FLIGHT SAFETY FOUNDATION Aviation Mechanics Bulletin MAYÐJUNE 1996 U.S. National Transportation Safety Board Issues “Urgent” Recommendations for Hazardous Cargo FLIGHT SAFETY FOUNDATION Aviation Mechanics Bulletin Dedicated to the aviation mechanic whose knowledge, craftsmanship and integrity form the core of air safety. Robert A. Feeler, editorial coordinator

MayÐJune 1996 Vol. 44 No. 3

U.S. National Transportation Safety Board Issues “Urgent” Recommendations for Hazardous Cargo ...... 1 News & Tips ...... 9

Maintenance Alerts...... 10 New Products ...... 14

AVIATION MECHANICS BULLETIN Copyright © 1996 FLIGHT SAFETY FOUNDATION INC. ISSN 0005-2140 Suggestions and opinions expressed in FSF publications belong to the author(s) and are not necessarily endorsed by Flight Safety Foundation. Content is not intended to take the place of information in company policy handbooks and equipment manuals, or to supersede government regulations. Staff: Roger Rozelle, director of publications; Girard Steichen, assistant director of publications; Rick Darby, senior editor; C. Claire Smith, editorial consultant; Karen K. Ehrlich, production coordinator; and Kathryn Ramage, librarian, Jerry Lederer Library. Subscriptions: US$35 (U.S.-Canada-Mexico), US$40 Air Mail (all other countries), six issues yearly. ¥ Include old and new addresses when requesting address change. ¥ Flight Safety Foundation, 601 Madison Street, Suite 300, Alexandria, VA 22314 U.S. ¥ Telephone: (703) 739-6700 ¥ Fax: (703) 739-6708

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U.S. National Transportation Safety Board Washington, D. C.

On May 11, 1996, at about 1415 Transportation Safety Board (NTSB) Eastern Daylight Time, a McDonnell has accumulated sufficient factual Douglas DC-9-32 crashed into the information to suggest issues need- Everglades swamp shortly after ing immediate attention. Preliminary takeoff from Miami (Florida, U.S.) evidence indicates that five cardboard International . The airplane, boxes containing as many as 144 N904VJ, was operated by ValuJet chemical oxygen generators, most Inc. as ValuJet Flight 592. with unexpended oxidizer cores, and Both pilots, the three flight attendants, three wheel/tire assemblies had been and all 105 passengers were killed. loaded into the forward cargo com- Before the accident, the flight crew re- partment shortly before departure. ported to that there These items were being shipped as was smoke in the cabin and cockpit. company material (COMAT). Addi- Visual meteorological conditions tionally, some passenger and existed in the Miami area at the time U.S. mail were loaded into the forward of the takeoff. The destination of the cargo compartment. The forward flight was Hartsfield International compartment of this was a Airport, Atlanta, Georgia, U.S. class D compartment, which had no fire- or smoke-detection system to Although the accident is still under alert the cockpit crew to a fire in the investigation, the U.S. National compartment.

FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ MAYÐJUNE 1996 1 [U.S. Federal Aviation Regulations A SabreTech shipping ticket, dated (FARs), Part 25.857 classifies lower May 10, 1996, for the five boxes of fuselage cargo compartments of large chemical oxygen generators was also passenger airplanes, i.e., those not offered to the ramp agent. The gener- accessible to crew members during ators were identified on the shipping flight, as either class C or class D. ticket as “Oxy Cannisters ‘Empty.’” Class C compartments must have “a separate, approved smoke detector or The ramp agent, who was busy off- fire-detector system to give warning loading the aircraft from its previous at the pilot or flight-engineering sta- flight, signed the shipping ticket for tion” and “an approved, built-in fire- the COMAT and instructed the Sa- extinguishing system controllable breTech driver to place the items on from the pilot or flight-engineer sta- an empty baggage . The ramp tions.” Class D cargo compartments agent stated that he asked the first require no fire- or smoke-detection or officer of Flight 592 for approval to fire-extinguishing systems. Instead, load the COMAT on the aircraft. Af- class D cargo compartments depend ter the ramp agent and the first offic- on the limited availability of oxygen er estimated the weight of the in the compartment to suppress a fire. COMAT, the three wheel/tire assem- This is controlled by compartment- blies and the five boxes containing size and leakage-rate requirements oxygen generators were loaded into found in Part 25.557. Further, class the forward cargo compartment. D compartment lining material must pass vertical and 45-degree Bunsen- The chemical oxygen generators load- or Tirrill-burner tests as outlined in ed on Flight 592 had been removed Parts 25.853 and 25.855.] from three McDonnell Douglas MD-80s that were being renovated for Shortly before the departure of Flight ValuJet at SabreTech’s Miami facili- 592, a driver from the SabreTech Inc. ty. These chemical oxygen generators maintenance facility at Miami had been installed in overhead com- delivered the partments on the MD-80s to provide COMAT (the boxes and wheel/tire emergency oxygen for passengers but assemblies) to the ValuJet lead ramp were removed because their 12-year agent for transport to ValuJet facilities shelf life had expired. Chemical oxy- in Atlanta. (SabreTech operates a gen generators are designed to func- U.S. Federal Aviation Administration tion safely when properly installed in [FAA]-approved aircraft repair and aircraft. The MD-80 maintenance maintenance facility at Miami manual specifies that after a genera- International Airport and had per- tor is removed from an airplane be- formed renovation work for ValuJet.) cause it has passed its expiration date,

2 FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ MAYÐJUNE 1996 it should be initiated (discharged) and Chemical Oxygen the oxidizer core fully expended. Dis- charged chemical oxygen generators Generator, Cut-away must be disposed of as hazardous View waste. Pin Spring- Lanyard Actuated Percussion Cap When a chemical oxygen generator Hammer is not installed as equipment on an airplane, a shipping cap must be mounted over the percussion cap Mounting Shell to prevent accidental initiation. Studs SabreTech mechanics who placed (3 places) the generators in cardboard boxes stated that shipping caps were not in- stalled over the percussion caps, and Oxidizer 15 or fewer of the generators had Core Thermal been discharged. Insulation

Filter A chemical oxygen generator (Fig- ure 1) is about the size of a can of Support Screen spray paint (a cylinder 2.75 inches Relief Oxygen Valve by 6.75 inches [6.99 centimeters by Outlet 17.15 centimeters]). The oxidizer Manifold Source: U.S. National Transportation core is primarily sodium chlorate Safety Board mixed with less than 6 percent bari- um peroxide and potassium perchlo- Figure 1 rate, and trace amounts of other materials. reaction can result in external shell temperatures up to 547 degrees F The chemical oxygen generators, (286 degrees C). (Manufacturer mea- which were manufactured by Scott surements of external shell tempera- Aviation Inc., produce oxygen when ture on oxygen generators during a pin is pulled, releasing a spring- operational testing indicated maxi- loaded firing mechanism that strikes mum shell temperatures between 450 a percussion cap and starts a chemical degrees F and 500 degrees F [232 reaction in the generator’s solid oxi- degrees C and 260 degrees C].) dizer core. The reaction produces oxygen for at least 15 minutes. The Chemical oxygen generators, when chemical reaction of the oxidizer transported as cargo, are considered releases heat, and the heat of a hazardous material. Classified as

FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ MAYÐJUNE 1996 3 oxidizers, they are regulated under effective and secure” through re- U.S. Department of Transportation search and programs that cut across (DOT) hazardous-materials regula- transportation modes.] tions (49 U.S. Code of Federal Reg- ulations, Parts 171Ð180), which The NTSB supports these actions but establish packaging, labeling and believes further action can and shipping requirements for their should be taken. Because chemical transport. oxygen generators are not reusable and must be discharged before dis- Although the origin of the in-flight posal, the NTSB believes that there fire on Flight 592 has not been is no need to transport expired and determined, the presence of the undepleted chemical oxygen gener- chemical oxygen generators in the ators as cargo on any passenger or forward cargo compartment of the cargo aircraft. Therefore, the NTSB aircraft created an extremely danger- believes that the FAA, in coopera- ous condition. The chemical reaction tion with the RSPA, should perma- of an oxidizer such as sodium chlo- nently prohibit the transportation of rate in a confined space will gener- generators as cargo on any passen- ate heat, and the oxygen resulting ger or cargo aircraft when the chem- from the reaction will sustain and ical oxygen generators have passed intensify a fire. In addition, the igni- their expiration dates and the oxidiz- tion temperature of ordinary mate- er cores have not been depleted. rials is lowered in an oxygen-rich environment. The NTSB also believes urgent action is needed to prevent the On May 24, 1996, the U.S. Research shipment of undeclared or inappro- and Special Programs Administra- priately packaged hazardous materi- tion (RSPA) issued an interim final als. The failure to properly identify rule1 that prohibits the transportation and properly package hazardous ma- of chemical oxygen generators on terials has resulted in other accidents passenger aircraft until Jan. 1, 1997, and incidents. and the FAA issued an emergency notice2 that any person who offers On Nov. 3, 1973, a Pan American for transportation or transports World Airways Boeing 707-321C chemical oxygen generators as car- crashed at Logan International Air- go aboard passenger aircraft will be port, Boston, Massachusetts, U.S., subject to swift enforcement action. killing all three crew members. Thir- [The RSPA is a DOT agency whose ty minutes after this cargo flight de- mission is to “make America’s trans- parted John F. Kennedy International portation systems more integrated, Airport, New York, New York, U.S.,

4 FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ MAYÐJUNE 1996 the flight crew reported smoke in the fire, which was found to have started cockpit, and the flight was diverted in a cargo compartment, burned to Logan, where it crashed short of through the cabin floor, spread rap- the . The NTSB determined idly through the cabin and destroyed that dense smoke in the cockpit seri- the airplane. ously impaired the flight crew’s vi- sion and ability to function effectively The NTSB concluded that the fire during the emergency. had started as a result of improper handling of the chemical oxygen gen- Although the source of the smoke erator associated with a seat back could not be established conclusive- temporarily stored in the compart- ly, the NTSB believed that the ac- ment. The NTSB learned, as a con- cident sequence was initiated by a sequence of this incident, that some spontaneous chemical reaction that air carriers were not aware that chem- occurred when nitric acid, a corro- ical oxygen generators were capable sive and oxidizing material, leaked of generating high temperatures and from a container (in which it was were classified as hazardous materi- improperly packaged and stowed) als when carried as COMAT in cargo onto the sawdust packing (which compartments. Consequently, some was also improper) around it. A air carriers were not taking the re- general lack of compliance with quired precautions when shipping existing regulations governing the oxygen generators. transportation of hazardous materi- als and inadequate government Following this incident, the FAA no- surveillance were found to be tified all domestic air carriers and for- contributing factors. Further, the eign airworthiness authorities of the NTSB concluded that most of circumstances of the incident and re- the personnel who handled the minded them that oxygen generators hazardous-material shipment were are oxidizers and, therefore, are clas- inadequately trained. sified as hazardous materials, which should be properly packaged and On Aug. 10, 1986, a McDonnell stowed securely. Douglas DC-10-40, operating as a nonscheduled flight from Honolulu, On Feb. 3, 1988, American Airlines Hawaii, U.S., to Chicago, Illinois, Flight 132, a DC-9-83, had an in- U.S., with an en route stop in Los flight fire while en route to Nashville Angeles, California, U.S., arrived (Tennessee, U.S.) Metropolitan Air- without incident at Chicago’s O’Hare port, from Dallas/Fort Worth (Tex- International Airport. After the as, U.S.) International Airport.3 As passengers and crew had deplaned, a the aircraft was on an instrument

FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ MAYÐJUNE 1996 5 landing system approach, a flight The NTSB noted that, although the attendant and a deadheading first of- American Airlines procedures for ac- ficer notified the cockpit crew of cepting packages containing declared smoke in the passenger cabin. The hazardous materials were thorough NTSB found that containers of hy- and American would likely have re- drogen peroxide solution (an oxidiz- jected the fiber drum containing the er) and a sodium orthosilicate-based oxidizer had it been properly identi- mixture had been shipped in the mid- fied, American Airlines procedures cargo compartment of the airplane. for accepting ordinary freight pack- The shipment was improperly pack- ages were not adequate. These pro- aged, and it was not identified as a cedures did not include routine hazardous material. inquiries about the possibility that hazardous materials might be includ- After the hydrogen peroxide leaked ed without being identified as such. from its container, a fire started in the class D cargo compartment. The The NTSB urged American Airlines fire eventually breached the cargo to develop checklist procedures and compartment, and the passenger questions to help freight clerks cabin floor over the midcargo com- identify undeclared hazardous mate- partment became hot and soft. The rials offered by general freight ship- aircraft landed without further in- pers who are unaware of federal cident, and the 120 passengers and hazardous-materials transportation six crew members were safely evac- safety regulations. Further, the NTSB uated from the aircraft. noted that the industry had also recognized that undeclared hazardous As a result of the fire on American materials present a problem. The In- Airlines Flight 132, the NTSB ternational Air Transport Association stated that, in addition to proper pack- dangerous-goods regulations (Section aging of hazardous materials, the safe 1.6.3) address precautionary measures transportation of hazardous materials against hidden hazards in cargo and depends on airlines having sufficient baggage. In addition, following a se- information to identify hazardous ries of misdeclarations of freight, materials presented for transporta- Swissair imposed new requirements tion. Accordingly, the NTSB noted on shippers who describe consign- that both shippers and carriers had a ments in generic terms — shipping responsibility to determine whether descriptions must include the phrase materials offered for transportation “not restricted.” Unless the additional were hazardous and whether they description is included with the ship- were packaged properly to ensure ping name, the cargo is assumed to safe . contain hazardous materials.

6 FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ MAYÐJUNE 1996 The NTSB is concerned, based on the On May 16, 1986, the FAA issued a facts learned during the ValuJet Flight final rule to amend fire-safety stan- 592 accident investigation, that the dards for cargo or baggage compart- practices, procedures and training of ments. The final rule adopted more personnel involved in the identifica- stringent cargo-liner burn-through tion and handling of hazardous mate- tests and made class D cargo com- rials remain inadequate. partments smaller, but it did not re- quire fire-detection systems in class When investigating the fire on D cargo compartments. American Airlines Flight 132, the NTSB noted that, because the car- The FAA cargo compartment fire- go compartment was not equipped protection research and testing did with a fire- or smoke-detection sys- not consider the effect that hazardous tem, the cockpit crew had no way materials might have on the ability of of detecting the danger until smoke the cargo compartment to contain a and fumes reached the passenger fire. The FAA concluded in its final cabin. After smoke was detected in rule that the effects of hazardous ma- the passenger cabin, the cockpit terials were beyond the scope of its crew had no way to identify the lo- rule-making notice. Nevertheless, the cation of the fire. Previously, on NTSB subsequently noted that the in- Aug. 8, 1984, the FAA had issued a cident aboard American Airlines Flight notice of proposed rule-making, 132 clearly demonstrated that the Notice 84-11, that addressed the possibility of hazardous-materials problem of fire containment in car- involvement in a cargo compartment go compartments by specifying a fire must be considered in all cargo new test method for determining the compartment fire-penetration safety flame-penetration resistance of standards, and hazardous materials compartment liners. that present unacceptable threats should be prohibited. When the NTSB commented on the rule-making on Oct. 9, 1984, it ad- As a result of the fire on American vised the FAA that, although the pro- Airlines Flight 132, the NTSB, on posed flame-penetration tests were Oct. 24, 1988, urged the FAA to: more stringent than previous ones, a ¥ Require fire- or smoke-detection fire should not be allowed to persist systems for all class D cargo in any state of intensity in an airplane compartments (A-88-122); and, without the knowledge of the flight crew, and a fire-detection system ¥ Consider the effects of autho- should be required in class D cargo rized hazardous-materials car- compartments. go in fires for all types of cargo

FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ MAYÐJUNE 1996 7 compartments, and require ap- hazardous materials. The NTSB propriate safety systems to pro- stressed in its report of the Ameri- tect the aircraft and occupants can Airlines Flight 132 incident the (A-88-127). importance of air carriers having policies, practices and training to On Aug. 10, l993, the FAA respond- effectively screen passenger baggage ed to Safety Recommendation and freight shipments for undeclared A-88-122 by stating that the FAA did or unauthorized hazardous materials. not believe that fire- or smoke-de- Nevertheless, acceptance of unde- tection systems would provide a sig- clared and unauthorized shipments nificant degree of protection to of hazardous materials continues to occupants of airplanes and that the pose a significant threat to passen- FAA had terminated its rule-making ger and cargo aircraft. action to require such systems. On Oct. 14, 1993, Safety Recommenda- Therefore, the NTSB recommends tion A-88-122 was classified by the that the FAA: NTSB “Closed — Unacceptable ¥ Immediately evaluate the prac- Action.” On April 19, 1993, after no tices of, and training provided response to a final follow-up letter by, all air carriers for accept- to the FAA, Safety Recommendation ing passenger baggage and A-88-127 was classified “Closed — freight shipments (including Unacceptable Action.” COMAT) and for identifying undeclared or unauthorized The NTSB is currently reviewing hazardous materials that are two other incidents reported by the offered for transport. This eval- FAA that involved fires associated uation should apply to the prac- with chemical oxygen generators tices and training of any person, being shipped by air. One incident including ramp personnel, who occurred on Nov. 6, 1992, in Los accepts baggage or cargo for Angeles, and the other on Sept. 23, transport on passenger and car- 1993, in Oakland, California, U.S. go aircraft (Class I, Urgent Ac- Information obtained to date indi- tion) (A-96-25); cates that neither shipment of oxygen generators was declared to ¥ Require all air carriers, based be a hazardous-materials shipment. on the evaluation performed under Safety Recommendation These occurrences involved oxidiz- A-96-25, to revise as necessary ing materials that were transported their practices and training for as cargo without having been de- accepting passenger baggage clared or properly packaged as and freight shipments and

8 FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ MAYÐJUNE 1996 for identifying undeclared have fire- or smoke-detection or unauthorized hazardous systems (Class I, Urgent Ac- materials that are offered for tion) (A-96-28).♦ transport (Class I, Urgent Action) (A-96-26); References ¥ In cooperation with the RSPA, 1. Temporary Prohibition of Oxygen permanently prohibit the trans- Generators as Cargo in Passenger portation of chemical oxygen Aircraft, Docket HM-224, at 61 FR generators as cargo on any pas- 26418 on May 24, 1996. senger or cargo aircraft when 2. Emergency Notice of Enforcement the generators have passed their Policy at 61 FR 26422 on May 24, expiration dates and the chem- 1996. ical cores have not been deplet- ed (Class I, Urgent Action) 3. U.S. National Transportation (A-96-27); and, Safety Board. In-flight Fire, McDonnell Douglas DC-9-83, ¥ In cooperation with the RSPA, N569AA, Nashville Metropolitan prohibit the transportation of Airport, Nashville, Tennessee, oxidizers and oxidizing mate- February 3, 1988. Hazardous rials (e.g., nitric acid) in cargo Materials Incident Report no. compartments that do not NTSB/HZM-88/02. 1988.

NEWS& TIPS

UNC Acquires UNC services include airframe main- Garrett Aviation tenance, modification and retrofitting Services services; avionics and aircraft interi- or installations; overhaul and repair UNC Inc., an aviation services com- of aircraft accessories and engines; pany based in Annapolis, Maryland, aircraft maintenance and pilot- U.S., has acquired Garrett Aviation training contract services; and the Services. The acquisition was said by manufacturing and rebuilding of jet a UNC spokesman to establish UNC engine and aircraft components. UNC as the world’s largest independent has 5,900 employees at 78 locations aviation services company. in the United States and worldwide.

FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ MAYÐJUNE 1996 9 Garrett Aviation, based in Phoenix, and distribution center in Crewe, Arizona, U.S., specializes in aircraft, Virginia. The Crewe facility will engine and avionics service for busi- also be the base for the Wilkerson ness aircraft powered by turbofan Tire Co., an independent air- and turbojet engines manufactured craft tire retread and distribution by AlliedSignal. It has 1,100 em- company. ployees in the United States. Dunlop offers in-house facilities for Dunlop Aircraft retreading and dynamic testing of Tires Opens New tires up with load capacity up to Distribution Center 135,000 pounds (61,236 kilograms) and takeoff and landing speeds up to Dunlop Aircraft Tires USA has 335 miles per hour (539 kilometers opened a new U.S. headquarters per hour).♦

MAINTENANCE ALERTS

Static Electricity and particularly during flight, could re- Unstable Oxygen-fuel sult in loss of life and property. Mixture Result in When the copilot turned on the air- Substantial Fire plane’s main oxygen supply valve on Damage the oxygen-system pressure reducer- regulator assembly, he heard a loud In February 1995, an Israel Aircraft hissing sound. A fire erupted almost Industries (IAI) 1124 (Westwind I) immediately, and the cockpit was en- business jet sustained substantial fire gulfed in flames. The copilot was able damage while parked at the ramp at to duck under the fireball and evacu- Stapleton International Airport, Den- ate the aircraft uninjured. The pilot, ver, Colorado, U.S. The fire occurred who was outside the aircraft, observed during a routine aircraft interior/ flames coming through the cabin main cockpit preflight check and was entry door. The fire melted the oxy- caused by a faulty oxygen system. gen regulator assembly, burned a hole Although no one was injured, the in the right forward side wall of the U.S. National Transportation Safety airplane and caused substantial dam- Board (NTSB) is concerned that a age to the cabin interior before the fire recurrence of this type of event, was extinguished by ramp personnel.

10 FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ MAYÐJUNE 1996 Because of the fire damage, the inves- an area of ‘ambient’ pressure, oxy- tigators were unable to effectively gen is momentarily in its most ‘un- examine the oxygen system regulator stable’ condition. It is believed the valve, but the oxygen supply cylinder presence of static electricity com- was removed and examined by bined with oxygen fueled by the oil the airframe manufacturer. Their within the oxygen supply caused ig- examination disclosed that the nition of the unstable oxygen/fuel cylinder contained deposits of mixture within the regulator’s cavi- phthalates, hydrocarbons, fatty acids ties of a force adequate to mechani- and n, n-diethyldithiocarbamate, the cally rupture a component of the latter being a known catalyst. The re- regulator. The fire was then free to port prepared by IAI concluded that burn uninhibited in the atmosphere oil was present in the deposits found until the fuel source was exhausted.” in the oxygen supply cylinder. A review of the oxygen supply cylin- The advisory alert issued to operators der maintenance records indicated by IAI included this hypothesis of the that it had been serviced by Tec-Air accident scenario: Service Inc., a certificated repair sta- tion in East Northport, New York, “Several known factors may have trig- U.S., in November 1990, and again gered the ignition. Atmospheric con- at Tec-Air’s Macon, Georgia, U.S., ditions existing at the time of the facility on Jan. 11, 1994. According incident were conducive to high to Tec-Air records, the service includ- static-charge build-up. Refueling of ed removing the cylinder valve, in- the aircraft had been completed only specting and cleaning the cylinder minutes before the incident. Refuel- interior, testing the cylinder hydro- ing of an aircraft can create high statically, cleaning and overhauling static-electrical potential. The crew the cylinder valve, purging/recharg- member’s clothing included a leather ing the cylinder and checking it for jacket which, when rubbed across the leakage. aircraft’s lambskin-covered cockpit seat covers, may have generated a high In December 1994, the U.S. Federal potential static charge. As this was Aviation Administration (FAA) had happening, he reached across the cock- inspected Tec-Air’s East Northport pit from the left side to grasp and open facility and found that it was in vio- the oxygen valve. lation of, or had failed to demonstrate compliance with, 10 sections of the “During the brief period oxygen is U.S. Federal Aviation Regulations being introduced at a high rate from (FARs). The investigation cited nu- a pressure source (storage bottle) to merous occasions on which Tec-Air

FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ MAYÐJUNE 1996 11 had approved oxygen-cylinder as- Technicians involved in maintaining semblies and aircraft fire extinguish- and inspecting aircraft with oxygen ers for return to service when the systems, or other emergency equip- equipment was actually unairworthy. ment using pressurized containers Based on the results of this investi- and associated components, should gation, the FAA suspended Tec-Air’s review the maintenance records and repair station certificate. Tec-Air ex- component certification tags to en- ecutives later pleaded guilty to five sure that components subjected to felony counts of providing substan- faulty work by Tec-Air facilities are dard equipment to customers. properly identified and inspected. This incident also illustrates that The FAA issued a notice in Adviso- oxygen systems are highly intoler- ry Circular (AC) 43-16, General Avi- ant of carelessness or neglect. ation Alerts, referring to unairworthy emergency equipment and recom- Fuel Contamination Is mending that appropriate action be taken to ensure that any oxygen com- Primary Cause of Fatal ponents serviced by Tec-Air were in- Helicopter Accident deed airworthy. The NTSB does not believe that the detailed service/in- In February 1995, a Eurocopter AS- spection requirements necessary to 350B helicopter operated as a public- ensure continued airworthiness use aircraft by the Massachusetts of such equipment, particularly (U.S.) State Police (MSP) lost engine oxygen-supply cylinders and regu- power shortly after takeoff and crashed lator assemblies, have been or will into a boathouse. Both pilots and two be complied with as a result of this passengers were killed, and the aircraft FAA advisory. was destroyed.

In view of the sudden and potentially After takeoff, the helicopter had catastrophic nature of oxygen system climbed to about 600 feet (183 failures, as illustrated by this incident meters) above ground level and pro- on this Westwind I aircraft, the NTSB ceeded over the Charles River. Wit- has issued a Safety Recommendation nesses on the ground reported calling for the FAA to issue an airwor- observing smoke coming from the thiness directive applicable to all engine as the aircraft turned toward emergency equipment last serviced by the river bank, descending at a steep Tec-Air Services, requiring detailed angle. They also reported that the inspection, testing and servicing as rotor blades appeared to be turning necessary to ensure its continued slowly when the aircraft struck airworthiness. metal structures attached to the

12 FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ MAYÐJUNE 1996 boathouse, eventually coming to rest ¥ The MSP had no written or ver- on its roof. bal maintenance procedures for the fuel storage and dispensing The U.S. National Transportation system. Safety Board (NTSB) determined that many factors led to the accident, but The NTSB found many other defi- the primary causal factor was fuel con- ciencies in the MSP public-use heli- tamination. Investigation by the NTSB copter operation, such as lack of revealed that the loss of engine power structured training, lack of published resulted from contaminated fuel that operations procedures, lack of flo- had clogged the engine fuel-injector tation equipment for the helicopter, ports. lack of personal flotation devices for passengers and crew and lack of Fuel samples from the 6,000-(U.S.) survival training. gallon (22,710-liter) storage tank from which the helicopter had been fueled This accident illustrates the impor- disclosed that the fuel had degraded tance of having a fuel-quality con- thermal properties and contained iron trol program to avoid allowing oxide (rust) and water. The water con- contaminated fuel to enter an aircraft tent of samples taken from the storage fuel tank. tank ranged from five times to 800 times the maximum allowable. Maintenance technicians should monitor fuel storage and dispensing In reviewing MSP policies and pro- facilities used in servicing their air- cedures for maintenance and quality craft. Even though another section of control of the fuel facility, the NTSB the operation (or a commercial deal- found that: er) may have direct responsibility for ¥ The tank had not been main- fuel facilities, technicians should pro- tained or inspected in 14 years; vide oversight to ensure that fuel dis- pensed into aircraft under their care ¥ The filter was a 25-micron sep- is free of contamination. A well- arator element, normally used documented, periodic inspection and in diesel fuel applications (the maintenance program is critical to filter manufacturer recom- ensuring that aviation fuel facilities mended a one-micron element provide clean, uncontaminated fuel at for use with jet fuel); and, all times.♦

FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ MAYÐJUNE 1996 13 NEW PRODUCTS

High-pressure “Bumpy Bar Codes” Cleaning System Aid Tracking of Offers Flexibility for Aircraft Tires Multiple Locations A “bumpy bar code” system for per- Alfred Kärcher Inc. has announced manently bar coding aircraft tires has the availability of high-pressure been developed for Goodyear Tire & facility-cleaning systems that supply Rubber Co. The raised bar codes will water through multiple stations, each be used on all aircraft tires produced programmed to provide water at the at the company’s factory at Danville, appropriate pressure and volume, Virginia, U.S. soap and chemicals. The systems fea- ture microprocessor control, low-oil Bar codes printed on gummed labels shutoff switches and temperature- were introduced on retail products safety switches. about 20 years ago, but bar codes have previously been unsuccessful in tire applications because they were susceptible to damage or were rubbed off in routine operations.

High-pressure cleaning system

Hot-water versions, which use either a built-in heater or the building water- heating system, are available.

For information, contact: Alfred Kärcher Inc. Telephone: (908) 356- 1199. Internet World Wide Web: http://www.Karcher.com/akus. Bumpy bar codes

14 FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ MAYÐJUNE 1996 Now, through a procedure created is regulated by a fingertip adjustment by Sensis Corp. of DeWitt, New setting. Models include brass, York, U.S., the bar code is molded nickel-plated and stainless-steel into the tire sidewall using an em- units, in three-gallons-per-minute bossing process during the tire cur- and 10-gallons-per-minute (11.3 ing process. The resulting bar code liters-per- minute and 37.9 liters- can help aviation operators and per-minute) capacities. regulatory agencies monitor tire use. An aviation tire can be retread- ed as many as 10 times during its service life, according to a Good- year spokesman, but the bumpy bar code can be read on a tire through- out its lifespan.

The patented bumpy bar code readers also read bar codes created through photochemical etching or laser engraving, in addition to those created by embossing and molding.

For information, contact: Goodyear Tire & Rubber Co. Telephone: (216) 796-4994. Detergent mixer

Mixer Produces For information, contact: Force-Flo Uniform Parts-cleaning Inc. Telephone: (216) 431-7270; Fax: Detergent (216) 292-5957.

Force-Flo Inc. has introduced a de- Bird-repellent tergent mixer that automatically Device Emits Varied blends detergent and water to create Ultrasonic Sounds a uniform emulsion in any proportion, using only water-line pressure. Bird-repellent devices to keep birds out of hangars have included The Force-Flo detergent mixer is stuffed owls, plastic hawks, sticky inserted into a 55-(U.S.) gallon (208- goos and various sound devices. liter) drum of parts-cleaning deter- Bird-X Inc. has introduced its gent, and the detergent-to-water ratio UX-4 ultrasonic sound generator,

FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ MAYÐJUNE 1996 15 which the company claims is more effective than other devices.

The system uses four piezo-ceramic speakers to project powerful ultra- sonic sound waves in a pattern of overlapping “fans,” which Bird-X says provides 360-degree coverage in a building. The broadcast is said to be harsh and irritating to birds, but too high-pitched for humans to hear. Adjustable variations in speaker se- quencing, frequency and warble rate are said to make it possible to tailor the system to end each bird infesta- Security chest tion problem. to bodies are said to provide increased The constantly changing sounds are theft protection. intended to make it difficult for birds to become acclimated to any sound Single- or double-latch tabs allow pattern. The unit has no moving padlock protection, and the chests parts, is easily mounted and can be include mechanical cover supports provided in 110-volt or 220-volt ver- and two 1.5-inch (3.8-centimeter) sions. For more information, contact: skids. Each chest is drilled for op- Bird-X Inc. Telephone: (312) 226- tional casters, and fold-down han- 2473; Fax: (312) 226-2480. dles on the ends are provided for carrying. Security Chests Protect Tools from The security chests are available in Theft and Weather sizes ranging from five cubic feet (1.5 cubic meters) to 25 cubic feet Power Team has announced a new (7.6 cubic meters). For information, line of job-site and maintenance se- contact: Power Team, 2121 W. curity chests to help protect valuable Bridge Street, Owatonna, MN tools and equipment from theft and 55060-0993. Telephone: (800) 541- weather. Constructed of 16-gauge 1418 (United States and Canada); steel, the chests are built with arc- (507) 455-7100; Fax: (800) 288- welded seams for extra strength. Full- 7031 (United States and Canada); length hinges securing chest covers (507) 455-7122.♦

16 FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ MAYÐJUNE 1996 BLANK INSIDE BACK COVER Flight Safety Foundation Wake Up! Fatigue-reduction Strategies for Aviation, Maritime, Railway and Trucking Operations September 17–18, 1996 Paris, France For more information contact J. Edward Peery, FSF. Telephone: (703) 739-6700 Fax: (703) 739-6708