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Safety Recommendation Details

Safety Recommendation A-91-089
Details
Synopsis: ON DECEMBER 26, 1989, UNITED EXPRESS, FLIGHT 2415 (SUNDANCE 415), A BRITISH AEROSPACE BA-3101 JETSTREAM, N41OUE, CRASHED APPROXIMATELY 400 FEET SHORT OF RUNWAY 21R AT TRI-CITIES AIRPORT, PASCO, WASHINGTON. THE AIRPLANE CRASHED WHILE EXECUTING AN INSTRUMENT LANDING SYSTEM (ILS) APPROACH TO THE RUNWAY AT APPROXIMATELY 2230 PACIFIC STANDARD TIME. VISUAL METEOROLOGICAL CONDITIONS PREVAILED BENEATH THE CLOUD BASES, WHICH WERE APPROXIMATELY 1,000 FEET ABOVE GROUND LEVEL AT THE TIME OF THE ACCIDENT. THE AIRPLANE WAS DESTROYED, AND THE TWO PILOTS AND ALL FOUR PASSENGERS RECEIVED FATAL INJURIES.
Recommendation: THE NTSB RECOMMENDS THE THE FEDERAL AVIATION ADMINISTRATION: REQUIRE MANUFACTURERS TO REVIEW THE PNEUMATIC DEICE BOOT SYSTEM DESIGNS FOR AIRCRAFT USED IN 14 CFR PARTS 121 AND 135, TO ENSURE THAT THE PNEUMATIC PRESSURE THEREHOLD AT WHICH EACH DEICE BOOT INDICATION LIGHT IS DESIGNED TO ILLUMINATE IS SUFFICIENT PRESSURE FOR EFFECTIVE PNEUMATIC DEICE BOOT OPERATION, AND ISSUE AIRWORTHINESS DIRECTIVES TO MODIFY SYSTEMS FOUND TO BE DEFICIENT IN THIS REGARD.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: PASCO, WA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA90MA011
Accident Reports: Unstabilized Approach and Loss of Controll NPA, Inc. dba United Express Flight 2415 British Aerospace BA-3101, N410UE
Report #: AAR-91-06
Accident Date: 12/26/1989
Issue Date: 11/19/1991
Date Closed: 4/18/2001
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Icing, Weather

Safety Recommendation History
From: NTSB
To: FAA
Date: 4/18/2001
Response: WITH THE ISSUANCE OF AD 2001-02-08, THE FAA HAS MET THE INTENT OF A-91-89; THEREFORE IT IS CLASSIFIED "CLOSED--ACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 2/16/2001
Response: Letter Mail Controlled 02/23/2001 1:17:37 PM MC# 2010160 THE FAA HAS ISSUED AIRWORTHINESS DIRECTIVE (AD) 2001-02-08 APPLICABLE TO SHORTS SD3-60 SHERPA, SD3-SHERPA, SD3-30, AND SD3-60 SERIES AIRPLANES. THE AD REQUIRES REPLACEMENT OF THE EXISTING PNEUMATIC DEICING BOOT PRESSURE INDICATOR SWITCH WITH A NEWLY DESIGNATED SWITCH. I HAVE ENCLOSED A COPY OF THE AD FOR THE BOARD'S INFORMATION. I CONSIDER THE FAA'S ACTION TO BE COMPLETED ON THIS RECOMMENDATION.

From: NTSB
To: FAA
Date: 1/5/2001
Response: THE SAFETY BOARD NOTES THAT EXCEPT FOR THE SHORTS BROTHER AIRCRAFT, THE FAA HAS COMPLETED THE WORK RECOMMENDED. PENDING COMPLETION OF ACTIONS ASSOCIATED WITH THE SHORTS AIRCRAFT, A-91-89 REMAINS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 9/14/2000
Response: Letter Mail Controlled 09/21/2000 2:56:01 PM MC# 2001380 THE FAA DETERMINED THAT ALL TRANSPORT AIRPLANE MODELS, EXCEPT THE CASA C-212, SAAB 340, SHORTS SD3-30/SD3-60, AND IAI 1124 AIRCRAFT, HAVE ACCEPTABLE PRESSURE INDICATION THRESHOLD SETTINGS. THE FAA ALSO COMPLETED ITS REVIEW OF THE DATA PROVIDED BY THE APPROPRIATE AIRWORTHINESS AND CONCLUDED THAT CASA C-212 AND SAAB 340 AIRCRAFT HAVE ACCEPTABLE PRESSURE INDICATION THRESHOLD SETTINGS. THE STATUS OF THE REMAINING AIRCRAFT IS AS FOLLOWS: IAI 1125 - ON 5/16/00, THE FAA ISSUED AIRWORTHINESS DIRECTIVE (AD) 2000-10-19, APPLICABLE TO CERTAIN ISRAEL AIRCRAFT INDUSTRIES, LTD., MODEL 1125 WESTWIND ASTRA AND ASTRA SPX SERIES AIRPLANES. THE AD REQUIRES REPLACEMENT OF THE EXISTING PNEUMATIC DEICING BOOT PRESSURE INDICATOR SWITCH WITH A NEWLY DESIGNED SWITCH. I HAVE ENCLOSED A COPY OF THE AD FOR THE BOARD'S INFORMATION. SHORTS SD3-30/SD3-60 - ON 9/30/99, THE FAA ISSUED A NOTICE OF PROPOSING RULEMAKING (NPRM) PROPOSING TO ADOPT AN AD APPLICABLE TO SHORTS SD3-60 SHERPA, SD3-SHERPA, SD3-30, AND SD3-60 SERIES AIRPLANES. THE NPRM PROPOSES TO REQUIRE REPLACEMENT OF THE EXISTING PNEUMATIC DEICING BOOT PRESSURE INDICATOR SWITCH WITH A NEWLY DESIGNED SWITCH. I HAVE ENCLOSED A COPY OF THE NPRM FOR THE BOARD'S INFORMATION. SHORTS BROTHER HAS INFORMED THE FAA THAT IT IS PUTTING TOGETHER A FINAL PACKAGE CONTAINING THE RESULTS OF THE FLIGHT TEST AND COMPANY ANALYSIS. THIS PACKAGE IS EXPECTED TO IDENTIFY THE PROPER CONFIGURATION AND SETTINGS REQUIRED TO QUALIFY THE PRESSURE SWITCHES ON SHORTS BROTHER AIRPLANES. THE FAA WILL TAKE APPROPRIATE ACTION BASED ON ITS EVALUATION OF THE INFORMATION CONTAINED IN THE SHORTS BROTHER PACKAGE. CASA CN-235 - ON 2/29/00, THE FAA ISSUED AD 2000-05-05 APPLICABLE TO ALL CASA CN-235-100 AND -200 SERIES AIRPLANES TO REQUIRE REPLACEMENT OF EXISTING ANTI-ICING DISTRIBUTOR VALVES WITH NEW IMPROVED VALVES TO PREVENT ICE ACCUMULATION ON THE WINGS OR TAIL OF THE AIRPLANE. I HAVE ENCLOSED A COPY OF THE AD FOR THE BOARD'S INFORMATION. FOKKER F-27 MARK 050 - ON 12/27/99, THE FAA ISSUED AD 99-19-19 APPLICABLE TO CERTAIN FOKKER F27 MARK 100, 200, 300, 400, 500, 600, AND 700 SERIES AIRPLANES AND F27 MARK 050 SERIES AIRPLANES. THE AD REQUIRES REVISING THE AIRPLANE FLIGHT MANUAL TO INCLUDE REQUIREMENTS FOR ACTIVATION OF THE AIRFRAME PNEUMATIC DEICING BOOTS. I HAVE ENCLOSED A COPY OF THE AD FOR THE BOARD'S INFORMATION. I WILL KEEP THE BOARD INFORMED OF THE FAA'S PROGRESS ON THE SHORTS SD3-30/SD3-60 SERIES AIRCRAFT.

From: NTSB
To: FAA
Date: 3/8/2000
Response: PENDING COMPLETION OF THESE ACTIONS, A-91-89 REMAINS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 11/22/1999
Response: Letter Mail Controlled 02/16/2000 9:07:56 AM MC# 991367 AS STATED IN ITS LETTER DATED 3/24/99, THE FAA HAS DETERMINED THAT ALL TRANSPORT AIRPLANE MODELS, EXCEPT THE CASA C-212, SAAB 340, SHORTS SD3-30/SD3-60, AND IAI 1124 AIRCRAFT, HAVE ACCEPTABLE PRESSURE INDICATION THRESHOLD SETTINGS. THE FAA FURTHER STATED THAT IT WAS WORKING WITH APPROPRIATE AIRWORTHINESS AUTHORITIES TO OBTAIN ADDITIONAL DATA ON THE CASA CN-235 AND FOKKER F-27 MK050 AIRCRAFT TO MAKE A DEFINITIVE FINDING ON THESE AIRCRAFT. THE FAA HAS COMPLETED ITS REVIEW OF THE DATA PROVIDED BY THE APPROPRIATE AIRWORTHINESS AUTHORITIES AND CONCLUDED THAT CASA C-212, AND SAAB 340 AIRCRAFT HAVE ACCEPTABLE PRESSURE INDICATION THRESHOLD SETTINGS. THE STATUS OF THE REMAINING AIRCRAFT IS AS FOLLOWS: IAI 1125: THE FAA PLANS TO ISSUE A NOTICE OF PROPOSED RULEMAKING (NPRM) AS SOON AS THE SERVICE BULLETIN FROM THE ISRAEL AIRWORTHINESS AUTHORITIES IS RECEIVED. SHORTS SD3-30/SD3-60: SHORTS BROTHER HAS REQUESTED THAT B.F. GOODRICH CONDUCT FLIGHT TEST TO QUALIFY THE PRESSURE SWITCHES ON SHORTS SD3-30/SD3-60. THE FAA WILL TAKE APPROPRIATE ACTION BASED ON THE RESULTS OF THE FLIGHT TEST. CASA C-235: THE SPAIN AIRWORTHINESS AUTHORITY HAS ISSUED AN AIRWORTHINESS DIRCTIVE TO ADDRESS THIS ISSUE. THE FAA IS DEVELOPING A CORRESPONDING FAA MANDATORY ACTION. FOKKER F-27 MARK 050: FOKKER HAS SUBSTANTIATED THAT THE PRESSURE THRESHOLD AT WHICH EACH DEICE BOOT INDICATION LIGHT IS DESIGNED TO ILLUMINATE IS PROPERLY SET ASSUMING THE ACTIVATION OF THE BOOT AT THE FIRST SIGN OF ICE ACCRETION IS ACCOMPLISHED IN THE HEAVY MODE. ON 7/30/99, THE FAA ISSUED AN NPRM (DOCKET NUMBER 99-NM-153-AD) APPLICABLE TO CERTAIN FOKKER F27 MARK 100, 200, 300, 400, 500, 600 AND 700 SERIES AIRPLANES AND F27 050 SERIES AIRPLANES. THE NPRM PROPOSES TO REQUIRE REVISING THE AIRPLANE FLIGHT MANUAL TO INCLUDE REQUIREMENTS FOR ACTIVATION OF THE AIRFRAME PNEUMATIC DEICING BOOTS. I HAVE ENCLOSED A COPY OF THE NPRM FOR THE BOARD'S INFORMATION. I WILL KEEP THE BOARD INFORMED OF THE FAA'S PROGRESS ON THIS SAFETY RECOMMENDATION.

From: NTSB
To: FAA
Date: 4/21/1999
Response: A-91-89 ASKED THE FAA TO REQUIRE MANUFACTURERS TO REVIEW THE PNEUMATIC DEICE BOOT SYSTEMS DESIGNS FOR AIRCRAFT USED IN 14 CFR PARTS 121 AND 135 TO ENSURE THAT THE PNEUMATIC PRESSURE THRESHOLD AT WHICH EACH DEICE BOOT INDICATION LIGHT IS DESIGNED TO ILLUMINATE IS SUFFICIENT PRESSURE FOR EFFECTIVE PNEUMATIC DEICE BOOT OPERATION AND ISSUE AIRWORTHINESS DIRECTIVES TO MODIFY SYSTEMS FOUND TO BE DEFICIENT IN THIS REGARD. PENDING ISSUANCE OF A FINAL RULE THAT MEETS THE INTENT OF A-91-89 IT IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 3/24/1999
Response: THE FAA HAS DETERMINED THAT ALL TRANSPORT AIRPLANE MODELS, EXCEPT THE CASA C-212, SAAB 340, SHORTS SD3-30/SD3-60, AND IAI 1124 AIRCRAFT, HAVE ACCEPTABLE PRESSURE INDICATION THRESHOLD SETTINGS. THE FAA IS WORKING WITH APPROPRIATE AIRWORTHINESS AUTHORITIES TO OBTAIN ADDITIONAL DATA ON THE CASA CN-235 AND FOKKER F-27 MK050 AIRCRAFT TO MAKE A DEFINITIVE FINDING ON THESE AIRCRAFT. THE FAA ANTICIPATES THAT CORRECTIVE ACTIONS WILL BE DEFINED AND IMPLEMENTATION SCHEDULES ESTABLISHED ON THOSE AIRPLANES THAT HAVE NOT BEEN FOUND TO HAVE ACCEPTABLE PRESSURE INDICATION THRESHOLD SETTINGS BY SEPTEMBER 1999. I WILL KEEP THE BOARD INFORMED OF THE FAA'S PROGRESS ON THIS RECOMMENDATION.

From: NTSB
To: FAA
Date: 7/19/1996
Response: THE BOARD NOTES THAT THE FAA COMPLETED ITS INQUIRIES WITH MANUFACTURERS TO DETERMINE WHETHER THE SYSTEMS PROPERLY ANNUNCIATE THE FUNCTIONING OF THE BOOT SYSTEMS ON TRANSPORT-CATEGORY AIRPLANES UTILIZING PNEUMATIC BOOTS FOR DEICING. THE INQUIRIES IDENTIFIED TWO AIRPLANE MODELS THAT HAVE PRESSURE SWITCH SETTINGS THAT DO NOT GIVE ASSURANCE THAT THE BOOTS ARE FULLY EFFECTIVE. PENDING DOCUMENTATION OF DESIGN CHANGES OR ISSUANCE OF APPROPRIATE ADS TO CORRECT ANY UNSAFE CONDITIONS, A-91-89 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 2/13/1996
Response: THE BOARD NOTES THAT THE FAA COMPLETED THEIR INQUIRIES WITH MANUFACTURERS TO DETERMINE WHETHER OR NOT THE SYSTEMS PROPERLY ANNUNICATE THE FUNCTIONING OF THE BOOT SYSTEMS ON TRANSPORT CATEGORY AIRPLANES UTILIZING PNEUMATIC BOOTS FOR DEICING. THE INQUIRIES IDENTIFIED TWO AIRPLANE MODELS THAT HAVE PRESSURE SWITCH SETTINGS THAT DO NOT GIVE ASSURANCE THAT THE BOOTS ARE FULLY EFFECTIVE.

From: NTSB
To: FAA
Date: 4/10/1992
Response: Safety Recommendations A-91-88 through -90 and A-91-122 also pertain to aircraft ice protection. We note that the FAA agrees with these safety recommendations and is taking action towards their satisfactory resolution. Pending the FAA's further response, these safety recommendations are classified as "Open--Acceptable Response."

From: FAA
To: NTSB
Date: 1/31/1992
Response: THE FAA AGREES WITH THIS SAFETY RECOMMENDATION. THE AIRCRAFT CERTIFICATION OFFICES RESPONSIBLE FOR CERTIFICATION AND CONTINUOUS AIRWORTHINESS OF TRANSPORT CATEGORY UTILIZING PNEUMATIC BOOTS FOR ANI-ICING OR DEICING WILL BE NOTIFIED OF THESE CONCERNS AND REQUESTED TO INITIATE INQUIRIES WITH THE MANUFACTURERS TO DETERMINE WHETHER OR NOT THE SYSTEMS PROPERLY ANNUNCIATE THE FUNCTIONING OF THE BOOT SYSTEMS. IF IT IS FOUND THAT SOME SYSTEMS DO NOT ADEQUATELY INFORM THE CREW OF ANY DEFICIENCY IN EFFECTIVENESS, DESIGN CHANGES WILL BE INCORPORATED THROUGH MANDATORY ACTION.