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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    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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    Safety Alert for Operators: 14 CFR, parts 91, 133, and 137 and Helicopter hot fueling/loading

    U.S. Department of Transportation
    Federal Aviation Administration
    SAFO
    Safety Alert for Operators
    SAFO 10020

    Flight Standards Service Washington, DC

    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: 14 CFR, parts 91, 133, and 137 and hot fueling/loading

    Purpose: This SAFO highlights current guidance and best-practices for Title 14 Code of Federal Regulations (14 CFR) parts 91, 133, and 137 operators that conduct fueling or chemical loading with the engines running (hot fueling/loading).

    Background: On May 30, 2009, a Bell 47G-2 helicopter operating under part 137 was being refueled with the engine running (hot fueling) when the ground crew spilled fuel onto the engine while trying to untangle a kink in the hose. The helicopter quickly caught fire and the pilot sustained serious injuries as a result. Additionally, on September 9, 2008, a Bell 206-B helicopter, operating under part 137, sustained substantial damage while conducting hot fueling and chemical loading simultaneously. After fueling was complete, but with the chemical hose still attached, the ground crew mistakenly gave an “all clear” hand signal to the pilot. As the pilot ascended, the chemical hose caused the helicopter to pitch nose down and roll to the right, contacting the ground.

    Recommended Action: Hot fueling/loading can be extremely hazardous and is not recommended except when absolutely necessary due to the nature of the operation. Operators who conduct hot fueling/loading should develop standard operating procedures (SOP) for flight and ground crew personnel. The operator’s procedures should address the following guidelines:

    • The Federal Aviation Administration (FAA) recommends that hot fueling be conducted only by aircraft utilizing JET A or JET A-1 fuel types. If strict operating procedures are not followed, hot fueling of aircraft utilizing AvGas can be extremely hazardous due to its low flash point. Aircraft being fueled while an engine is operating should have all potential ignition sources located above the fuel inlet port(s) and above fuel vent or tank openings. Sources of ignition include, but are not limited to: engines, exhausts, auxiliary power units (APU), and combustion-type cabin heater exhausts. In accordance with 14 Code of Federal Regulations (14 CFR) section 91.9, hot fueling is not permitted if the Airplane or Rotorcraft Flight Manual contains an associated operating limitation.
    • An appropriately certificated and rated pilot should be at the flight controls during the entire hot fueling/loading process with controls appropriately adjusted to prevent aircraft movement. The pilot should unbuckle all restraints, and be prepared to immediately shut-down the engine and egress the aircraft, if necessary. The pilot should not conduct any extraneous duties during hot fueling/loading. Other personnel should not be on-board the aircraft during hot fueling/loading.
    • Only designated personnel, with proper training in hot fueling/loading operations, should operate fueling or chemical loading equipment. The operator’s written procedures should include: precautions for safe handling of the fuel or chemical, emergency shutoff procedures, fire extinguisher use, hand signal use, and precautions regarding moving propeller and rotor blades.
    • At least two ground personnel should be present during hot fueling/loading. One person conducts the fueling/loading, while the other stands by prepared to activate the fuel/chemical emergency shutoff and handle fire extinguishers if necessary. The aircraft should remain well clear of the fuel source, and at no time should the aircraft wing or helicopter blades extend over the fueling source
    • Before fueling, the aircraft must be bonded to the fuel source to equalize static electricity between the fuel source and the aircraft. Grounding of the aircraft and/or fuel truck is no longer recommended because it does not prevent sparks at the fuel source, and the grounding cable may not be sufficient to discharge the electrical current.
    • All doors, windows, and access points allowing entry to the interior of the aircraft that are adjacent to, or in the immediate vicinity of, the fuel inlet ports should be closed and should remain closed during fueling operations.
    • Fuel should be dispensed into an open port only from approved deadman-type nozzles, with a flow rate not to exceed 10 gallons per minute (38 liters per minute). Close port pressure fueling ports are preferable because the potential for spillage is reduced.
    • A fire extinguisher of an appropriate type and size for the fueling operation must be within easy reach of ground personnel at all times during hot fueling operations. Operators who conduct hot fueling should also equip the aircraft with a fire extinguisher in the cockpit, if possible.
    • When fueling/loading is complete, the pilot must ensure that the seatbelt and shoulder harness are properly re-secured as necessary prior to any aircraft movement.
    • Operators should include this SAFO in initial and recurrent training programs for pilots and ground personnel.

    References:

      ? Aeronautical Information Manual (AIM) – Helicopter Rapid Refueling
      ? AC 00-34A, Aircraft Ground Handling and Servicing
      ? National Fire Prevention Association (NFPA) 407 Standard for Aircraft Fuel Servicing
      ? Include review of this SAFO in initial and recurrent training, and flight reviews.
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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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    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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  • 2011 SAFO: The Importance of Properly Inflated Aircraft Tires

    SAFO 11001 DATE: 11/6/11
    Flight Standards Service Washington, DC
    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: The Importance of Properly Inflated Aircraft Tires

    Purpose: This SAFO stresses the importance of ensuring properly inflated tires and the potential consequences improper tire pressure can have on the performance of aircraft operations during Taxi, Takeoff and Landing.
    Background: The probable causes of numerous accidents have highlighted the importance of ensuring proper aircraft tire pressure. For instance, a Douglas DC-8-61 crashed shortly after takeoff from Jeddah, Saudi Arabia killing all 261 on board. The probable cause of the crash was under-inflated tires, which in turn caused an overheated tire to explode during taxi, which then caused other tires to catch on fire during the takeoff role. The fire continued as the wheels were retracted into the wheel well, eventually causing a loss of hydraulic control and finally an in-flight break-up which destroyed the aircraft. This accident also revealed numerous human factor issues that contributed to the underinflated tire.
    Recently, the National Transportation Safety Board (NTSB) determined that inadequate maintenance of the airplane’s tires was the probable cause of an accident where a Learjet 60 overran the runway in Columbia, South Carolina. The inadequate maintenance of tires resulted in multiple tire failures during the takeoff roll due to severe under inflation. This accident took the lives of both flightcrew members and two passengers; two other passengers were seriously injured.

    Discussion: Aircraft tires are designed to carry specified loads during a variety of temperatures and wheel speeds. When aircraft tires are improperly serviced as illustrated in the background paragraph above, they are severely compromised and catastrophic consequences can occur. The Federal Aviation Administration (FAA) suggests any individual associated with the operation of aircraft under Title 14 Code of Federal Regulations (14 CFR) part 121, 125, 129, 135 and 91 subpart K (91K), including those who perform servicing and maintenance functions at a certificated or non certificated repair facility (maintenance providers), make certain their procedures ensure tire pressure checks frequently to ensure tires remain inflated to within the maintenance manual-specified inflation range.
    Research has shown that transport-category airplanes can lose as much as five percent of tire pressure per day under typical operations. At a pressure rate loss of five percent per day, it would only take a few days before they require servicing. Tires not serviced within an acceptable range may require tire replacement due to under inflation limitations specified in the maintenance manual. Additionally, servicing of underinflated tires without proper protection such as a tire screen or other protective devices may cause damage to the aircraft or injury to the individual servicing an underinflated tire.

    Distributed by: AFS-200 OPR: AFS-330

    Recommended Action: Air Carrier Certificate Holders, Fractional Ownership Program Managers, Training Center Managers, Directors of Maintenance, Accountable Managers, Maintenance Providers and others with responsibility for maintenance should become familiar with the contents of this SAFO. This SAFO’s intent is to ensure appropriate personnel are made aware of the importance of proper tire pressures, appropriately calibrated tire pressure gauges and servicing safety precautions. The maintenance manual tire pressure interval checks are followed to ensure proper tire pressure is accurately maintained. Failure to follow the published procedures with aircraft tires could result in personal injury or catastrophic aircraft loss.

    Contact: Questions or comments concerning this SAFO can be directed to Aircraft Maintenance Divisions Air Carrier Maintenance Branch, AFS-330 at (202) 385-6426.

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