Recommendation A00-12

Assessment of Response to Aviation Safety Recommendation A00-12

View document in PDF

You need a PDF reader to access this file. Find out more on our help page.

Evaluate the Need for Mandatory Action by the FAA

Background

On 18 July 1998, at about 0850 Eastern Daylight Time, a flight instructor and a student took off on a local training flight from Runway 25 at Montréal/Les Cèdres Aerodrome, Quebec. The student pilot was practicing spins and recoveries. The student initiated a spin to the left, his sixth of the day, at an altitude of 3600 feet above sea level. The first 5 spins were to the right. The aircraft entered the spin normally. After 1.5 turns, the flight instructor asked the student to recover. The student applied pressure on the right rudder pedal, as taught by the flight instructor, and the rotation did not stop. The flight instructor took over the controls and applied pressure on the right rudder pedal to stop the rotation, but the rotation did not stop. The aircraft, by then, was established in a stabilized spin, rotating to the left, and continuing its descent. The flight instructor applied full power for a moment, then full flaps, to no avail. Throughout the recovery attempt, the flight instructor continued in his efforts to avoid the crash. The aircraft struck the surface of Lac Saint-François. The student pilot sustained serious injuries, but managed to evacuate the sinking aircraft through the right, rear window. He then tried to pull out the unconscious flight instructor, but without success. A fisherman close to the scene rescued the student and transported him ashore where emergency vehicles were standing by. The flight instructor did not evacuate the aircraft and died in the accident.

The Board concluded its investigation and authorized the release of report A98Q0114 on 06 July 2000.

Board Recommendation A00-12 (14 July 2000)

The Federal Aviation Administration (FAA), as the regulatory body in the state of design and manufacture, has primary responsibilities with regard to continuing airworthiness of both the Cessna 150 and 152 aircraft. Therefore, the Board recommends that:

The National Transportation Safety Board review the circumstances and findings of this investigation and evaluate the need for mandatory airworthiness action by the Federal Aviation Administration.
A00-12

National Transportation Safety Board Response to A00-12 (09 March 2001)

In its response, the National Transportation Safety Board (NTSB) indicated that its staff has reviewed Aviation Investigation Report A98Q0114 and the recommended safety actions therein. On 22 January 2001, Cessna Aircraft Company issued a service bulletin (SEB 01-1) that addresses issues related to rudder over-travel. Specifically, it recommends a design change to increase the size of the rudder horn stop bolt to preclude over-travel of the rudder. In addition, the Board brought the circumstances and findings of this investigation to the attention of the FAA, particularly the Small Aircraft Directorate and the Aircraft Accident Investigation staff. To complete its activities regarding this recommendation, the NTSB has evaluated the need for FAA action and has determined that further action regarding TSB Safety Recommendation A00-12 is dependent upon the FAA's assessment of the need to mandate Cessna Aircraft Company's service bulletin.

Board Assessment of the National Transportation Safety Board Response to A00-12 (21 March 2001)

The NTSB's response reports that their staffs has reviewed Aviation Investigation Report A98Q0114 and Cessna Aircraft Company's Service Bulletin SEB01-1, which recommends a design change to preclude over-travel of the rudder. In addition, NTSB brought the circumstances and findings of the TSB investigation to the attention of the FAA. NTSB reports that it has evaluated the need for FAA action and has determined that further action regarding this TSB recommendation is dependent upon the FAA's assessment of the need to mandate Cessna Service Bulletin SEB01-1. The NTSB is aware that the FAA does not intend to mandate SEB01-1.

NTSB's review of the occurrence circumstances and the Cessna SEB01-1, and its consultations with FAA meet the intent of this recommendation.

Consequently, NTSB's response is assessed as Fully Satisfactory.

Next TSB action

Further action is unwarranted.

This deficiency file is assigned an Inactive Status.