Issued: 21-MAR-2003 | To: ICAO | B-18255 (1) |
The ASC strongly recommends that all civil aviation accident investigation agencies to collaborate with their regulatory authorities to take appropriate action requiring all operators of transport-category aircrafts with pressure vessel repairs. Identified as a result of structural damage other than those covered by Boeing service bulletin documentation ASB B747-53A2489 for an immediate inspection on the repaired area to determine whether any hidden damage is present.
An improperly treated scratch on the aircraft pressure vessel skin, especially if covered under a repair doubler, could be a hidden damage that might develop into fatigue crack eventually causing structure failure. |
Issued: 08-APR-2003 | To: FAA | A-03-10 |
Require the manufacturers of pressurized transport-category airplanes to include in their structural repair manuals, training programs, and other maintenance guidance, warnings about the possibility of structural failure resulting from hidden damage. (Open - Acceptable Response) |
Issued: 08-APR-2003 | To: FAA | A-03-7 |
Establish appropriate criteria (taking into account the size of the repair and other relevant considerations) to identify those pressure vessel repairs to transport-category airplanes that could be hiding damage that, if not addressed, may lead to multiple-site fatigue damage and fatigue cracking and could result in structural failure of the airplane. (Closed - Acceptable Action) |
Issued: 08-APR-2003 | To: FAA | A-03-8 |
Issue an airworthiness directive requiring all operators of transport-category airplanes with pressure vessel repairs identified as a result of applying the criteria discussed in Safety Recommendation A-03-07 (other than those covered by Service Bulletin 747-53A2489) to (Open - Acceptable Response) |
Issued: 08-APR-2003 | To: FAA | A-03-9 |
Inform maintenance personnel about the circumstances of this accident and emphasize that improper repairs to the pressure vessel may be hiding damage that allows the development of multiple-site fatigue damage and fatigue fracturing that could lead to structural failure. (Closed - Acceptable Action) |
Issued: 25-FEB-2005 | To: CAA Taiwan | B-18255 (10) |
Ensure that the process for determining implementation threshold for mandatory continuing airworthiness information, such as RAP, includes safety aspects, operational factors, and the uncertainty factors in workmanship and inspection. The information of the analysis used to determine the threshold should be fully documented. |
Issued: 25-FEB-2005 | To: CAA Taiwan | B-18255 (11) |
Encourage operators to establish a mechanism to manage their maintenance record keeping system, in order to provide a clear view for inspector/auditors conducting records reviews. |
Issued: 25-FEB-2005 | To: CAA Taiwan | B-18255 (12) |
Encourage operators to assess and implement safety related airworthiness requirements at the earliest practicable time. |
Issued: 25-FEB-2005 | To: CAA Taiwan | B-18255 (13) |
Consider the implementation of independent power sources for flight recorders and dual combination recorders to improve the effectiveness in flight occurrence investigation. |
Issued: 25-FEB-2005 | To: CAA Taiwan | B-18255 (14) |
Consider adding cabin pressure as one of the mandatory FDR parameter. |
Issued: 25-FEB-2005 | To: CAA Taiwan | B-18255 (15) |
Closely monitor international technology development regarding more effective non-destructive inspection devices and procedure. |
Issued: 25-FEB-2005 | To: Boeing | B-18255 (16) |
Re-assess the relationship of Boeings field service representative with the operators such that a more proactive and problem solving consultation effort to the operators can be achieved, especially in the area of maintenance operations. |
Issued: 25-FEB-2005 | To: Boeing | B-18255 (17) |
Develop or enhance research effort for more effective non-destructive inspection devices and procedures. |
Issued: 25-FEB-2005 | To: FAA | B-18255 (18) |
Consider the implementation of independent power sources for flight recorders and dual combination recorders to improve the effectiveness in flight occurrence investigation. |
Issued: 25-FEB-2005 | To: FAA | B-18255 (19) |
Consider adding cabin pressure as one of the mandatory FDR parameter. |
Issued: 25-FEB-2005 | To: China Airlines | B-18255 (2) |
Perform structural repairs according to the SRM or other regulatory agency approved methods without deviation, and perform damage assessment in accordance with the approved regulations, procedures, and best practices. |
Issued: 25-FEB-2005 | To: FAA | B-18255 (20) |
Ensure that the process for determining implementation threshold for mandatory continuing airworthiness information, such as RAP, includes safety aspects, operational factors, and the uncertainty factors in workmanship and inspection. The information of the analysis used to determine the threshold should be fully documented. |
Issued: 25-FEB-2005 | To: Taiwan Government | B-18255 (21) |
ASC should coordinate with the Ministry of Defense to sign a Memorandum of Agreement for the utilization of the defense tracking radar information when necessary, to improve efficiency and timeliness of the safety investigations. |
Issued: 25-FEB-2005 | To: Taiwan Government | B-18255 (22) |
ASC should coordinate with the Ministry of Justice to develop an autopsy guidelines and procedures in aviation accident investigation. |
Issued: 25-FEB-2005 | To: China Airlines | B-18255 (3) |
Review the record keeping system to ensure that all maintenance activities have been properly recorded. |
Issued: 25-FEB-2005 | To: China Airlines | B-18255 (4) |
Assess and implement safety related airworthiness requirements, such as the RAP, at the earliest practicable time. |
Issued: 25-FEB-2005 | To: China Airlines | B-18255 (5) |
Review the self-audit inspection procedures to ensure that all the mandatory requirements for continuing airworthiness, such as CPCP, are completed in accordance with the approved maintenance documents. |
Issued: 25-FEB-2005 | To: China Airlines | B-18255 (6) |
Enhance maintenance crews awareness with regard to the irregular shape of the aircraft structure, as well as any potential signs that may indicate hidden structural damage. |
Issued: 25-FEB-2005 | To: China Airlines | B-18255 (7) |
Re-assess the relationship with the manufacturers field service representative to actively seek assistance and consultation from manufacturers field service representatives, especially in maintenance and repair operations. |
Issued: 25-FEB-2005 | To: CAA Taiwan | B-18255 (8) |
Ensure that all safety-related service documentation relevant to ROC-registered aircraft is received and assessed by the carriers for safety of flight implications. The regulatory authority process should ensure that the carriers are effectively assessing the aspects of service documentation that affect the safety of flight. |
Issued: 25-FEB-2005 | To: CAA Taiwan | B-18255 (9) |
Consider reviewing its inspection procedure for maintenance records. This should be done with a view to ensuring that the carriers systems are adequate and are operating effectively to make certain that the timeliness and completeness of the continuing airworthiness programs for their aircraft are being met. |