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NTSB · Safety Recommendation

Safety Recommendation A-97-069

Recommendation

TO THE FEDERAL AVIATION ADMINISTRATION: Review the adequacy of current industry practice and if warranted, require that Part 121 air carriers and Part 145 repair facilities performing maintenance for air carriers develop and implement a system requiring items delivered to shipping and receiving and stores areas of the facility to be properly identified and classified as hazardous or non-hazardous, and procedures for tracking the handling and disposition of hazardous materials.

Safety Issue and Context

On 5/11/96, about 1415 eastern daylight time, a McDonnell Douglas DC-9-32 crashed into the everglades swamp shortly after takeoff from Miami International Airport, Miami Florida, the airplane, N904VJ, was operated by ValuJet Airlines, Inc., as ValuJet flight 592. Both pilots, the three flight attendants, and all 105 passengers were killed. Before the accident, the flightcrew reported to air traffic control that it was experiencing smoke in the cabin and cockpit. Visual meteorological conditions existed in the Miami area at the time of the takeoff. The destination of the flight was Hartsfield International Airport, Atlanta, Georgia.

Flight 592 was on an instrument flight rules flight plan.

Response History

February 23, 2004 · NTSB Correspondence · FAA

The Safety Board reviewed Chapter 11 of AC 120-16D, which discusses procedures, information, instructions, guidance, and precautions that should be contained in operators' manuals concerning hazardous materials.

This information includes identifying or recognizing aircraft components or consumable materials that contain hazardous materials; the safe movement, storage, or handling of those aircraft components or consumable materials within the facility; determining the proper packaging, marking, labeling, and materials compatibility of aircraft components or consumable materials containing hazardous materials while they are within the facility; specific hazards associated with aircraft components or consumable materials containing hazardous materials to be moved, stored, or handled; and proper disposal of unserviceable aircraft components or consumable materials containing hazardous materials.

Issuance of the AC including Chapter 11 meets the intent of Safety Recommendations A-97-67 and -69, which are classified "Closed--Acceptable Action."

July 21, 2003 · Recipient Response · FAA

Letter Mail Controlled 8/7/2003 10:17:48 AM MC# 2030379 AC 120-16D applies to 14 CFR Parts 119, 121, and 135 air carriers. For 14 CFR Part 135 operations, the AC applies only to operations conducted with aircraft type-certificated for a seating capacity of 10 seats or more (excluding any pilot seat). Chapter 11 of the AC discusses procedures, information, instructions, guidance, and precautions that should be contained in operators' manuals concerning hazardous materials.

Read Recommendation

Recommendation Facts

Status
Closed - Acceptable Action
Issued
September 9, 1997
Priority
CLASS II
Recipient
FAA
Adopted
August 19, 1997
Closed
February 23, 2004
Related Investigation
DCA96MA054
Related Report
AAR-97-06

This includes identifying or recognizing aircraft components or consumable materials that contain hazardous materials; the safe movement, storage, or handling of those aircraft components or consumable materials within the facility or one of the maintenance providers' facilities; determining the proper packaging, marking, labeling, and materials compatibility of aircraft components or consumable materials containing hazardous materials while they are within the facility or maintenance provider's facilities; specific hazards associated with aircraft components or consumable materials containing hazardous materials to be moved, stored, or handled within the facility; and proper disposal of unserviceable aircraft components or consumable materials containing hazardous materials.

Additionally, Chapter 10 of the AC includes human factors as part of the initial training program. The FAA believes that the requirements for improved and specific hazardous material training programs, authorizations, and notifications included in the NPRM in response to Safety Recommendation A-97-65 will complete the requirements of these recommendations. I believe that the FAA has satisfactorily responded to these safety recommendations, and I look forward to your response.

April 24, 2001 · NTSB Correspondence · FAA

PENDING ISSUANCE OF REVISIONS TO AC 120-16C THAT MEET THE INTENT OF THESE RECOMMENDATIONS, A-97-67, -69, AND -73 REMAIN CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

October 2, 2000 · Recipient Response · FAA

Letter Mail Controlled 10/04/2000 3:48:25 PM MC# 2001485 ON 5/22/98, THE FAA ISSUED FLIGHT STANDARDS HANDBOOK BULLETIN FOR AIRWORTHINESS 98-10, AIR CARRIER CONTROL AND HANDLING OF AIRCRAFT COMPONENTS OR CONSUMABLE MATERIALS THAT CONTAIN HAZARDOUS MATERIALS. THE BULLETIN PROVIDED INFORMATION AND GUIDANCE TO PRINCIPAL INSPECTORS WITH CERTIFICATE AND SURVEILLANCE RESPONSIBILITIES FOR AIR CARRIERS THAT HAVE AIRCRAFT COMPONENTS OR CONSUMABLE MATERIAL CONTAINING HAZARDOUS MATERIALS. THE BULLETIN PROVIDED SIMILAR HAZARDOUS MATERIALS INFORMATION FOR REPAIR STATIONS.

THE FAA ALSO INFORMED THE BOARD THAT ADVISORY CIRCULAR (AC) 120-16C, CONTINUOUS AIRWORTHINESS MAINTENANCE PROGRAMS, WOULD BE REVISED TO INCORPORATE THE INFORMATION CONTAINED IN THE BULLETINS. ON 7/23/99, THE BOARD STATED THAT IT DID NOT BELIEVE THE BULLETIN MEETS THE INTENT OF A-97-65 BECAUSE IT DID NOT REQUIRE AN INSPECTOR'S SIGNATURE BLOCK ON WORK CARDS THAT CALL FOR HANDLING A COMPONENT CONTAINING HAZARDOUS MATERIALS. THE BOARD FURTHER STATED THAT IT WAS CONCERNED THAT WORK DONE BY 14 CFR PART 145 REPAIR STATIONS AND 14 CFR PART 121 OR 135 AIR CARRIERS IS NOT ADDRESSED IN THE BULLETIN. THE BOARD CLASSIFIED A-97-65 IN AN "OPEN UNACCEPTABLE" STATUS PENDING ADDITIONAL INFORMATION.

A-97-67, -69, AND -73 WERE CLASSIFIED IN AN "OPEN ACCEPTABLE" STATUS PENDING THE ISSUANCE OF ORDER 8300.10 AND REVISED AC 120-16C. THE FAA HAS CONSIDERED THE BOARD'S CONCERNS AND BELIEVES ITS CURRENT AND PLANNED ACTIONS ARE APPROPRIATE TO ADDRESS THESE RECOMMENDATIONS. THE FAA ISSUED HAZARDOUS MATERIALS INFORMATION AMENDMENTS TO THE AIRWORTHINESS INSPECTOR'S HANDBOOK THROUGH FLIGHT STANDARDS HANDBOOK BULLETIN FOR AIRWORTHINESS 98-10 FOR AIR CARRIERS AND FLIGHT STANDARDS HANDBOOK BULLETIN FOR AIRWORTHINESS 99-10 FOR REPAIR STATIONS.

THESE TWO BULLETINS HAVE SIGNIFICANTLY HEIGHTENED AWARENESS OF CURRENT HAZARDOUS MATERIALS HANDLING AND SHIPPING REGULATIONS FOR AIR CARRIERS AND REPAIR STATIONS. THE FAA IS CONTINUING ITS EFFORT TO REVISE AC 120-16C TO INCLUDE HAZARDOUS MATERIAL INFORMATION. IN THE LONG TERM, THE FAA IS CONSIDERING RULEMAKING TO AMEND THE CURRENT AIR CARRIER HAZARDOUS MATERIALS MANUAL REQUIREMENTS AND TRAINING REGULATIONS IN 14 CFR PARTS 121, 145, AND 135 TO INCORPORATE SPECIFIC REQUIREMENTS FOR IMPROVED AND SPECIFIC HAZARDOUS MATERIALS TRAINING PROGRAMS.

THE RULES WOULD IDENTIFY THE SPECIFIC HAZARDOUS TRAINING NEEDED FOR EACH AIR CARRIER OR REPAIR STATION EMPLOYEE BASED ON THE NATURE OF THE HAZARDOUS MATERIALS FUNCTION OR RESPONSIBILITY PERFORMED BY THE EMPLOYEE. IT IS ANTICIPATED THAT THE AC WILL BE ISSUED BY DECEMBER 2000. I WILL PROVIDE THE BOARD WITH A COPY OF THE AC AS SOON AS IT IS ISSUED.

January 11, 2000 · NTSB Correspondence · FAA

Notation 7215: The National Transportation Safety Board has reviewed the Federal Aviation Administration's (FAA) notice of proposed rulemaking (NPRM), "Part 145 Review: Repair Stations," which was published in the Federal Register, Volume 64, No. 118, on June 21, 1999. The FAA proposes to update and revise the regulations for repair stations. According to the NPRM, this action is necessary because many portions of the current repair station regulations do not reflect changes in repair station business practices and aircraft maintenance practices, or advances in aircraft technology.

In general, the Safety Board agrees with the FAA that to ensure that the regulations are appropriate for today's repair station industry, Part 145 should be extensively revised. Where possible, the Safety Board's specific comments are organized by sections to correspond with sections in the NRPM. However, in some instances, the Board's comments extend across several sections of the NPRM.

Manufacturers' Maintenance Facilities The FAA proposes to eliminate the "limited" ratings for manufacturers and to require that these facilities obtain the appropriate repair station certification. These ratings had previously been granted to allow manufacturers to perfoml maintenance on articles manufactured by them. However, manufacturers' systems for inspection, recordkeeping, and quality control vary considerably from those used by repair stations.

Because maintenance practices and aircraft technologies have evolved since the establishment of limited ratings for manufacturers, the FAA has detern1ined that all repair facilities' systems for inspection, recordkeeping, and quality control should be consistent, and that the issuance of limited ratings for manufacturers is no longer appropriate. The Safety Board concurs with this proposed revision to Part 145.

Deviation Authority The FAA proposes to include deviation authority to provide flexibility to operations subject to Part 145 that may be safely or satisfactorily conducted as an alternative means of compliance with portions of Part 145. The FAA further indicates that if deviation authority is granted, the FAA would require that operations be conducted to certain conditions and limitations and these would be placed in the Operations Specifications.

Without specific criteria, or examples of the types of conditions or limitations'that would be imposed, the Safety Board questions the practicality of this section of the proposed rule or how consistency in granting deviation authority can be assured. Further, the Safety Board questions the basis for the FAA's contention that limited deviations would be sought and that letters of deviation authority would likely be limited in scope. The Safety Board does not support the inclusion of deviation authority, as currently written, in the final rule.

Ratings and Classes The FAA proposes to revise the ratings and classes that can be issued to certificated repair stations. In response to the FAA's request for comments as to whether ratings and classes should be prescribed in a separate regulation, the Safety Board believes that the proposed system of ratings and classes can be appropriately prescribed in the proposed revisions to Part 145. The Safety Board supports the proposed revisions to ratings and classes, and specifically the establishment of a new rating for computer systems to account for the technological developments and advances in aircraft design and manufacturing.

However, the Safety Board has expressed concerns in the past about how ratings and classes are applied, the interpretation of those ratings by the FAA, and, as a result, repair stations performing maintenance that exceeds the authority of their rating. The proposed ratings and classes provide no better guidance to certificate holders and FAA inspectors than the current ratings and classes in terms of what ratings are required for specific repair station work.

In its report of the uncontained engine failure/fire of ValuJet Airlines flight 597 in Atlanta, Georgia, on June 8,1995, the Safety Board concluded that the Operations Specifications of the repair station that performed maintenance on the failed engine could reasonably have been read to indicate that the repair station did not have authority under Part 145 to overhaul the type of engine that it did overhaul and that ultimately failed.

The Safety Board asked the FAA in Safety Recommendation A-96-78 to review the air agency certificates and repair station Operations Specifications of all repair stations and ensure that the language used in the Operations Specifications clearly indicates the extent of the repair station's authority. In response to this recommendation, the FAA issued Flight Standards Information Bulletin for Airworthiness 97-17A, "Certificate and Operations Specifications Evaluation of Limited Specialized Services Rated Repair Station."

The bulletin directed principal inspectors to review the Operations Specifications and certificate to determine if the Operations Specifications were appropriate for the rating that had been issued. The review found that 53 repair stations were operating beyond their certificate privileges, 134 repair station Operations Specifications were reissued, 16 repair stations were recertified, and 108 repair stations received rating changes. Although the discrepancies uncovered by this review were corrected, the findings suggest a lack of consistency in how ratings are applied.

The Safety Board suggests that given the proposed revisions to ratings, the opportunity exists for the FAA to provide better guidance to certificate holders and inspectors regarding what ratings are required for specific repair station work. Using the organizational structure of Appendix A: Job Functions, the FAA could prepare a master list of the maintenance capabilities, by make and model of part or article, on which those functions can be performed. Such a list, published as an advisory circular and as a supplement to FAA Handbook 8300.10, would ensure a more consistent application of ratings to maintenance operations.

It would also serve as a reference for the FAA certificate holding district offices (CHDO), which will continually be evaluating changes to capability lists.

An example that illustrates the Board's concern in this area is the maintenance of flight data recorders (FDRs). Most repair stations perfornling maintenance on FDRs currently work under a "limited rating for specialized service." The Safety Board's experience with FDRs indicates that some of these maintenance facilities do not possess the necessary special testing equipment and software to properly maintain the FDRs. Specific guidance is not provided in the proposed regulations as currently written. The Safety Board urges the FAA to include "inspect, test, and validate flight data recorders" in Appendix A: Job Functions.

A repair station should also be required to list flight data recording equipment, by make and model, in its capability list.

Further, principal maintenance inspectors should be provided better guidance concerning the rating appropriate for maintenance, preventive maintenance, or alteration of FDRs.

Repair Station Manual, Quality Assurance, and Capability List In general, the Safety Board concurs with the proposed revisions to these sections that require repair stations to (1) maintain an approved repair station manual that covers all of the repair station's technical operations, (2) establish quality assurance systems to ensure that maintenance, preventive maintenance, or alterations (including the maintenance and alterations performed by a repair station's contractors) are consistently performed in accordance with all applicable requirements, and (3) maintain a capability list that would specify all articles on which the repair station is capable of performing work.

Under the proposal, prior to working on an article, a repair station woul

July 23, 1999 · NTSB Correspondence · FAA

A-97-67, -69, AND -73 ARE CLASSIFIED "OPEN--ACCEPTABLE RESPONSE," PENDING FURTHER CORRESPONDENCE REGARDING THE SAFETY BOARD'S CONCERNS.

July 23, 1998 · Recipient Response · FAA

Letter Mail Controlled 7/27/98 3:17:30 PM MC# 980931: On May 22, 1998, the FAA issued Flight Standards Handbook Bulletin for Airworthiness 98-10, Air Carrier Control and Handling of Aircraft Components or Consumable Materials That Contain Hazardous Materials. The bulletin provides information and guidance to principal inspectors with certificate and surveillance responsibilities for air carriers that have aircraft components or consumable materials containing hazardous materials. The bulletin directs principal inspectors to ensure that their air carriers include the following information in their manuals and that they provide appropriate personnel training:

* Procedures and information to assist maintenance, shipping, and stores personnel in identifying or recognizing aircraft components or consumable materials that contain hazardous materials. If those aircraft components or consumable materials are to be moved, stored, or handled within the air carriers or contract maintenance providers' facilities, procedures and instructions relating to the safe movement, storage, or handling of those aircraft components or consumable materials must be included.

* Procedures and information for determining the proper packaging, marking, labeling, and materials compatibility, including instructions for the safe movement, storage, and handling of aircraft components or consumable materials that contain hazardous materials while they are within the air carriers' facilities.

* Information, guidance, and precautions regarding the specific hazards associated with aircraft components or consumable materials containing hazardous materials that are to be moved, stored, or handled within the air carriers' facilities.

* Information, instructions, and detailed procedures for the proper disposal of unserviceable aircraft components or consumable materials containing hazardous materials.

The bulletin also directs principal inspectors to ensure that air carriers are aware of all regulations governing air transportation of hazardous materials, that they conduct hazardous materials training in accordance with 14 CFR Part 172, and that they implement a system to ensure that their personnel remain current on the hazardous materials regulations. I have enclosed a copy of the bulletin for the Board's information.

The FAA is also revising FAA Order 8300.10, Airworthiness Inspector Handbook, and Advisory Circular (AC) 120-16D, Continuous Airworthiness Maintenance Programs, to incorporate the information contained in the bulletin.

I will provide the Board with copies of the order and AC as soon as they are revised.

November 17, 1997 · Recipient Response · FAA

The FAA agrees with the intent of these safety recommendations and is revising FAA Order 8300.10, Airworthiness Inspector Handbook, and Advisory Circular (AC) 120-16D, Continuous Airworthiness Maintenance Programs. These documents will be revised to incorporate the information to address each of these safety recommendations. It is anticipated that the order will be revised by April 1998 and the AC by October 1998. I will provide the Board with copies of these documents as soon as they are revised.

As an immediate response, the FAA will issue a flight standards handbook bulletin to address specific programs, procedures, information, and training to assist maintenance, shipping, and stores personnel in identifying or recognizing aircraft components or consumable material that contains hazardous materials. The bulletin will provide information, guidance, and precautions regarding specific hazards associated with aircraft components or consumable materials that are to be moved, stored, or handled by air carrier or maintenance provider personnel. It is anticipated that the bulletin will be issued in November 1997.

I will provide the Board with a copy of the bulletin as soon as it is issued.