2011 SAFO: The Importance of Properly Inflated Aircraft Tires

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  • SAFO: Beechcraft Duke (BE-60) Flap Preflight Check

    U.S. Department of Transportation
    Federal Aviation Administration
    SAFO
    Safety Alert for Operators
    SAFO 11002 DATE: 2/4/11

    Flight Standards Service Washington, DC

    SAFO URL
    A SAFO contains important safety information and may include recommended action. SAFO content should be especially valuable to air carriers in meeting their statutory duty to provide service with the highest possible degree of safety in the public interest. Besides the specific action recommended in a SAFO, an alternative action may be as effective in addressing the safety issue named in the SAFO.

    Subject: Beechcraft Duke (BE-60) Flap Preflight Check Purpose: This SAFO informs Beechcraft Duke (BE-60) model airplane operators and those who oversee
    them on the need to properly check flap operation prior to takeoff.
    Background: On December 4, 2007, a Beechcraft Duke (BE-60) was destroyed when it crashed after takeoff. The pilot was killed and the aircraft was destroyed. The investigation revealed that the flap actuators may have undergone improper maintenance practices. One actuator was fully retracted and the other was fully extended which may have contributed to the accident.

    Recommended Action: Pilots and operators of the Duke (BE-60) should properly verify the full operation of their wing flaps prior to takeoff in accordance with the Before Takeoff procedures. The Pilot’s Operating Manual reads “Flaps – Check operation and set.” This can include a visual verification of flap position and corresponding agreement with cockpit indicators. If improper operation is suspected, they should visually inspect each flap position.

    Contact: Questions or comments concerning this SAFO can be directed to the Flight Standards Service, Commercial Operations Branch, AFS-820 at (202) 267-8212.
    Distributed by: AFS-200 OPR: AFS-820

    Download Safety Alert For Operators PDF here

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  • SAFO: Adverse Levels of Porous Coke for All Engine and Oil Combinations

    A SAFO contains important safety information and may include recommended action. SAFO content should be especially valuable to air carriers in meeting their statutory duty to provide service with the highest possible degree of safety in the public interest. Besides the specific action recommended in a SAFO, an alternative action may be as effective in addressing the safety issue named in the SAFO.

    Subject: Adverse Levels of Porous Coke for All Engine and Oil Combinations

    Purpose: This SAFO provides safety information related to engine problems associated with potentially hazardous porous-coke conditions to airplane operators in general and with emphasis to Title 14 Code of Federal Regulations (14 CFR) part 121 Extended-Range Operations (ETOPS) airplane operators.

    Background: The Federal Aviation Administration (FAA) issued Airworthiness Directive (AD) 2007-02-05 requiring initial and repetitive borescope inspections of the high pressure and intermediate pressure turbine internal and external oil vent tubes for coking and carbon buildup, and cleaning or replacing the vent tubes if necessary. The AD resulted from an incident where an RB211 Trent 700 series turbofan engine had an oil vent tube rupture as a result of blockage, leading to significant loss of engine oil and uncontained engine failure. Contributing to the cause was the absence of measures to adequately monitor and evaluate risk of in service performance of engine/oil combinations.

    Discussion: An engine borescope inspection revealed that the HP/IP turbine bearing chamber internal vent tube was obstructed with porous coke. An airflow check of the vent tube revealed that the air passage was not completely blocked. Although coke formations within oil tubes are not uncommon, the type, amount, and location of the carbon deposits found in the vent tube of the engine were unusual and inconsistent with coke formation seen on other Trent engines or from other service experiences. Investigation revealed that the operator had switched from Mobile jet oil II to MJO 291 after two months of engine in-service operation.

    Recommended Action: Operators should review their Continuous Analysis and Surveillance System (CASS) measures for all engine and oil combinations currently in service, with particular emphasis on the evaluation of airplanes approved for ETOPS with two engines, to determine that they have gathered and evaluated sufficient data, including operational experience and engine hardware disassembly inspection findings, to ensure that these combinations are not at risk of producing potentially hazardous porous-coke conditions. If such data is insufficient, develop and implement appropriate CASS measures, including periodic inspections, to collect and evaluate the necessary data until the risk associated with the presence of porous coke is either ruled out or properly controlled.

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  • | |

    Release: NTSB Urges Changes

    The National Transportation Safety Board today issued two urgent safety recommendations to the Federal Aviation Administration (FAA) regarding two recent occurrences in which the fan midshaft on General Electric GEnx-1B engines fractured or exhibited crack indications; and a GEnx -2B incident that appears similar in nature. The recommendations are: (1) Issue an airworthiness directive to require, before further flight, the immediate ultrasonic inspection of the fan midshaft in all GEnx-1B and -2B engines that have not undergone inspection, and (2) Require repetitive inspections of the fan midshaft at a sufficiently short interval that would permit multiple inspections and detection of a crack before it could reach critical length and the fan midshaft fractures.

    On July 28, 2012, the NTSB initiated an investigation of an engine failure that occurred on a Boeing 787 during a pre-delivery taxi test in Charleston, South Carolina. This investigation is ongoing.

    “The parties to our investigation — the FAA, GE and Boeing — have taken many important steps and additional efforts are in progress to ensure that the fleet is inspected properly,” said NTSB Chairman Deborah A.P. Hersman. “We are issuing this recommendation today because of the potential for multiple engine failures on a single aircraft and the urgent need for the FAA to act immediately.”

    In addition, on August 31, 2012, a GEnx-1B engine installed on a Boeing 787 that had not yet flown was found to have an indication of a similar crack on the fan midshaft. The fan midshaft was removed from the engine for further inspection and examination. As a result of the investigative work to date, the NTSB has determined that the fan midshafts on the GEnx engines fractured or cracked at the forward end of the shaft where the retaining nut is installed.

    GE developed a field ultrasonic inspection method to inspect the fan midshaft in the area where the fracture and crack occurred that can be accomplished with the engine still installed on the airplane. To date, all in-service and spare GEnx-1B engines have been inspected. In addition, all GEnx-2B engines on passenger airplanes have been inspected. However, the NTSB is aware of approximately 43 GEnx-2B engines on 747-8F cargo airplanes that have not yet been inspected and is concerned that they are potentially susceptible to a fan midshaft failure.

    More recently, a Boeing 747-8F cargo flight, operated by Air Bridge Cargo, equipped with General Electric GEnx-2B turbofan engines, experienced a loss of power in one of the engines during the takeoff roll in Shanghai, China. The airplane had accelerated through 50 knots when the engine’s low pressure rotor speed dropped. The pilot rejected the takeoff and returned to the ramp. Photographs of the low pressure turbine show damage similar to the GEnx-1B engine from the Charleston incident. The NTSB will continue to coordinate with our investigative counterparts in China.

    Read the Recommendation Letter:

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  • | |

    FAA: Publishes SAFO on Runway Incursion increase

    11004
    From the SAFO:

    Recommendations describe a top down approach, a coordinated effort to mitigate identified hazards. Suggestions include management emphasis and training of pilots and support personnel (air carrier mechanics, ground personnel, and tug/tow drivers.)

    There are recommendations in each of these categories:

    • Planning
    • Situational Awareness
    • Written Taxi Instructions
    • Crew Resource Management
    • Communication
    • Taxi
    • Exterior Lighting

    The full pdf is available here
    https://airflightdisaster.com/wp-content/uploads/2011/06/SAFO11004.pdf

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  • |

    SAFO: Maintenance of Night Vision Imaging Systems (NVIS)

    Purpose: This SAFO alerts operators of aircraft equipped with a Night Vision Imaging System (NVIS) of
    potential deficiencies in the configuration and condition of installed NVIS equipment.

    Background: Recent Federal Aviation Administration (FAA) assessments of NVIS-equipped aircraft have shown that the likelihood of configuration and maintenance problems increases as aircraft continue in service after NVIS modifications. This means that operators of NVIS-equipped aircraft may not be adequately meeting the inspection and maintenance requirements of NVISs.

    The assessment also concluded that operators are installing light-emitting or light-reflecting equipment, which affects the NVIS compatibility of the aircraft, without ensuring that the equipment is properly evaluated.

    Discussion: The FAA’s Aviation Safety (AVS) organization recently directed a nation-wide sampling of NVIS- equipped aircraft. FAA teams, made up of Flight Standards Service (AFS) inspectors and Aircraft Certification Service (AIR) inspectors/engineers, conducted the sampling and discovered that NVIS-equipped aircraft were frequently out of compliance with NVIS requirements for three primary reasons:
    ? Operators installed light-emitting or light-reflecting equipment that caused the aircraft to no longer be properly configured for use with Night Vision Goggles (NVG);
    ? Operators failed to properly maintain the installed NVIS equipment; and
    ? Flightcrews were aware of conditions that reduced the ability to see necessary instruments/equipment during day, night, NVG-aided, or NVG-unaided flights. Another common problem was improperly filtered light-emitting equipment. Flightcrews did not communicate these discrepancies to the maintenance department or maintenance personnel.

    After assessing and analyzing the data collected, the FAA has determined it is likely that other NVIS-equipped aircraft may not be properly configured or maintained for NVG operations. The term night vision device was intended to include all necessary equipment that is installed or modified as part of the entire NVIS, which includes NVGs. Failure to properly maintain an aircraft’s NVIS configuration and equipment can degrade NVG acuity (i.e., blind spots for flight crewmembers using NVG) and prevent the flightcrew from clearly seeing aircraft instrumentation.
    Distributed by: AFS-200 OPR: AFS-300

    Recommended Action: Directors of Maintenance, Directors of Safety, Directors of Operations, Chief Pilots, mechanics, and pilots operating or maintaining NVIS-equipped aircraft should take appropriate action to confirm the following:
    1. Instructions for Continued Airworthiness (ICA) are current, correct, applicable by serial number, and are being properly applied by maintenance departments and personnel. If the ICA has been incorporated into an inspection program, confirm that all the additional ICA requirements are being met;
    2. Installed NVIS equipment are properly maintained;
    3. Maintenance personnel are appropriately trained on the maintenance and inspection of NVIS installations;
    4. Flightcrews fully understand the importance of reporting NVIS-related problems to maintenance personnel;
    5. Aircraft configuration/conformity is periodically checked to ensure that installed NVIS equipment complies with the Supplemental Type Certificate (STC); and
    6. Current and complete data is available to maintenance personnel to support the NVIS equipment.
    NOTE: An aircraft that does not comply with the STC and/or ICA requirements, or that has inoperative or improperly maintained equipment, should not be operated until corrective action has been taken. Operators may use or apply for Minimum Equipment List (MEL) relief as applicable. MEL information is contained in FAA Order 8900.1, Flight Standards Information Management System (FSIMS), Volume 4, Chapter 4, Minimum Equipment Lists (MEL) and Configuration Deviation Lists (CDL), as well as MMEL Policy Letter 127.

    Please visit http://www.faa.gov/aircraft/air_cert/design_approvals/rotorcraft/nvis/ for additional information on NVIS-equipped aircraft.
    Contact: Questions or comments concerning this SAFO can be directed to your Certificate Holding District Office (CHDO).

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    SAFO: Embraer ERJ-190 Series Thrust Reverser Cowling Safety

    http://www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/safo
    A SAFO contains important safety information and may include recommended action. SAFO content should be especially valuable to air carriers in meeting their statutory duty to provide service with the highest possible degree of safety in the public interest. Besides the specific action recommended in a SAFO, an alternative action may be as effective in addressing the safety issue named in the SAFO.

    Subject: Embraer ERJ-190 Series Thrust Reverser Cowling Safety Purpose: This SAFO notifies maintenance personnel of a potentially hazardous situation which
    can cause serious injury while working on or around the EMB 190 thrust reversers.

    Background: During a visit to Embraer Aircraft Maintenance Service (EAMS), a Maintenance Repair Organization (MRO), technicians reported that instances have occurred where the thrust reverser power door opening (PDO) actuator failed. Also, during high wind conditions, with the thrust reverser cowl open, the cowling can flex sufficiently enough to displace the locking feature of the PDO actuator. The failure of the PDO actuator can cause the thrust reverser cowl- door to come down on personnel, causing serious injury. As a precautionary safety means, and an interim option, EAMS installed the trust reverser hold-open-jib which is part of the engine- change boot-strap-kit. The jib is utilized to provide additional support to the PDO thrust reverser cowling-door in the event of a PDO failure. Embraer is evaluating the development of a tool to support the thrust reverser cowling while opened. However, until this tool is available, extreme caution is recommended during maintenance of the thrust reverser.

    Recommended Action: It is recommended that air carriers who operate this type of equipment, immediately alert maintenance to exercise extreme caution working around the area with the thrust reverser cowling opened, especially during high wind conditions. In addition, it is recommended that maintenance personnel utilize the thrust reverser hold-open-jib which is part of the engine change boot-strap-kit, to secure the door. The jib is utilized to provide additional support to the PDO thrust reverser cowling door in the event of a PDO failure.

    Contact: Questions or comments regarding this SAFO should be directed to Aircraft Maintenance Division, AFS-300, at (202) 385-6422.
    Distributed by: AFS-200 OPR: AFS-300

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