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NTSB · Safety Recommendation

Safety Recommendation A-82-057

Recommendation

THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REVIEW AND EVALUATE THE DESIGN OF ALL ISOPROPYL ALCOHOL WINDSHIELD DEICING SYSTEM INSTALLATIONS ON AIRCRAFT TO VERIFY COMPLIANCE WITH APPLICABLE FEDERAL AVIATION REGULATIONS PERTAINING TO FLAMMABLE FLUID FIRE PROTECTION, AND TAKE ACTION TO CORRECT ANY DEFICIENCIES FOUND.

Safety Issue and Context

ON FEBRUARY 21, 1982, A PILGRIM AIRLINES DHC-6-100, N127PM, OPERATING AS FLIGHT 458 BETWEEN GROTON, CONNECTICUT, AND BOSTON, MASSACHUSETTS, WAS FORCED TO MAKE AN EMERGENCY DESCENT FROM CRUISING ALTITUDE BECAUSE OF AN IN-FLIGHT FIRE IN THE COCKPIT AND FORWARD CABIN AREAS. THE AIRCRAFT, WITH 10 PASSENGERS AND 2 CREWMEMBERS ON BOARD, CRASHLANDED ON THE FROZEN SURFACE OF THE SCITUATE RESERVOIR NEAR PROVIDENCE, RHODE ISLAND, THE FIRE CONTINUED TO BURN AFTER THE AIRCRAFT CAME TO REST AND COMPLETELY DESTROYED THE COCKPIT AND PASSENGER CABIN. ONE PASSENGER WAS KILLED AS A RESULT OF THE ACCIDENT.

THE SAFETY BOARD BELIEVES THAT THE ISOPROPYL ALCOHOL WINDSHIELD DEICING INSTALLATION ON THE DHC-6 MODEL AIRCRAFT CONFIGURED FOR OPERATION IN ICING CONDITIONS PRESENTS A FIRE HAZARD WHICH SHOULD BE ELIMINATED. IT IS THE SAFETY BOARD'S UNDERSTANDING THAT DEHAVILLAND AIRCRAFT OFFERS A HEATED WINDSHIELD AS AN ALTERNATE INSTALLATION FOR THOSE AIRCRAFT.

Response History

June 22, 1984 · NTSB Correspondence · FAA

We are pleased to receive the FAA's review and evaluation of the design of all isopropyl alcohol windshield deicing systems on aircraft to verify compliance with Federal Aviation Regulations pertaining to flammable fluid fire protection. We are also pleased to receive a copy of the FAA's of General Aviation Airworthiness Alert No. 64, issued in November 1983, calling attention to the fire hazard resulting from the isopropyl alcohol deicer installation. The actions taken fully comply with Safety Recommendation A-82-57 which is now classified in a "Closed--Acceptable Action" status.

May 14, 1984 · Recipient Response · FAA

FAA COMMENT: ENCLOSED FOR THE BOARD'S INFORMATION IS A COPY (COVER PAGE AND PAGE 10 ONLY) OF THE NOVEMBER 1983 ISSUE OF THE GENERAL AVIATION AIRWORTHINESS ALERTS, ALERT NO. 64 (ADVISORY CIRCULAR (AC) 43-16). THIS ALERT CALLS ATTENTION TO OUR MUTUAL CONCERN RELATIVE TO ISOPROPYL ALCOHOL DEICE SYSTEMS. AS REQUESTED IN YOUR LETTER DATED JANUARY 18, 1984, ENCLOSED IS A COPY OF THE FEDERAL AVIATION ADMINISTRATION'S (FAA) REVIEW AND EVALUATION OF THE DESIGN OF ALL ISOPROPYL ALCOHOL WINDSHIELD DEICING SYSTEMS ON AIRCRAFT TO VERIFY COMPLIANCE WITH FEDERAL AVIATION REGULATIONS PERTAINING TO FLAMMABLE FLUID FIRE PROTECTION.

THE FAA'S REVIEW AND EVALUATION DID NOT IDENTIFY ANY NONCOMPLIANCE ITEMS NOR WERE THERE ANY UNSAFE CONDITIONS NOT ALREADY CORRECTED BY AIRWORTHINESS DIRECTIVE ACTION.

January 18, 1984 · NTSB Correspondence · FAA

We are pleased to note that the FAA has completed its review and evaluation of the design of all isopropyl alcohol windshield deice systems on small airplanes to verify compliance with Federal Aviation Regulations. The FAA's action to send a General Notice to alert appropriate facilities to problems in isopropyl alcohol systems and recommending surveillance and reporting of unsafe conditions is an extra step that should greatly reduce the probability of this type of event occurring again. We are pleased also that you will further publicize this problem in the November General Aviation Airworthiness Alerts. The actions taken and ongoing

comply with this recommendation which is now classified in a "Open--Acceptable Action" status. Prior to closing this recommendation, we would appreciate receiving a copy of the FAA's evaluation and details as to the models and number of aircraft affected.

September 20, 1983 · Recipient Response · FAA

FAA LETTER: THIS REVIEW HAS BEEN COMPLETED AND REVEALED THAT ON OTHER THAN THE MODEL DHC-6 AIRPLANE THERE IS VERY LIMITED ADVERSE SERVICE HISTORY. IN ADDITION, AND ON THE BASIS OF OUR INVESTIGATION, WE BELIEVE THAT ONLY A LIMITED NUMBER OF THE SMALL AIRPLANE POPULATION UTILIZES ISOPROPYL ALCOHOL DEICE SYSTEMS, AND OF THOSE INSTALLATIONS CONFIRMED, AN EVEN SMALLER NUMBER ARE SUSPECTED OF HAVING UNPROTECTED ALCOHOL COMPONENTS WITHIN OCCUPIED COMPARTMENTS. ENCLOSED FOR THE BOARD'S INFORMATION AND FILE IS A COPY OF A GENERAL NOTICE (GENOT) THAT WAS SENT TO ALL APPROPRIATE FAA FACILITIES ALERTING THEM TO THE PROBLEMS WITH ISOPROPYL ALCOHOL SYSTEMS.

THE GENOT RECOMMENDS SURVEILLANCE OF MAINTENANCE MANUALS, PROCEDURES, AND INSPECTION INTERVALS. THE GENOT ALSO REQUESTS THAT ANY UNSAFE CONDITIONS ENCOUNTERED BE REPORTED TO THE SMALL AIRPLANE CERTIFICATION DIRECTORATE FOR EVALUATION AND APPROPRIATE ACTION. THE FAA IS ALSO PUBLISHING A SAFETY ITEM CONCERNING ISOPROPYL ALCOHOL DEICE SYSTEMS IN THE FAA'S GENERAL AVIATION AIRWORTHINESS ALERTS NOVEMBER PUBLICATION.

July 5, 1983 · NTSB Correspondence · FAA

The project being implemented by the Small Airplane Certification Directorate should, when completed, satisfy the intent of this recommendation. Pending receipt of the results to the Directorate's review and evaluation, Safety Recommendation A- 82-58 will be held in an "Open--Acceptable Action" status.

April 7, 1983 · Recipient Response · FAA

FAA LETTER: THE FAA'S SMALL AIRPLANE CERTIFICATION DIRECTORATE IN KANSAS CITY ESTABLISHED A PROJECT TO HAVE ALL AIRCRAFT CERTIFICATION OFFICES REVIEW AND EVALUATE THE DESIGN OF ALL ISOPROPYL ALCOHOL WINDSHIELD DEICE SYSTEMS ON SMALL AIRPLANES, THE INSTALLATION OF THESE SYSTEMS IN OCCUPIED COMPARTMENTS, AND SYSTEM COMPLIANCE WITH APPLICABLE FEDERAL AVIATION REGULATIONS. WHEN THIS REVIEW AND EVALUATION IS COMPLETED, WE WILL ADVISE THE BOARD OF OUR CONCLUSIONS AND ANY ACTIONS TAKEN. WE EXPECT OUR REVIEW TO BE COMPLETED BEFORE JULY 1983.

November 2, 1982 · NTSB Correspondence · FAA

We note that a project is being established to review the design of isopropyl alcohol windshield de-ice systems for compliance with the Federal Aviation Regulations. Pending the results of the FAA's findings, this recommendation is also classified in an "Open--Acceptable Action" status.

September 28, 1982 · Recipient Response · FAA

FAA LTR: THE FAA'S SMALL AIRCRAFT CERTIFICATION DIRECTORATE IN KANSAS CITY IS ESTABLISHING A PROJECT TO HAVE ALL AIRCRAFT CERTIFICATION OFFICES REVIEW AND EVALUATE THE DESIGN OF ALL ISOPROPYL ALCOHOL WINDSHIELD DEICE SYSTEMS ON SMALL AIRPLANES. THE SURVEY WILL VERIFY COMPLIANCE OF THE DEICING SYSTEMS WITH APPLICABLE FEDERAL AVIATION REGULATIONS.

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Recommendation Facts

Status
Closed - Acceptable Action
Issued
July 13, 1982
Priority
CLASS II
Recipient
FAA
Adopted
July 2, 1982
Closed
June 22, 1984
Related Investigation
DCA82AA016
Related Report
AAR-82-07