007, when we first informed the Board of the KSI concept.

The FAA believes these existing regulations, advisory material, and processes are sufficient to identify safety-critical systems during certification. Therefore, we no longer see a benefit in pursuing the KSI AC concept. Existing regulations, advisory material and processes that address the Board' s recommendation are described below:

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Recommendation Facts

Status
Closed - Acceptable Action
Issued
May 17, 2006
Priority
CLASS II
Recipient
FAA
Adopted
May 17, 2006
Closed
November 2, 2015
Related Investigation
80707
Related Report
SR-06-02

• As of January 1, 1999, § 25.1 309, Equipment, Systems, and Installations, requires applicants to prepare System Safety Analysis (SSA) reports to document safety analyses. These reports identify safety critical systems, describe the failure conditions associated with these systems, and classify the hazards associated with failure conditions as catastrophic, hazardous, or major. SSA reports follow guidance provided in AC 25.1309-1 A, System Design and Analysis, or in the Aviation Rulemaking Advisory Committee draft advisory material adopted through an equivalent level of safety determination.

• AC 25- l9A, Certification Maintenance Requirements (CMR), issued on October 3, 2011, contains the process to determine CMRs from SSA reports. CMRs define maintenance tasks and intervals developed to achieve compliance with § 25. 1309, through detection of safety significant latent failures and wear out type failures. Once CMRs are identified, they are treated as operating limitations and are typically placed in the Airworthiness Limitations section of the airplane maintenance manual.

In addition, in developing this recommendation, the Board referred to the Alaska Airlines flight 261 and USAir flight 427 accidents as examples of situations where it would be useful to provide access to information about the design integrity and requirements to maintain the certified level of safety. With the application of AC 25-1 9A, the CMRs identified in the operating limitations provide the requested identification of safety critical systems and ensure their integrity throughout the service life of the airplane.

AC 25- l9A fulfills the intent of the proposed KSI AC by providing visibility to the procedures and maintenance tasks that must be protected, maintained, and performed throughout the service life of the airplane(s).

This AC is available at the following Website: http://rgl.faa.gov/Regulatoryand_Guidance_Library/rgAdvisoryCircular.nsfi'O/fab5c2606a93d0248625792f00514dc8/$FILE/ AC%2025-19A.pdf • Since issuance on April 19, 2001, Amendment 25-l 02 to part 25, introduced additional requirements specific to fuel tank systems and fuel tank ignition prevention. Since issuance of this safety recommendation, Appendix H25.4, Airworthiness Limitations, effective on January 14, 2011, was revised to require identification of Critical Design Configuration Control Limitations (COCCL) which prevents development of ignition sources within fuel tank systems.

The CDCCLs are defined in the Airworthiness Limitations section and describe specific design features in the fuel tank system that must be maintained throughout the service life of the airplane. • On November 4, 2014, Amendment 25- 123 to part 25, introduced additional requirements specific to electrical wiring interconnection systems (EWIS). As part of this amendment, new part 25 standards were introduced to require that all electrical wiring be considered as a separate system. In addition, Appendix H25.4 was revised to require identification in the Airworthiness Limitations section of EWIS component mandatory replacement times.

Certification project data retention requirements described in FAA Order 811 0.4C, Type Certification, require the certification data supporting the above compliance requirements to be retained by either the type certificate holder or the FAA office responsible for the type certification project.

The above guidance and required actions, taken together, satisfy the intent of the proposed KSI AC and the objective of this safety recommendation.

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

December 9, 2014 · NTSB Correspondence · FAA

In your May 6, 2011, letter, you said that you planned to issue a Key Safety Information (KSI) advisory circular (AC) that would reflect the findings of the Commercial Aviation Safety Team Safety Enhancement 172, which used KSIs to perform an analysis of maintenance processes used with aircraft to ensure that the certified design level of safety was maintained throughout the operational life of an airplane.

On September 14, 2011, we replied that the development and use of KSIs would constitute an acceptable response to this recommendation provided that the information used to develop the KSI (such as the rationale, analysis methods, failure scenarios, supporting evidence, and associated issue papers used to identify and assess safety-critical systems) were placed in the official type certification project file. We asked that you describe the methods and procedures that would ensure that the appropriate information were placed in this file.

In your October 28, 2013, letter, you said that the System Safety Assessment (SSA) is the project-level compliance document that contains the failure scenarios and supporting evidence used to develop the KSI. You explained that the SSA is covered under the data retention requirements of FAA Order 8110.4C, Appendix 10, and is retained by either the type certificate holder or the FAA office responsible for the type certification project. You also said that you planned to issue, by December 31, 2013, a draft KSI AC applicable to Part 25 products that would be available for public comment. However, you have not yet issued the draft AC.

We recently learned from your staff that you no longer intend to issue it, but have instead developed several other actions that you believe will fully satisfy Safety Recommendation A 06 36.

The procedures used under FAA Order 8110.4C to retain the information in the SSA satisfy our concern that the information must be available in the type certification project file. Had you issued the KSI AC, it likely would have completed the action recommended. However, we are concerned with your lack of progress in fully implementing this recommendation, which is now 8 1/2 years old. We are not aware of the mitigations in place of the KSI AC that you believe will fully satisfy this recommendation; therefore, we cannot comment on whether or not they will do so.

Pending our receipt of details regarding your planned mitigations and your timely completion of action that fully satisfies Safety Recommendation A-06-36, the recommendation remains classified OPEN—ACCEPTABLE RESPONSE.

October 28, 2013 · Recipient Response · FAA

-From Michael P. Huerta, Administrator: In our May 6, 2011, response, the FAA conveyed our plan to issue a Key Safety Information (KSI) advisory circular (AC) coordinated with the findings of the Commercial Aviation Safety Team Safety Enhancement 172.

We initially planned to issue the AC only for part 25 aircraft but delayed implementation for part 25 aircraft while we considered the benefits of implementation for parts 23, 27, 29, and 33 products. We recently determined that the AC should be applied to a broader group of type certificated products. However, as there have been significant delays in issuing this AC across product types, we will not further delay the implementation for part 25 products. We plan to issue a draft KSI AC applicable to part 25 products for public comment by December 31, 2013.

The proposed AC will provide the rationale for selection of KSI and the recommended analysis methods. The System Safety Assessment (SSA) is the project-level compliance document that contains the failure scenarios and supporting evidence used to develop the KS I. The SSA is considered an analysis report covered under the data retention requirements of FAA Order 81 10.4C, Appendix 10 and thus is retained by either the type certificate holder or the FAA office responsible for the type certification project. We believe that upon publication of the AC and with the existing requirements of Order 8110.4, the intent of this recommendation will be fulfilled.

I will keep the Board informed of the FAA's progress on this safety recommendation and provide a further response by August 31, 2014.

September 14, 2011 · NTSB Correspondence · FAA

Staff from the FAA and the NTSB met on March 28, 2007, to discuss in detail the FAA’s planned actions in response to the recommendations issued in the NTSB’s special study of the treatment of safety-critical systems. In this meeting, the FAA indicated that an important development in analysis methods during type certification would be the identification of key safety information (KSI), using various certification safety assessments. At that time, the FAA was developing a white paper to document the process for developing KSI, and the white paper was to constitute the basis for an advisory circular (AC) that would be issued.

Since that meeting, the FAA finished the white paper, and, using KSI, performed an analysis of maintenance processes used with aircraft to ensure that the certified design level of safety is maintained throughout the operational life of the airplane. Having completed this maintenance analysis, the FAA plans to publish an AC concerning KSI.

The development and use of KSI will constitute an acceptable response to this recommendation provided that the information used to develop the KSI (such as the rationale, analysis methods, failure scenarios, supporting evidence, and associated issue papers used to identify and assess safety-critical systems) is placed in the official type certification project file. The NTSB asks the FAA to describe the methods and procedures that will be implemented after the AC is issued to ensure that the appropriate information is placed in this file.

Pending issuance of the AC and details concerning the methods and procedures that will be used to retain, in the official type certification project file, the information used to develop the KSI, Safety Recommendation A-06-36 remains classified OPEN—ACCEPTABLE RESPONSE.

May 6, 2011 · Recipient Response · FAA

CC# 201100201: - From J. Randolph Babbitt, Administrator: Following our August 17, 2006 response, the Federal Aviation Administration (FAA) forwarded a copy of the Key Safety Information (KSI) team's white paper to the Board. In October 2007, the Commercial Aviation Safety Team approved an activity to ensure that maintenance processes maintain the certified design level of safety for the operational life of the airplane as a follow on to KSI. This activity is identified as Safety Enhancement (SE) 172.

SE 172 began its work in September 2009 and plans to address concerns that there may be gaps in the governing maintenance processes that could inhibit the intended design level of safety from being sustained throughout an airplane's life. This team reviewed the overarching processes that govern maintenance to determine if such gaps exist within or between these processes and to recommend solutions to address any gaps discovered. The FAA plans to publish a KSI Advisory Circular (AC) fully coordinated with the findings of the SE 172 team. The draft AC is currently in development and is expected to be published by December 2011.

September 12, 2007 · NTSB Correspondence · FAA

During the March 28, 2007, meeting, the FAA discussed its efforts to develop and implement a safety management system (SMS) integral to all certification projects. The FAA indicated that an important development in analysis methods during type certification will be the identification of key safety information (KSI). KSI will be identified and documented using various certification safety assessments; the process for doing so is being developed by the FAA in a white paper, which will later be used as the basis of an advisory circular. The FAA believes that the development and implementation of the process is responsive to this recommendation.

The Safety Board is encouraged by the FAA’s plans to develop and implement an SMS, including KSI, as part of each type certification project. Pending the completion of the actions outlined above, Safety Recommendation A-06-36 is classified OPEN -- ACCEPTABLE RESPONSE.

August 17, 2006 · Recipient Response · FAA

Letter Mail Controlled 8/29/2006 8:26:32 AM MC# 2060429: - From Marion C. Blakey, Administrator: The FAA agrees with the intent of these safety recommendations, and we have been working on several initiatives that we feel address the issues underlying them. For example, based on the outcome of our Certification Process Study (CPS), we launched a number of initiatives, including an initiative called Key Safety Information, which is closely related to the safety critical systems concept. Other initiatives address maintenance human factors as well as oversight of repairs, alterations, and maintenance.

In response to these recommendations, we have formed an internal team to evaluate current FAA initiatives. This team will assess the CPS initiatives, FAA’s research program, and rulemaking projects to determine relevance to the recommendations. The team will then identify any shortfalls and propose any refinements to our strategy, if necessary. We plan to complete that assessment by September 2006. We would like to meet with your staff after that time to discuss the results. A member of my staff will contact you to establish a meeting date. After those discussions, we will revise our plans for addressing the recommendations and provide you with a formal status update by January 31, 2007.

I will keep the Board informed of the FAA’s progress on these safety recommendations.

Minutes of 3/28/07 Meeting between FAA and NTSB staff discussing recommendations from Certification Study The FAA indicated that as part of its efforts to develop a Safety Management System (SMS), it would continue to review and revise existing guidance in an integrated manner. Although the Safety Board believes development of an SMS to be an excellent practice that should be encouraged, Safety Recommendation A-06-36 asks for a specific action. That action is creation of a list of safety critical systems for each certification project, and that a permanent record including supporting analysis and evidence be maintained.

The FAA indicated that it intended to focus on all safety critical information not just information about safety critical systems. The FAA considers proper development and implementation of the KSI concept will address this recommendation.