NTSB · Safety Recommendation
Safety Recommendation A-90-099
Recommendation
THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REQUIRE AIR CARRIERS TO PERFORM A ONE-TIME INSPECTION OF THE OXYGEN SYSTEMS ON THEIR AIRPLANES AND PROMPTLY REPAIR ALL LEAKS.
Safety Issue and Context
ON OCTOBER 14,1989, ABOUT 1411 MOUNTAIN DAYLIGHT TIME, A FIRE ERUPTED ON N530DA, A BOEING 727-232 THAT HAD BEEN PARKED AT GATE C4 AT SALT LAKE CITY INTERNATIONAL AIRPORT (SLC), SALT LAKE CITY, UTAH. THE AIRPLANE HAD BEEN OPERATED UNDER TITLE 14 CODE OF FERDERA REGULATIONS (CFR) PART 121 AS DELTA AIR LINES FLIGHT 1558, A SCHEDULED INTERNATIONAL REVENUE PASSENGER FLIGHT FROM LOS ANGELES, CALIFORNIA, TO EDMONTON, ALBERTA, CANADA, WITH A STOP AT SLG. THREE FLIGHT CREWMEMBERS, 4 FLIGHT ATTENDANTS AND 12 THROUGH PASSENGERS WHO HAD BOARDED AT LOS ANGELES WERE ON BOARD THE AIRPLANE WHEN THE FIRE ERUPTED.
THE SECOND OFFICER WAS SEATED AT THE FLIGHT ENGINEER'S CONSOLE WHILE THE CAPTAIN AND FIRST OFFICER, WHO HAD JUST ENTERED THE AIR PLANE, WERE STANDING JUST FORWARD OF THE ENTRANCE TO THE COCKPIT. A DELTA AIR LINES MECHANIC WAS IN THE ELECTRICAL EQUIPMENT (EE) COMPARTMENT BELOW THE CABIN SERVICING THE PASSENGER OXYGEN SYSTEM.
Response History
March 4, 1993 · NTSB Correspondence · FAA
THE BOARD NOTES THAT THE FAA BELIEVES THAT NOTICE 8300.85 ADDRESSES THE CONCERNS OF THE BOARD BECAUSE IT REQUIRES PRINCIPAL MAINTENANCE INSPECTORS TO ENSURE THAT EACH OPERATOR'S PROGRAM IS STRUCTURED TO DETECT & REPAIR LEAKING AIRCRAFT OXYGEN SYSTEMS ON A CONTINUING BASIS. FURTHERMORE, SPECIFIC MAINTENANCE ACTIONS ON INDIVIDUAL AIRCRAFT ARE AN INTEGRAL PART OF AN OPERATOR'S FAA-APPROVED CONTINUOUS AIRWORTHINESS MAINTENANCE PROGRAM. BASED ON THIS INFO, THE BOARD CLASSIFIES RECOMMENDATION A-90-99 "CLOSED--ACCEPTABLE ALTERNATE ACTION."
August 17, 1992 · Recipient Response · FAA
THE FAA DOES NOT AGREE WITH THIS SAFETY RECOMMENDATION. THE FAA REQUIRES AIR CARRIERS TO PERFORM A ONE-TIME INSPECTION IF THERE IS AN INDICATION OF AN IMMINENT UNSAFE CONDITION. THIS IS NOT THE SITUATION WITH THE SUBJECT OF THIS SAFETY RECOMMENDATION. THE FAA BELIEVES THAT ACTION DESCRIBED IN NOTICE 8300.85, SERVICING AND MAINTAINING OXYGEN SYSTEMS ON AIR CARRIER AIRCRAFT WHILE PASSENGERS ARE ABOARD, ADDRESSES THE CONCERNS OF THE SAFETY BOARD.
IT MUST BE NOTED THAT FOCUSING ON INDIVIDUAL MAINTENANCE ACTIONS ON INDIVIDUAL AIRCRAFT WILL SOLVE AN OXYGEN LEAK ON A PARTICULAR AIRCRAFT AT A PARTICULAR TIME BUT WILL DO NOTHING TO ADDRESS AIRCRAFT OXYGEN LEAKS ON A LONG-TERM AND CONTINUING BASIS. SINCE SPECIFIC MAINTENANCE ACTIONS ON INDIVIDUAL AIRCRAFT ARE AN INTEGRAL PART OF AN OPERATOR'S FAA-APPROVED CONTINUOUS AIRWORTHINESS MAINTENANCE PROGRAM, THE INTENT OF THE BOARD'S RECOMMENDATION IS ALREADY IN PLACE, ALTHOUGH ON A CONTINUING BASIS RATHER THAN ON A SINGULAR BASIS.
NOTICE 8300.85 REQUIRES PRINCIPAL MAINTENANCE INSPECTORS TO ENSURE THAT EACH OPERATOR'S FAA-APPROVED CONTINUOUS AIRWORTHINESS MAINTENANCE PROGRAM IS STRUCTURED TO DETECT AND REPAIR LEAKING AIRCRAFT OXYGEN SYSTEMS ON A CONTINUING BASIS RATHER THAN ON A SINGULAR BASIS.
February 21, 1991 · NTSB Correspondence · FAA
Safety Recommendation A-90-99 states that the FAA should require air carriers to perform a one-time inspection of the oxygen systems on their airplanes and promptly repair all leaks. The FAA's stated intention to review maintenance programs and to correct individual problems as they arise is not responsive to A-90-99. Focusing on air carrier maintenance programs alone would overlook specific maintenance actions that are performed on individual airplanes. Since the FAA letter attributes the October 14, 1989 Delta Airlines fire to "alleged violations of existing regulations," the FAA's intended action would not have included this airplane.
The Safety Board requests that the FAA reevaluate its position. Until then, Safety Recommendation A-90-99 is classified "Open--Unacceptable Response."
November 21, 1990 · NTSB Correspondence · FAA
The Safety Board notes that the FAA is reviewing Safety Recommendations A-90-93 through -96 and A-90-98 and -99 and that it will apprise the Safety Board of its course of action. We will hold these safety recommendations in an "Open--Await Response" status.
October 15, 1990 · Recipient Response · FAA
THE FAA DOES NOT AGREE THAT AN IMMINENTLY "UNSAFE" CONDITION EXISTS TO REQUIRE THE INSPECTIONS & THAT THIS ACCIDENT WAS CAUSED BY VIOLATIONS OF EXISTING REGULATIONS. AFTER ANALYSIS OF EACH OPERATOR'S PROGRAMS, INDIVIDUAL PROBLEMS WILL BE FOUND AND CORRECTED.
September 6, 1990 · Recipient Response · FAA
"THE FAA IS IN THE PROCESS OF REVIEWING THESE SAFETY RECOMMENDATIONS. I WILL APPRISE THE BOARD OF THE FAA'S COURSE OF ACTION TO ADDRESS EACH OF THESE SAFETY RECOMMENDATIONS AS SOON AS THE REVIEW IS COMPLETED."