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Safety Recommendation Details

Safety Recommendation A-91-090
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 THAT THE FEDERAL AVIATION ADMINISTRATION: REVISE ADVISORY CIRCULAR (AC) 20-73, "AIRCRAFT ICE PROTECTION," AND AC 23.1419-1, "CERTIFICATION OF SMALL AIRPLANES FOR FLIGHT IN ICING CONDITIONS," TO INCLUDED GUIDANCE FOR THE FULFILLMENT OF 14 CFR PARTS 23.1416(C) AND 25.1416(C) BY ENSURING THAT PNEUMATIC PRESSURE THRESHOLD AT WHICH EACH DEICE BOOT INDICATION LIGHT IS DESINGED TO ILLUMINATE IS SUFFICIENT PRESSURE FOR EFFECTIVE PNEUMATIC DEICE BOOT OPERATION.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate 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: 1/12/2000
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s): Icing, Weather

Safety Recommendation History
From: NTSB
To: FAA
Date: 1/12/2000
Response: THE SAFETY BOARD HAS REVIEWED THESE AC'S AND FINDS THAT THEIR ISSUANCE MEETS THE INTENT OF A-91-90; THEREFORE, IT IS CLASSIFIED "CLOSED--ACCEPTABLE ALTERNATE ACTION."

From: FAA
To: NTSB
Date: 9/15/1999
Response: ON 8/19/98, THE FAA ISSUED ADVISORY CIRCULAR (AC) 23.1419-2A, CERTIFICATION OF SMALL AIRPLANES FOR FLIGHT IN ICING CONDITIONS. THE AC INCLUDES GUIDANCE 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. A COPY OF AC 23.1419-2A WAS PROVIDED TO THE BOARD ON 12/11/98. ON 12/11/98, THE FAA ALSO INFORMED THE BOARD THAT IT WOULD INCORPORATE APPROPRIATE INFORMATION ON 14 CFR PART 25 AIRPLANES IN AC 25.1419-1, CERTIFICATION OF TRANSPORT CATEGORY AIRPLANES FOR FLIGHT IN ICING CONDITIONS, IN LIEU OF REVISING AC 20-73. ON 3/1/99, THE BOARD AGREED WITH THIS ACTION AND CLASSIFIED THIS RECOMMENDATION AS "OPEN ACCEPTABLE ALTERNATE ALTERNATE RESPONSE" PENDING ISSUANCE OF AC 25.1419-1. ON 8/18/99, THE FAA ISSUED AC 25.1419-1, WHICH INCLUDES GUIDANCE 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. I HAVE ENCLOSED A COPY OF AC 25.1419-1 FOR THE BOARD'S INFORMATION. I BELIEVE THAT THE ISSUANCE OF AC 25.1419-1 COMPLETES THE FAA'S ACTION IN RESPONSE TO THIS RECOMMENDATION, AND I PLAN NO FURTHER ACTION.

From: NTSB
To: FAA
Date: 3/1/1999
Response: A-91-90 ASKED THE FAA TO REVISE AC 20-73, "AIRCRAFT ICE PROTECTION," AND AC 23.1419-1, "CERTIFICATION OF SMALL AIRPLANES FOR FLIGHT IN ICING CONDITIONS," TO INCLUDE GUIDANCE FOR THE FULFILLMENT OF 14 CFR PARTS 23.1416 (C) AND 25.1416(C) BY ENSURING 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. THE FAA'S ACTION TO INCORPORATE IMPROVEMENTS TO THE ICING CERTIFICATION TESTING PROCESS BY REVISING ITS GUIDANCE MATERIAL IS A POSITIVE STEP IN CLARIFYING THIS IMPORTANT AREA OF THE CERTIFICATION PROCESS. PENDING FINAL ISSUANCE OF AC 25.1419-1X, A-91-90 IS CLASSIFIED "OPEN--ACCEPTABLE ALTERNATE RESPONSE."

From: FAA
To: NTSB
Date: 12/11/1998
Response: Letter Mail Controlled 02/19/1999 10:03:45 AM MC# 981470 ON 8/19/98, THE FAA PUBLISHED AC 23.1419-2A, CERTIFICATION OF SMALL AIRPLANES FOR FLIGHT IN ICING CONDITIONS. THE AC INCLUDES GUIDANCE TO ENSURE THAT THE PNEUMATIC PRESSURE THRESHOLD AT WHICH EACH DE-ICE BOOT INDICATION LIGHT IS DESIGNED TO ILLUMINATE IS SUFFICIENT PRESSURE FOR EFFECTIVE PNEUMATIC DE-ICE BOOT OPERATION. I HAVE ENCLOSED A COPY OF AC 23.1419-2A FOR THE BOARD'S INFORMATION. IN LIEU OF REVISING AC 20-73, THE FAA INCORPORATED APPROPRIATE INFORMATION ON 14 CFR PART 25 AIRPLANES IN DRAFT AC 25.1419-1X, CERTIFICATION OF TRANSPORT CATEGORY AIRPLANES FOR FLIGHT IN ICING CONDITIONS. A NOTICE ANNOUNCING PROPOSED AC 25.1419-1X WAS PUBLISHED IN THE FEDERAL REGISTER ON 10/5/98. THE COMMENT PERIOD ENDS 12/4/98. I HAVE ENCLOSED A COPY OF THE APPLICABLE INFORMATION IN THE AC THAT ADDRESSES THIS SUBJECT.

From: NTSB
To: FAA
Date: 7/19/1996
Response: THE BOARD NOTES THAT THE FAA PLANS TO REVIEW APPENDIX C OF 14 CFR PART 25, REVISE ACS 25-7 & 23.1419, & DEVELOP A NEW AC 25-1419 TO ADDRESS THE CERTIFICATION OF 14 CFR PART 25 AIRPLANES FOR FLIGHT IN ICING CONDITIONS. THE BOARD ALSO NOTES THAT THE FAA AGREED, IN A 1/31/92, LETTER, THAT ADVISORY MATERIALS FOR USE IN FINDING COMPLIANCE WITH THE ICING REQUIREMENTS OF 14 CFR PARTS 23 & 25 SHOULD INCLUDE GUIDANCE MATERIAL TO ENSURE THAT THE PNEUMATIC PRESSURE THRESHOLD AT WHICH EACH DEICE BOOT INDICATION LIGHT SHOULD ILLUMINATE IS SUFFICIENT FOR EFFECTIVE PNEUMATIC DEICE BOOT OPERATION. PENDING THE COMPLETION OF THE FAA'S REVISIONS TO THE ACS, A-91-90 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 2/13/1996
Response: THE BOARD NOTES THAT THE FAA PLANS TO REVIEW APPENDIX C OF 14 CFR PART 25, REVISIONS TO AC'S 25-7 & 23.1419, & THE DEVELOPMENT OF A NEW AC 25.1419 WHICH WILL ADDRESS THE CERTIFICATION OF 14 CFR PART 25 AIRPLANES FOR FLIGHT IN ICING CONDITIONS.

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 THAT GUIDANCE MATERIAL RELATED TO THIS REQUIREMENT SHOULD BE INCLUDED IN ADVISORY MATERIALS FOR USE IN FINDING COMPLIANCE WITH THE ICING REQUIREMENTS OF 14 CFR PARTS 23 AND 25. THE FAA WILL PUBLISH ADVISORY MATERIAL TO PROVIDE CRITERIA FOR CERTIFICATION OF THE CAUTION ASSOCIATED WITH ABNORMAL FUNCTIONING OF THE ANTI-ICE OR DEICE BOOT SYSTEMS.