System Component Failure – Powerplant

Following the first and second Loss of Control working groups, the GAJSC decided to focus on System Component Failure-Powerplant (SCF-PP) fatal accidents. Beginning in 2014, the SCF-PP working group began examining accidents categorized as having SCF-PP as a factor in the outcome. The working group ultimately reviewed 70 randomly selected accidents to conduct a root cause analysis and identify prospective interSCF-PP_bgventions. Following the GAJSC’s approval of the proposed interventions, the working group developed Safety Enhancements (SEs) for each intervention. The approved SEs are detailed in the SCF-PP report, available for download here: System Component Failure – Powerplant Report: June 2016 (4599 downloads)

A list of the recommendations detailed in the report follow.

35 Mitigating the Risk of Improper Torquing: To help prevent fatal general aviation accidents due to failure of the powerplant system, the general aviation community should educate the maintenance community about the fatal and other accident risk caused by improper torquing techniques. The community should also determine if there are potential technology solutions for new and legacy aircraft that can cost effectively be implemented to eliminate or mitigate the risk of improper torquing. One technology that should be considered is Direct Tension Indicating (DTI) technology utilizes visual indications for mechanics to confirm proper torque. Currently, ASTM F959 provides a standard for compressible washer DTI for structural engineer. In their current state, they are single-use mechanical load cells used to indicate when the required tension has been achieved in structural fastener assemblies.

FAA Magazine: A Most Vulnerable Spot – The Importance of Proper Torque: July 2018

2019 AMT Course: Proper Torque

36 Vmc Scenario Training: FAA and industry to encourage the development of training scenarios based on fatal accidents caused by VMC related LOC to be used in multiengine training.

SE Topic of the Month: November 2015; March 2018 (Emergency Procedure Training)

EAA Pilot Proficiency Center: Simulation Missions (August 2021)

37 Multi-engine Emergency Management Technology: Encourage a research program to develop requirements and performance specifications for proposed VMC-imminent warning device designs under asymmetric thrust conditions, as well as research and develop technological solutions to prevent pilots from feathering the wrong engine. FAA/industry to implement developed solutions.

Garmin Smart Rudder Bias: Safety-Enhancing Technology for Twin-Engine Piston Aircraft (December 15, 2020) (ref: Beechcraft B58/58A and Piper PA-31-300 through 325)

Aviation International News: Garmin Certifies Smart Rudder Bias on CE-414: (Sept. 16, 2021)

39 Smart Cockpit Technology: Industry to research and develop smart cockpit technology that helps identify emergency situations, prompts pilots (aurally/visually) through pertinent checklist items, and provides instructions based on aircraft position and condition of flight.

SE Topic of the Month: April 2018

Garmin Continues to Enhance Aviation Safety with the Introduction of Smart Glide: July 2021

41 Accident Survivability:FAA/industry to research survivability issues and potential solutions (air bags, shoulder harnesses, UV wear indication, helmets, fire prevention, ballistic parachutes, etc.) and implement recommendations.

SE Topic of the Month: October 2015; October 2017

FAA InFO 17004: Seat Belt Repair and Alterations

AOPA Safety Spotlight: Survival Safety (Course Sunset)

Report: SE-41 Final Report – Crashworthiness and Survivability Recommendations 103017

FAA Safety Brief: The Art of Survival – Crashworthiness Study Highlights Need for Occupational Safety Features (May/June 2019)

42  Mitigating V-Band Clamp Failures: To help prevent fatal general aviation accidents due to failure of the powerplant system, the general aviation community should develop an appliance-specific document addressing the safety of exhaust related v-band clamp assemblies.

Three accidents were identified with v-band clamp issues in the SCF-PP analysis. Specifically noted were fatigue cracking at spot welds that led to exhaust leaks which then propagated into inflight fires and powerplant failures. In some cases the v-band clamp cracking was due to improper installation and in other cases corrosion. In addition to being noted in the SCF-PP dataset, historical documentation has noted an ongoing issue with v-band clamps (reference NTSB accident investigations, and OEM and FAA service documents). Considering the three representative accidents, as well as the historical OEM, FAA, and NTSB documents, the FAA shall investigate the need for an appliance-specific airworthiness directive.

SE-42 adopted from SCF-PP SERFI status January 2018.

Exhaust System Turbocharger to Tailpipe V-Band Coupling / Clamp Working Group – Final Report

Airworthiness Directives published by the FAA since SE-42 adopted:

Beechcraft Models A36TC, B36TC, S35, V35, and V35B – AD2018-06-11

FAA Magazine – Nuts, Bolts, and Electrons: FAA Clamps Down on V-Band Failures: Sept. 2018

44 Modernized Maintenance Safety Reporting System: FAA evaluate the feasibility of a modernized maintenance data exchange program to take the place of the current M&D/SDR process and improves the ability to identify issues/trends with components across multiple OEMs and across multiple certification offices.
45 Maintenance Placard: Industry to develop, distribute, and promote a tool/device to be displayed in the windscreen of aircraft undergoing maintenance and aircraft that have not been maintained in a substantial amount of time.

GAMA Publication 18 Aircraft in Maintenance Publication

SE Topic of the Month: February 2018 – Maintenance Placards – FAA Fact Sheet

FAA Safety Team: Maintenance Placards (YouTube)

47 A&P Education and Training: Improved guidance and improved availability of guidance to maintenance professionals and improved training and outreach. Additionally, compilation of research and additional research as required in regards to human factors in maintenance.

SE Topic of Month: November 2017 – Engine Maintenance and Performance Monitoring – FAA Fact Sheet

48 Ignition Systems: Improve reliability in reciprocating engine ignition systems through research and possible promotion of alternative ignition systems.

SE Topic of the Month: December 2017 – FADEC – FAA Fact Sheet

AOPA Safety Spotlight: Aircraft Ownership and Maintenance

Lycoming Introduces Electronic Ignition System: July 2019

49 SCF-PP Outreach:

SE Topic of the Month: March 2017; August 2018 (Maneuvering Flight)

AOPA Air Safety Institute Online Course: Essential Aerodynamics (June 2021)

SE Topic of the Month: January 2018 – Enhanced Vision System (EVS) – FAA Fact Sheet

SE Topic of the Month: May 2018 (Best Glide Speed)