Safety Recommendation A-95-148

On February 7, 1997, the FAA issued Special Airworthiness Information Bulletin (SAIB) No. ANE-97-01 concerning potential unairworthy emergency equipment products returned to service by Tec-Air Services repair stations. The bulletin solicits the assistance of owners and/or operators in identifying these products and determining whether aircraft emergency equipment and appliances overhauled, repaired, or services by Tec-Air meet all applicable requirements. The FAA's letter indicates that the public's response to SAIB ANE-97-01 disclosed no confirmed failures of products last serviced by Tec-Air and that no unsafe conditions exists associated with these products.

In December 1994, the FAA inspected Tec-Air's East Northport, New York, facility, Repair Station No. MA1R315K, and found that Tec-Air violated or failed to demonstrate compliance with 10 sections of the Federal Aviation Regulations relating to Parts 21, 43, and 145. The investigation cited numerous occasions on which Tec-Air had approved oxygen cylinder assemblies and aircraft fire extinguishers for return to service, including parts utilized on passenger-carrying aircraft under Part 121, when such equipment was unairworthy.

Based on Tec-Air's inadequate record system, it could not be determined whether Tec-Air replaced parts as required during overhaul, utilized old parts, or changed the parts at all. Additionally, Tec-Air manufactured and/or altered oxygen hose assemblies without appropriate parts-manufacturing approval and subsequently sold the parts under false pretenses, indicating that they were manufactured by another (authorized) manufacturer. Based on the above information, the FAA concluded that other aircraft emergency equipment, including oxygen regulators, panels, valves, and masks, might also have been improperly overhauled or repaired before it was returned to service.

On January 4, 1995, Tec-Air's East Northport repair station certificate was suspended under an emergency order. In view of the above, the Safety Board does not believe that the FAA's issuance of SAIB ANE-97-01 concerning further identification of potential unairworthy products overhauled, repaired, or serviced by Tec-Air is an appropriate or timely response to this safety recommendation. SAIB No ANE-97-01 was issued for informational purposes only and the recommendations therein, e.g., requesting that owner/operators determine whether or not Tec-Air serviced emergency equipment is airworthy, are not mandatory.

Therefore, it is unlikely that all applicable emergency equipment has been identified and, since SAIB No. ANE-97-01 prescribes no specific procedures for disassembly or testing, the airworthiness of the 640 items that were identified is problematical. The Safety Board believes, based on the FAA's December 1994 inspection of Tec-Air, and the accident on February 21, 1995, involving an oxygen system fire on an Israel Aircraft Industries (IAI) 1124 airplane, N66JE, that an airworthiness directive should have been issued requiring detailed inspection and testing of emergency equipment last serviced by Tec-Air to ensure its continued airworthiness.

Moreover, the Safety Board believes that some of the potentially unairworthy emergency equipment last serviced by Tec-Air consituted an in-flight fire/explosion hazard that the FAA should have addressed immediately. Therefore Safety Recommendation A-95-148 is classified "Closed--Unacceptable Action."

On February 7, 1997, the Federal Aviation Administration (FAA) issued Special Airworthiness Information Bulletin No. ANE-97-01 against Tec-Air emergency equipment products in service. The bulletin alerted all aircraft and/or rotorcraft operators and FAA principal maintenance inspectors of potential unairworthy products returned to service by Tec-Air Services repair stations. The bulletin asked that all owners and/or operators review their internal operations for products last serviced by Tec-Air and formulate a list of those products by type of equipment, manufacturer, model, part number, serial number, applicability, and quantity of each product.

The bulletin also asked that appropriate action be taken by all owners and/or operators to determine whether aircraft emergency equipment and appliances overhauled, repaired, or serviced by Tec-Air, to be utilized on aircraft, meet all applicable requirements. A copy of the bulletin was provided to be Board on March 12, 1997. In response to the bulletin, the FAA received a list of 640 products that have been serviced by Tec-Air since 1991. Each operator providing the information had independent quality control systems in place and reviwed its records for possible trends in unscheduled removals and/or confirmed failures of their products last serviced by Tec-Air.

Each operator stated that there were no abnormal problems or increase in removals and/or confirmed failures of these products. The results of this survey indicate that there is no unsafe condition associated with products serviced by Tec-Air. Consequently, the FAA does not plan to issue an airworthiness directive (AD) against any emergency equipment last serviced by Tec-Air. With respect to the oil contamination concerns raised in the Board's letter dated June 17, 1997, there are many ways contaminants can be introduced into an oxygen system.

Contamination can occur during a scheduled overhaul of the system by a repair station or any time an oxygen system component is handled for repair, replenishing, or installation if it is not done with extreme caution in accordance with manufacturer guidelines and industry standards. The more a system is handled, the greater the risk of contamination occurring. The FAA has investigated the maintenance records of Israel Aircraft Industries 1124 Westwind airplane for all oxygen system-related entries between January 11, 1994, when the overhaul was performed by Tec-Air and February 21, 1995, when the incident occurred.

It was determined that maintenance was completed at facilities which utilize proper precautionary measures in addition to the manufacturer's instructions. The right combination of oil and oxygen can result in spontaneous ignition. If enough oil is present and there is limited air circulation, the chemical reaction between the oil and oxygen will release enough heat to raise the temperature until the ignition temperature is reached. This was not the case in the incident airplane, since the fire did not occur in the oxygen bottle. If Tec-Air's servicing introduced sufficient contaminants to result in spontaneous ignition, there would be more incidents of aircraft fires.

THE BOARD SUPPORTS THE ACTIONS CITED IN SAIB ANE-97-01, AS IT DID THE FAA'S 1995 REFERENCE IN ADVISORY CIRCULAR (AC) 43-16, "GENERAL AVIATION AIRWORTINESS ALERTS," TO UNAIRWORTHY EMERGENCY EQUIPMENT. HOWEVER, THE BOARD IS DISAPPOINTED BY THE SIGNIFICANT AMOUNT OF TIME THAT HAS ELAPSED WITHOUT MANDATORY ACTION TO ELIMINATE AN AIRWORTHINESS CONDITION THAT COULD CAUSE FUTURE ACCIDENTS. PART OF THE RATIONALE PROVIDED BY THE FAA FOR NOT TAKING MANDATORY ACTION RELEVANT TO TEC-AIR INCLUDES THE POSSIBILITY THAT OIL CONTAMINATION COULD HAVE BEEN INTRODUCED INTO THE ASSEMBLY BY SEVERAL MEANS INDEPENDENT OF TEC-AIR'S ACTIONS.

HOWEVER, THE FAA DOES NOT CITE ANY ACTIONS TAKEN TO REMEDY SUCH A POSSIBILITY. ADDITIONALLY, THE FAA CITES THE POSSIBILITY THAT THE FIRE ABOARD THE ACCIDENT AIRPLANE MAY HAVE BEEN INITIATED BY A FAILURE OF THE PRESSURE REDUCER REGULATOR. THE FAA ADDED THAT SERVICE DIFFICULTY REPORTS REVEALED FOUR INCIDENTS OF OXYGEN LEAKS ATTRIBUTED TO PRESSURE REGULATOR FAILURES. ASTRA JET CORPORATION, THE DISTRIBUTOR FOR WESTWIND, IS CONSIDERING ISSUING A SERVICE BULLETIN TO MODIFY THE EXISTING OXYGEN SYSTEM ON ISRAEL AIRCRAFT INDUSTRIES' AIRCRAFT, AND THE FAA WILL CONSIDER MANDATING CORRECTIVE ACTIONS IF DEEMED NECESSARY.

THE SAFETY BOARD CONTINUES TO BELIEVE THAT SOME TYPE OF MANDATORY ACTION IS NECESSARY TO ENSURE THAT THE CIRCUMSTANCES THAT LED TO THE ACCIDENT THAT PROMPTED A-95-148 ARE NOT REPEATED. IF THE REASON(S) FOR THE FIRE-SHOULD INCLUDE SOURCES OTHER THAN TEC-AIR, IT WOULD BE APPROPRIATE FOR THE FAA TO TAKE WHATEVER ACTION IS NECESSARY TO CORRECT ANY DEFICIENCIES FOUND. THE BOARD IS DISAPPOINTED THAT SUCH ACTION HAS NOT YET BEEN TAKEN. CONSEQUENTLY, A-94-148 IS CLASSIFIED "OPEN--UNACCEPTABLE RESPONSE," PENDING A TIMELY ASSURANCE FROM THE FAA THAT ACTIONS HAVE BEEN COMPLETED TO ELIMINATE THE HAZARD(S) THAT CAUSED THE FIRE ABOARD THE ACCIDENT AIRPLANE.

THE FAA HAS TWO INITIATIVE UNDERWAY TO ADDRESS THIS RECOMMENDATION. THE FIRST INITIATIVE IS TO EVALUATE TEC-AIR'S EMERGENCY EQUIPMENT NOW IN SERVICE TO ASSESS WHETHER THOSE PRODUCTS POSE AN UNSAFE CONDITION. THE SECOND INITIATIVE IS TO DETERMINE IF A PREMATURE PRESSURE REGULATOR FAILURE MAY HAVE BEEN INVOLVED IN THIS INCIDENT. WITH RESPECT TO THE EQUIPMENT SERVICED BY TEC-AIR, THE FAA ISSUED SPECIAL AIRWORTHINESS INFO BULLETIN NO. ANE-97-01 ON 2/7/97, AGAINST TECH-AIR EMERGENCY EQUIPMENT PRODUCTS IN SERVICE.

THE BULLETIN ALERTS ALL AIRCRAFT AND/OR ROTORCRAFT OPERATORS AND FAA PRINCIPAL MAINTENANCE INSPECTORS OF POTENTIAL UNAIRWORTHY PRODUCTS RETURNED TO SERVICE BY TEC-AIR SERVICE REPAIR STATIONS. THE BULLETIN ALSO ASKS THAT ALL OWNERS AND/OR OPERATORS REVIEW THEIR INTERNAL OPERATIONS FOR PRODUCT LAST SERVICED BY TEC-AIR AND FORMUATE, A LISTING OF THOSE PRODUCTS BY TYPE OF EQUIPMENT, MANUFACTURER, MODEL, PART NUMBER, SERIAL NUMBER, APPLICABILITY, AND QUANTITY OF EACH PRODUCT.

THE BULLETIN ALSO ASKS THAT APPROPRIATE ACTION BE TAKEN BY ALL OWNERS AND/OR OPERATORS TO DETERMINE WHETHER AIRCRAFT EMERGENCY EQUIPMENT AND APPLIANCES OVERHAULED, REPAIRED, OR SERVICED BY TEC-AIR, TO BE UTILIZED ON AIRCRAFT, MEET ALL APPLICATION REQUIREMENTS. OWNERS AND.OR OPERATORS ARE ASKED TO INDICATE ANY ACTION TAKEN AS PART OF THE LISTING AND FORWARD THE INFO TO THE FAA. BASED ON THE RESULTS OF THIS SURVEY AND OTHER ELEMENTS OF THE INVESTIGATION, THE FAA WILL DETERMINE WHETHER MANDATORY CORRECTIVE ACTIONS ARE NECESSARY. THE OXYGEN CYLINDER WAS LAST SERVICED BY TEC-AIR ON 1/14/93-13 MONTHS BEFORE THE ACCIDENT.

DURING THAT PERIOD THE OXYGEN CLYINDER WAS REPLENISHED ON NUMEROUS OCCASIONS WHICH SUGGESTS THAT OIL CONTAMINATION COULD HAVE BEEN INTRODUCED INTO THE ASSEMBLY BY SEVERAL MEANS INDEPENDENT OF TEC-AIR'S ACTIONS. FURTHERMORE, THE FAA REVIEWED THE MAINTENANCE PRACTICES OF THE LAST FACILITY TO SERVICE THE ASSEMBLY (TEC-AIR SERVICES OF MACON, GEORGIA.) THE FAA'S REVIEW OF THE OVERHAUL RECORDS RECEIVED ON THE OXYGEN CYLINDER RETURNED TO SERVICE BY TEC-AIR SERVICES OF MACON, GEORGIA, DID NOT REVEAL ANY MAINTENANCE PRACTICES THAT LED TO QUESTION THE AIRWORTHINESS OF THE PRODUCT OR WERE INCONSISTENT WITH FAA-APPROVED PROCEDURES.

FURTHER INVESTIGATION OF THE POSSIBLE CAUSE OF THE FIRE ON BOARD THE ACCIDENT AIRPLANE CENTERED ON POSSIBLE PREMATURE FAILURE OF THE PRESSURE REDUCER REGULATOR. A REVIEW OF SERVICE DIFFICULTY REPORT DATA REVEALED FOUR INCIDENTS OF OXYGEN LEAKS THAT WERE ATTRIBUTED TO PRESSURE REGULATOR FAILURE. ASTRA JET CORPORATION, THE DISTRIBUTER FOR THE WESTWIND, IS CONSIDERING DEVELOPING A SERVICE BULLETIN TO MODIFY THE EXISTING OXYGEN SYSTEM ON ISRAEL AIRCRAFT INDUSTRIES' AIRCRAFT. THE TRANSPORT AIRPLANE DIRECTORATE WILL CONTINUE THE INVESTIGATION OF A POSSIBLE FAULTY REGULATOR AND WILL ADDRESS THE NEED FOR MANDATING CORRECTIVE ACTION AS NECESSARY.

THE BOARD NOTES THAT THE FAA IS REVIEWING THIS ISSUE TO DETERMINE WHAT COURSE OF ACTION SHOULD BE INITIATED. THIS REVIEW INCLUDES AN EXAMINATION OF THE WORK ORDERS AND OVERHAUL RECORDS FOR THE MAINTENANCE THAT WAS ACCOMPLISHED BY TEC-AIR ON THE OXYGEN BOTTLES FROM THE WESTWIND AS WELL AS THE MAINTENANCE RECORDS FOR THE BOTTLE AND ALL VALVES, REGULATORS, AND OXYGEN MASKS. IF IT IS FOUND, BASED ON THESE SERVICE RECORDS, THAT TEC-AIR USED PROCEDURES CONTRARY TO FAA-APPROVED PROCEDURES AND THAT SUCH PROCEDURES CONTRIBUTED TO THE INCIDENT THAT PRECIPITATED THE BOARD'S RECOMMENDATION, THE FAA WILL CONSIDER APPROPRIATE REGULATORY ACTION.

THE BOARD IS DISAPPOINTED THAT THE FAA DID NOT TAKE AD ACTION AS RECOMMENDED IN A-95-148. THE INVESTIGATION THAT LED TO THIS SAFETY RECOMMENDATION REVEALED THAT IN DECEMBER 1994, THE FAA INSPECTED TEC-AIR'S EAST NORTHPORT, NEW YORK, FACILITY, REPAIR STATION NO. MA1R315K, AND FOUND THAT TEC-AIR HAD VIOLATELD OR FAILED TO DEMONSTRATE COMPLIANCE WITH 10 SECTIONS OF THE FAA REGULATIONS RELATING OF PART 21,43, AND 145. THE INVESTIGATION CITED NUMEROUS OCCASIONS ON WHICH TEC-AIR HAD APPROVED OXYGEN CYLINDER ASSEMBLIES & AIRCRAFT FIRE EXTINGUISHERS FOR RETURN TO SERVICE, INCLUDING PARTS USED ON PASSENGER-CARRYING AIRCRAFT UNDER 121, WHEN SUCH EQUIPMENT WAS UNAIRWORTHY.

THE BOARD BELIEVES THAT REGULATORY ACTION PREMISED UPON A REVIEW OF EXISTING TEC-AIR SERVICE RECORDS IS INAPPROPRIATE AND INCONSISTENT WITH FAA'S 1994 FACILITY INSPECTION THAT DISCLOSED THAT TEC-AIR FAILED TO MAINTAIN RELIABLE, CREDIBLE RECORD-KEEPING SYSTEM. THE BOARD CONTINUES TO DOUBT THE VERACITY OF SUCH RECORDS AND BELIEVES THAT THE FAA SHOULD EXPEDITE THIS MATTER BY ISSUING AN AD AS RECOMMENDED. IN THE INTERIM A-95-148 IS CLASSIFIED "OPEN--UNACCEPTABLE RESPONSE."

THE FAA AGREES WITH THE INTENT OF THIS SAFETY RECOMMENDATION AND IS REVIEWING THIS ISSUE TO DETERMINE WHAT COURSE OF ACTION SHOULD BE INITIATED. THE FAA IS EXAMINING THE WORK ORDERS AND OVERHAUL RECORDS FOR THE MAINTENANCE THAT WAS ACCOMPLISHED BY TEC-AIR ON THE OXYGEN BOTTLES FROM THE WESTWIND AS WELL THE MAINTENANCE RECORDS FOR THE BOTTLE AND ALL VALVES, REGULATORS, AND OXYGEN MASKS. THE FAA IS COMPARING THE TEC-AIR MAINTENANCE RECORDS ON THE SUSPECT OXYGEN BOTTLES WITH THE PROCEDURES OUTLINED IN THE FAA APPROVED REPAIR STATION PROCEURES MANUAL AND COMPONENT MAINTENANCE MANUAL.

IF TEC-AIR USED PROCEDURES THAT WERE CONTRARY TO THE FAA-APPROVED PROCEDURES & OUR REVIEW REVEALS THAT THESE PROCEDURES CONTRIBUTED TO THE INCIDENT, THE FAA WILL CONSIDER APPRPRIATE REGULATORY ACTION.