Leita
Design change to spoiler actuator
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The Icelandic Transportation Safety Board (ITSB) recommends to Moog, in co-operation with the airplane’s manufacturer, set up a program to support fleet wide replacement of the blocking and thermal relief valve housing with the fatigue improved unit made from stainless steel.
Afgreiðsla
Moog has redesigned the Blocking and Thermal Relief Valve Housing with thicker material section and more radius in the area of the fracture surface. The redesigned Blocking and Thermal Relief Valve Housing is made from stainless steel instead of aluminum. This results in better fatigue performance of the Blocking and Thermal Relief Valve Housing. In addition the FAA has issued Safety Recommendation 15.115, a Boeing 757 airplane level safety issue, mandating evaluation of the spoiler actuator's blocking and thermal relief valve housing failure to determine appropriate corrective action.
Fleet implement of design change
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The Icelandic Transportation Safety Board (ITSB) recommends to Boeing, to issue the planned service bulletin 757-SB57A0154 to support fleet wide replacement of the Blocking and Thermal Relief Valve Housing in co-operation with the actuator‘s manufacturer.
Afgreiðsla
Boeing plans to release Boeing Alert Service Bulletin 757-SB-27A0154 on June 25 2016. In addition the FAA has issued Safety Recommendation 15.115, a Boeing 757 airplane level safety issue, mandating evaluation of the spoiler actuator's blocking and thermal relief valve housing failure to determine appropriate corrective action.
Research of similar design
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The Icelandic Transportation Safety Board (ITSB) recommends to Boeing, to research other Boeing large transport category aircraft for similar spoiler actuator design and take corrective action as needed .
Afgreiðsla
The FAA has issued Safety Recommendation 15.116, gathering and reviewing compliance data, including hazard assessments, for each type of Title 14, Code of Federal Regulations (14 CFR) Part 25 airplane operating under part 121. The FAA will be addressing Safety Recommendation 15.116 for U.S.-manufactured aircraft.
FAA mandate of design change
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The Icelandic Transportation Safety Board (ITSB) recommends to the FAA, to research the need for making inspections, and possible replacement, of spoiler actuator’s Blocking and Thermal Relief Valve Housing mandatory via issue of airworthiness directive, for Boeing 757 airplanes.
Afgreiðsla
The FAA has issued Safety Recommendation 15.115, a Boeing 757 airplane level safety issue, mandating evaluation of the spoiler actuator's blocking and thermal relief valve housing failure to determine appropriate corrective action.
Update 31.01.2017:
The FAA has reviewed and determined that the latent failure of the spoiler power control unit Blocking and Thermal Relief Valve (BTRV) housing does manifest itself when the hydraulic system it is attached to fails. The failure causes an uncommanded extension of the spoiler panel, known as spoiler panel float. The result of multiple spoiler panel floating can lead to the loss of the airplane. The FAA's Aircraft Certification Service has determined this is a safety issue and the FAA is in the process of publishing an airworthiness directive to address it.
Updated 6.10.2017:
The FAA has issued Airworthiness Directive 2017-04-07, mandating that within 51 months after January 23 2017, for all Boeing 757-200, -200PF, -200CB, and -300 series airplanes, certificated in any category, each spoiler power control unit (PCU) must be replaced with a new or changed PCU at spoiler positions 2, 3, and 4 on the left wing, and spoiler positions 9, 10, and 11 on the right wing, in accordance with the Accomplishment Instructions of Boeing Alert Service Bulletin 757-27A0154, dated July 22, 2016. This concludes the above safety recommendation issued by the Icelandic Transportation Safety Board on August 13th, 2015.
FAA mandate of research of similar design
Tillaga í öryggisátt
The Icelandic Transportation Safety Board (ITSB) recommends to the FAA, to research the need for making inspections, and possible replacement, of spoiler actuator’s Blocking and Thermal Relief Valve Housing mandatory via issue of airworthiness directive, for other large transport category aircraft with similar spoiler actuator design.
Afgreiðsla
The FAA has issued Safety Recommendation 15.116, gathering and reviewing compliance data, including hazard assessments, for each type of Title 14, Code of Federal Regulations (14 CFR) Part 25 airplane operating under part 121. The FAA will be addressing Safety Recommendation 15.116 for U.S.-manufactured aircraft. Furthermore, the FAA recommended to the ITSB to provide a similar recommendation to foreign aviation authorities for each State of design. The board of ITSB approved on a board meeting held on January 15th, 2016, to contact other states of designs of aircraft of similar spoiler design and extend the recommendation as needed.
Update: 31.01.2017:
The FAA has reviewed the design, manufacturing, and service information and determined the Boeing Model 757 failed BTRV housing was under-designed in that it had insufficient fatigue life. The reason for this was found to be a design error that led to a premature failure. The valve itself was designed by a third party, Moog, which reported that the valve is used only on the Boeing Model 757 series airplanes. Therefore this under-designed part is not on any other transport airplanes. Additionally, a quary of the FAA Service Difficulty Report (SDR) database did not reveal any other spoiler issue associated with the blocking/thermal relief valves in the past fifteen years on any transport airplanes. The FAA considers its action to Safety Recommendation 15.116 completed.
Critical pulley fastener notification
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The Icelandic Transportation Safety Board (ITSB) recommends to Technify Motors to issue a service letter to operators, advising of this incident and remind them never to loosen the belt pulley fastener in the crankshaft, due to its critical torque value.
Afgreiðsla
Technify Motors added several notes to repair procedures (RM-02-02) during which the mechanic might have the idea to demount the pulley and informed all registered users regarding the new versions.
Design of pulley fastener locking
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The Icelandic Transportation Safety Board (ITSB) recommends to Technify Motors to reconsider the design of the crankshaft belt pulley fastener P/N 05-7223-K000501 in order to prevent loosening of the fastener.
Afgreiðsla
Technify Motors reconsidered the design of the crankshaft belt pulley fastener P/N 05- 7223-K000501 in order to prevent loosening of the fastener and provided a report to EASA. In the report different options of locking mechanism were considered. The preferred solution was to mark the bolt with torque seal and decided to implement it. This way, the security of the correct sit of the crankshaft main bolt could be checked during inspections, to see if it was loosening over time.
Sjónflugsflugvélar í blindflugsaðstæðum
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RNSA leggur áherslu á að flugmenn, og þá sérstaklega þeir sem hafa mikla blindflugsreynslu, vanmeti ekki þær aðstæður sem geta skapast í sjónflugi á flugvélum sem ekki eru útbúnar til blindflugs.
Afgreiðsla
Þessari tillögu er beint til flugmanna almennt og því er henni lokið með útgáfu hennar. Að auki mun RNSA ræða þessa tillögu á næstu flugöryggisfundum.
Mörk svæða sýnilegri úr lofti
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RNSA leggur til að Samgöngustofa endurskoði staðsetningu Austursvæðis og Sandskeiðs með tilliti til marka þeirra þannig að þau verði auðséð úr lofti.
Afgreiðsla
Samgöngustofa setti af stað verkefni um endurskipulagningu svæða og sjónflugsumferðar fyrir austan BIRK. Reglur um breytta tilhögun sjónflugs í Austursvæði og austur af BIRK tóku gildi 1. júní 2016. Hin breytta tilhögun er byggð á hættugreiningu og áhættumati sem unnið var af Isavia að beiðni SGS. Flugumferðarstjórar sem og notendur loftrýmis (m.a. einkaflugmenn, prófdómarar, þyrluflugmenn) tóku þátt í þeirri vinnu og SGS stýrði síðan úrvinnslu lokatillagna, sem aftur voru rýndar af SGS og tryggði SGS að sömu aðilar kæmu ekki að úrvinnslu tillagna og rýni.
Eftirfarandi breytingar má finna í AIP, sjá hér.
Fjarlægðir milli svæða
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RNSA leggur til að Samgöngustofa endurskoði staðsetningu Austursvæðis og Sandskeiðs með tilliti til fjarlægðar á milli þeirra.
Afgreiðsla
Samgöngustofa setti af stað verkefni um endurskipulagningu svæða og sjónflugsumferðar fyrir austan BIRK. Reglur um breytta tilhögun sjónflugs í Austursvæði og austur af BIRK tóku gildi 1. júní 2016. Hin breytta tilhögun er byggð á hættugreiningu og áhættumati sem unnið var af Isavia að beiðni SGS. Flugumferðarstjórar sem og notendur loftrýmis (m.a. einkaflugmenn, prófdómarar, þyrluflugmenn) tóku þátt í þeirri vinnu og SGS stýrði síðan úrvinnslu lokatillagna, sem aftur voru rýndar af SGS og tryggði SGS að sömu aðilar kæmu ekki að úrvinnslu tillagna og rýni.
Eftirfarandi breytingar má finna í AIP, sjá hér.