Summary of Safety Action Taken in Response to TSB SR 111 Investigation Safety Communications

Summary of Safety Action Taken in Response to TSB SR 111 Investigation Safety Communications

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No. Released Type
(TSB file number)
Title
(A98H0003 Section 4.1 reference)
NTSB TC FAA Boeing Swissair Additional
1 22-Dec-98 Aviation Safety
Advisory
(980031-1)
MD-11 Wiring
(4.1.1)
issued recommendation to FAA nil
  1. issued numerous ADs as part of Wiring Corrective Action Plan established Enhanced Airworthiness Program for Airplane Systems (EAPAS)
  2. enhanced its .Aircraft Wiring Practices. interactive training
  3. produced an Internet-based training aid entitled, "Aircraft Wiring Practices (Job Aid)"
  1. generated wire related service bulletins
  2. developed improved wire inspection and practices training course
  3. revised Standard Wire Practices Manual
  1. conducted wiring related inspections on MD-11 fleet
  2. conducted special inspection of MD-11 avionics compartment
  3. developed new wire maintenance (best practices) concept and training program
Swiss FOCA reviewed and reissued FAA ADs as Swiss Ads
Swiss AAIB concurs with TSB Advisory Letter
2 09-Mar-99 Aviation Safety
Recommendations
(A99-01 thru A99-04)
Flight Recorder Duration
and Power Supply (4.1.2)
issued similar recommendations to FAA
  1. harmonize regulations with FAA/JAA
  2. FAA NPRMs to be tabled at CARAC
  3. Issued NPA
drafting NPRMs in line with NTSB recs published SB to power MD-11 recorders on separate buses intends to comply with recorder SB Swiss AAIB concurs with TSB recommendations
3 11-Aug-99 Aviation Safety
Recommendations
(A99-07 & A99-08)
Thermal Acoustic Insulation
Materials
(4.1.3)
concur with TSB recommendations
  1. harmonize regulations with FAA/JAA
  2. surveyed Canadian registered aircraft
  1. issued two NPRMs
  2. issued ADs requiring MPET removal
  3. issued NPRM regarding new flammability test criteria for thermal acoustic insulation material
providing engineering support to operators for AD compliance
  1. Immediately removed MPET insulation blankets from selected areas in Swissair MD-11s
  2. started full replacement of MPET in Nov 2000 in compliance with FAA AD
Swiss FOCA reviewed and reissued FAA AD as Swiss AD
Swiss AAIB concurs with TSB recommendations
4 03-Mar-00 Aviation Safety
Advisory
(A000008-1)
MD-11 Flight Crew Reading
Light (Map Light)
(4.1.4)
forwarded TSB letter to FAA for action nil Issued ADs to incorporate Boeing ASB
  1. Issued ASB detailing map light recurrent inspections
  2. Coordinated maplight redesign with Hella Aerospace resulting in maplight SB
complied with FAA ADs Swiss FOCA reviewed and reissued FAA ADs as Swiss Ads FCRL manufacturer (Hella Aerospace) redesigned FCRL and issued SB
Swiss AAIB concurs with TSB Advisory Letter
5 04-Dec-00 Aviation Safety
Recommendations
(A00-16 thru A00-20)
In-Flight Firefighting
(4.1.5)
concur with TSB recommendations concur with TSB recs, working to harmonize regulations with FAA/JAA
  1. concurs with recommendations: reviewing existing programs
  2. intends to harmonize changes with TC/JAA
Conducted in-depth review of existing designs and in-flight firefighting procedures instituted "MD-11 Modification Plus" program which improved in-flight firefighting checklists, procedures, training, incorporated improved detection and suppression systems, replaced some materials with more heat tolerant materials UK CAA taking active measures
Swiss AAIB concurs with TSB recommendations
UK AAIB concurs with TSB recommendations
6 29-Dec-00 Aviation Safety
Information Letter
(A000061-1)
Flight Crew Reading Light
(4.1.4)
agreed with the TSB, encouraged the FAA to take appropriate action nil issued AD mandating recurring inspections which will remain in force until the unsafe condition has been eliminated in cooperation with Hella Aerospace, a redesigned maplight has been developed to address the unsafe condition raised in the FAA's AD incorporated Hella's SB which improves the maplight's short-circuit protection Swiss FOCA reviewed and reissued FAA AD as a Swiss AD Hella Aerospace, the maplight manufacturer, worked with Boeing on maplight redesign
7 29-Dec-00 Aviation Safety
Information Letters
(A000062-1, -2)
MD-11 Overhead Aisle and
Emergency Lights
(4.1.6)
nil nil reviewed MD-11 Overhead Aisle and Emergency Lights installation and determined that no unsafe condition existed Boeing determined that the fixture met existing certification standards nil
8 01-Aug-01 Aviation Safety
Advisory
(A010020-1)
Air Traffic Controller Training
(4.1.11)
nil Liaised with ATS service providers to ensure TSB's concerns are addressed nil nil nil Nav Canada has revised Air Traffic Controller training and amended its Air Traffic Control Manual of Operations accordingly
No. Released Type
(TSB file number)
Title
(A98H0003 Section 4.1 reference)
NTSB TC FAA Boeing Swissair Additional
9 28-Aug-01 Aviation Safety
Recommendations
(A01-02 thru A01-04)
Material Flammability Standards
(4.1.10)
concur with TSB recommendations concur with TSB recs, working to harmonize regulations with FAA/JAA
  1. FAA is confident that previously announced initiatives (e.g. Improved Flammability Requirements for Thermal/Acoustic Insulation) will address the deficiencies raised in TSB recommendations A01-02 and A01-03.
  2. FAA believes that current regulations coupled with existing programs such as the Arc-Fault Circuit Breaker initiatives will address the deficiency raised in TSB's A01-04 recommendation.
Boeing issued SB to inform MD-11 operators of an FAA-approved modification procedure that uses steel vice aluminum components in the crew oxygen system as a fire-hardening measure. incorporated SB replacing aluminium components as part of its .MD-11 Modification Plus. program
10 28-Sep-01 Aviation Safety
Advisory
(A010042-1, -2)
Standby Instrumentation
(4.1.9)
nil nil will address TSB's emergency instrumentation issues at its Aviation Rulemaking Advisory Committee reviewed their current standby instrumentation equipment to identify any areas that could be optimized As part of its .MD-11 Modification Plus. program, installed a secondary flight display system with a layout similar to the primary flight display in the MD-11 aircraft which also incorporates an auxiliary battery
11 N/A N/A In-Flight Entertainment/
Supplemental Type Certificate
(4.1.7)
nil nil conducted an SCR of STC ST00236LA-D resulting in the withdrawal of its IFEN certification. Additionally, the FAA has acted to enhance its STC process. conducted a design review of its installations to confirm that no unsafe conditions existed. disabled then removed the IFEN systems in both its MD-11 and Boeing 747 fleets FOCA cancelled validations of the IFEN STCs
sections.
12 N/A N/A Circuit Breaker Reset Philosophy
(4.1.8)
nil published an article in the its Aviation Safety Letter issued a Joint Flight Standards Information Bulletin which summarizes the FAA.s position on the issue of resetting tripped CBs states that no CB reset is allowed in-flight except under emergency conditions as duly authorized by the pilot-in-command. Additionally, it stipulates that no CB resets associated with fuel pump circuits were to be carried out under any circumstances.
  1. Issued an AOM Bulletin regarding a revision to CB reset procedures
  2. after a review of its CB reset policy, Swissair's maintenance provider revisited the subject as part of continuation training for its technician
Airbus issued a CB reset policy which only allows a CB reset in flight under emergency conditions when authorized by the pilot-in-command.

Legend
AD Airworthiness Directive
AOM Aircraft Operations Manual
ASB Alert Service Bulletin
Boeing The Boeing Company
CARAC Canadian Aviation Regulation Advisory Council
CB circuit breaker
FAA United States Federal Aviation Administration
FCRL Flight Crew Reading Light
FOCA Swiss Federal Office for Civil Aviation
Hella Hella Aerospace GmbH
JAA Joint Aviation Authorities
MPET metallized polyethylene terephthalate
NPA Notice of Proposed Amendment
NPRM Notice of Proposed Rulemaking
NTSB United States National transportation Safety Board
SB service bulletin
SCR Special Certification Review
Swissair Swiss Air Transport Company Limited
Swiss AAIB Swiss Aircraft Accident Investigation Bureau
TC Transport Canada
TSB Transportation Safety Board of Canada
UK AAIB United Kingdom Air Accidents Investigation Branch
UK CAA United Kingdom Civil Aviation Authority