Air transportation safety recommendation A03-02
Reassessment of the responses to from Transport Canada to Aviation Safety Recommendation A03-02
Thermal acoustic insulation materials: Proposed ceritfication standard for thermal acoustic insulation materials
On 02 September 1998, Swissair Flight 111, a McDonnell Douglas MD-11 aircraft, departed John F. Kennedy Airport in New York, New York, en route to Geneva, Switzerland. Approximately one hour after take-off, the crew diverted the flight to Halifax, Nova Scotia, because of smoke in the cockpit. While the aircraft was manoeuvring in preparation for landing in Halifax, it struck the water near Peggy's Cove, Nova Scotia, fatally injuring all 229 occupants on board. The investigation revealed that the flight crew had lost control of the aircraft as a result of a fire in the aircraft's ceiling area, forward and aft of the cockpit bulkhead.
The Board concluded its investigation and released report A98H0003 on 27 March 2003.
Board Recommendation A03-02 (27 March 2003)
By developing the Radiant Panel Test (RPT), the Federal Aviation Administration (FAA) has successfully designed a single certification test that, while a major improvement over the vertical Bunsen burner test, may not successfully evaluate the performance of all types of thermal acoustic insulation materials under representative conditions. Given these limitations of the FAA's proposed RPT, the Board recommended that:
Regulatory authorities develop a test regime that will effectively prevent the certification of any thermal acoustic insulation materials that, based on realistic ignition scenarios, would sustain or propagate a fire.
Transportation Safety Recommendation A03-02
Response to A03-02 (16 June 2003)
In its 16 June 2003 response to Recommendation A03-02, Transport Canada (TC) provided the following comments:
- TC agrees with the objective of this recommendation.
- TC considers that the TSB's concerns have or are being addressed.
- TC states that the FAA is developing advisory material to address these issues that will be used concurrently with the final rule implementing the RPT.
- TC has contacted the FAA to raise this "issue" with the FAA's International Aircraft Materials Fire Test Working Group.
Board Assessment of the Response to A03-02 (29 October 2003)
In brief, the deficiencies raised by TSB's Recommendation A03-02 deal with the following limitations of the FAA's proposed RPT: specimen orientation, preheat, testing materials as a system, and the role of in-service contamination.
As stated in the TC response, the FAA has declared its intention to develop advisory material in support of its final RPT rule. However, the FAA did not issue this advisory material in concert with the final RPT rule, but rather indicated that advisory material would be forthcoming to deal with specifics such as test sample configurations, insulation on air ducts, and the installation techniques for insulation materials. The final rule does not indicate whether the advisory material will deal with either the preheat or contamination issues. The advisory material has yet to be published. The planned action when fully implemented will substantially reduce or eliminate the safety deficiency.
Therefore, the response is assessed as Satisfactory Intent.
Next TSB action
The TSB Air Branch will monitor the development of the FAA's advisory material and TC's subsequent follow-up in reaction to it, in an effort to assess whether or not the deficiencies raised in Recommendation A03-02 have been mitigated. The extent to which any forthcoming advisory material alleviates the limitations of the final RPT rule will establish the conditions for reassessment of TC's response.
Response to A03-02 (14 December 2005)
In its update of active recommendations dated 14 December 2005, TC indicated that an update to Recommendation A03-02 was not available due to scheduling conflicts for some Swissair Recommendation team members. Furthermore, TC indicated that an update will follow as soon as team members can meet and draft updates.
Board Reassessment of the Response to A03-02 (12 July 2006)
TC's letter to the TSB dated 14 December 2005 did not include an update with respect to Recommendation A03-02. As of this date, TC has yet to update the TSB as to whether or not it has taken action with respect to harmonizing the Canadian Aviation Regulations (CARs) with the applicable amendments to the Federal Aviation Regulations (FAR 25.856 + Parts VI & VII of APP F of FAR 25) and the FAA Advisory Circular 25.856-1 as stated in its June 2003 response to the TSB.
It is the Board's understanding that TC remains committed to providing an update to its original action plan, which, if fully implemented, will substantially reduce or eliminate the deficiencies as described in the Recommendation A03-02.
Therefore, the assessment remains at Satisfactory Intent.
Response to A03-02 (07 February 2007)
TC's response reviews previously known regulatory action taken to develop and implement improved flammability standards for thermal acoustic insulation materials used in transport category airplanes. TC advises that it has adopted the FAA's revised flammability-related design standards for thermal acoustic insulation materials as Airworthiness Manual Chapter 525, Section 525.856 of its CARs. TC also states that its activity to address the deficiency identified in Recommendation A03-02 is complete.
Board Reassessment of the Response to A03-02 (24 July 2007)
TC's response states that it has harmonized its CARs with the FAA's revised regulations dealing with improved flammability standards for thermal acoustic insulation materials. However, as projected in a previous response to the TSB dated June 2003, TC has yet to state its position relating to FAA's Advisory Circular 25.856-1, which was published to address some, if not all, of the risks associated with the deficiency identified in Recommendation A03-02. Furthermore, TC states that its actions with respect to the deficiency identified in Recommendation A03-02 are complete.
TC's action will not substantially reduce the deficiency; therefore, the assessment is Satisfactory in Part.
Response to A03-02 (11 March 2008)
TC's response repeats previously known regulatory action to adopt revised design standards for thermal acoustic materials. Additionally, TC indicates that Notice of Proposed Amendments (NPAs) 2005-044 and 2005-068 are in progress to develop operational rules to address newly manufactured aeroplanes and for replacement of existing insulation materials. These NPAs would be applicable to Transport Category aeroplanes operating under Section 705 of the CARs.
Consequently, TC considers this recommendation closed because:
- TC has completed the task and has communicated to the Board in response to the recommendation.
- Appropriate mitigation is in place for the unacceptable risks identified.
- Any further changes in this area will take place as a result of international regulation harmonization.
Board Reassessment of the Response to A03-02 (13 August 2008)
TC's response states that it has harmonized its CARs design standards with the FAA's revised regulations for thermal acoustic materials. Consequently, in accordance with paragraph 4 (a) of TC's Airworthiness Manual Advisory Index, dated 01 December 2004, the associated FAA Advisory Circular 25.856-1 is considered acceptable to TC. Additionally, TC states that its NPAs, to change Section 705 of the CARs operational rules dealing with newly manufactured aeroplanes and the replacement of insulation materials in existing aircraft, have yet to be finalized.
TC's action, when fully implemented, will substantially reduce or eliminate the deficiency.
Therefore, the response is assessed Satisfactory Intent.
Review of A03-02 Deficiency File Status (23 September 2009)
In its latest position statement regarding the deficiency identified in Recommendation A03-02, TC states that based on the adoption of new design standards and regulatory changes in progress it considers this recommendation closed and plans no further action.
Therefore, the assessment remains at Satisfactory-in-Part
The Board also concludes that, as no further action is planned by TC to address any residual risk, continued reassessment will not likely yield further results.
Next TSB action
TSB Air Branch staff will not actively monitor TC's regulatory activities to develop a test regime that will effectively prevent the certification of any thermal acoustic insulation materials that would sustain or propagate a fire.
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