NTSB · Safety Recommendation
Safety Recommendation A-85-029
Recommendation
THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: ISSUE A TELEGRAPHIC ALERT TO SUPPLIERS AND OWNERS OF THE EASTERN AERO MARINE MODEL GA-12 FLOTATION DEVICES THAT THESE DEVICES MAY BE MISLABELED, THAT THE CO2 CYLINDERS MAY BE LOOSE, AND THAT THEY MAY NOT COMPLY WITH TSO-C72B BUOYANCY AND PRESSURE TEST CRITERIA; AND ADVISE SUPPLIERS AND OWNERS TO HAVE THESE DEVICES OVERHAULED IN ACCORDANCE WITH EASTERN AERO MARINE'S INSPECTION, MAINTENANCE AND REPAIR MANUAL.
Safety Issue and Context
ON AUGUST 2, 1984, A BRITTEN-NORMAN BN-2A6 AIRPLANE OPERATED BY VIEQUES AIR LINK (VAL) CRASHED INTO THE SEA NEAR THE VIEQUES AIRPORT, PUERTO RICO. THE AIRPLANE, WITH A PILOT AND EIGHT PASSENGERS ONBOARD, HAD JUST TAKEN OFF FROM THE VIEQUES AIRPORT WHEN, AT AN ALTITUDE OF ABOUT 200 FEET, IT TURNED BACK TO THE AIRPORT, LOST ALITUDE, AND CRASHED INTO THE WATER. THE AIRPLANE CAME TO REST IN ABOUT 20 FEET OF WATER, AND ALL PERSONS ONBOARD WERE KILLED.
Response History
September 27, 1988 · NTSB Correspondence · FAA
The Safety Board does not agree that the intent of Safety Recommendation A-85-29 has been met. Due to the fact that a large number of the flotation devices were produced and sold, many probably have been resold by the original owners. As stated in the Safety Board's letter of August 19, 1985, similar flotation devices were found mislabeled on a New York Helicopter, Inc., Aerospatiale 360 which crashed in New York on April 26, 1985. It is also probable that a number of these devices are in use on foreign aircraft. The Maintenance Bulletin published by the FAA and the Service Information Letter are non-binding and even at that, they may not be
available, other than when flotation devices are reinspected at a facility which Eastern Aero has advised, or which maintains the FAA Maintenance Bulletins. It is believed that Eastern Aero Marine and the FAA have had good intentions in attempting to resolve this matter; however, the actions taken could not have addressed all devices in use. Due to the time which has passed since this safety recommendation was issued, the Safety Board must agree that the timing for a telegraphic alert notice to owners has also passed. The Safety Board has therefore classified Safety Recommendation A-85-29 as "Closed--Unacceptable Action."
July 12, 1988 · Recipient Response · FAA
"THE FAA BELIEVES THAT THE INTENT OF THIS SAFETY RECOMMENDATION HAS BEEN MET. IN SEPTEMBER 1984, EASTERN AERO MARINE ISSUED A SERVICE INFORMATION LETTER TO NOTIFY ALL DISTRIBUTORS AND AUTHORIZED OVERHAUL STATIONS TO AMEND THE LABELING OF THOSE DEVICES WHICH HAD BEEN RELEASED WITH ERRONEOUS INFORMATION. EASTERN AERO MARINE ALSO NOTIFIED THE MAJOR CUSTOMERS OF THE POSSIBILITY OF LOOSE CYLINDERS AND REQUESTED NOTIFICATION IF ANY WERE FOUND. NO LOOSE CYLINDERS HAVE BEEN REPORTED. THE FAA CONSIDERS THE LOOSE CYLINDER DISCREPANCIES AN ISOLATED CASE DUE TO A FAULTY INSPECTION PROCEDURE OF VIEQUES AIR LINK (THE OPERATOR). ON JULY 18, 1985, THE FAA PUBLISHED MAINTENANCE BULLETIN NO.
25-44 IN HANDBOOK 8430.1A ADVISING ALL MAINTENANCE INSPECTORS OF THE MISLABELING SITUATION AND THE POSSIBILITY OF LOOSE CYLINDERS....THE FAA DOES NOT BELIEVE THAT AN ADDITIONAL TELEGRAPHIC ALERT TO ALL OWNERS IS NECESSARY...AND I PLAN NO FURTHER ACTION..."
August 19, 1985 · NTSB Correspondence · FAA
While the issuance of the planned maintenance bulletin may correct the problems with these devices that are in the possession of air carriers, there are potentially thousands of individual private owners of GA-12 devices who will not be reached by a maintenance bulletin. The Safety Board continues to believe that all owners of these devices should be notified of the problems found with the GA-12 device. We continue to believe that a telegraphic alert is the best way to accomplish this. Pending FAA's reconsideration of this recommendation, Safety Recommendation A-85-29 has been classified as "Open--Unacceptable Action."
June 13, 1985 · Recipient Response · FAA
FAA LETTER: THE OWNERS AND SUPPLIERS OF THE EAM MODEL GA-12 FLOTATION DEVICES WERE NOTIFIED THAT SOME OF THE FLOTATION DEVICES HAD BEEN MISLABELED AND THAT THE CO2 CYLINDERS MIGHT BE LOOSE, AND THAT PROPER INSPECTIONS HAD NOT BEEN CONDUCTED AND PROPER PROCEDURES NOT FOLLOWED. WE BELIEVED THAT THIS ACTION AND THE ISSUANCE OF AN FAA MAINTENANCE BULLETIN, AS NOTED IN OUR RESPONSE TO RECOMMENDATION A-85-28, MEETS THE INTENT OF THIS RECOMMENDATION. THEREFORE, WE PLAN NO FURTHER ACTION ON THIS RECOMMENDATION.