NTSB recommendation reinforces Part 91 operators’ ADHERENCE to SMS

NTSB finds history of certain defective oil-filter adapters

Defect might have been detected by SMS

FAA, Air Safety Institute and FAA offer scalable system for Members

The NTSB has issued a recommendation (see below) directed to the FAA based on a record of accident reports. It is fair to assume that, if the Safety Management System was mandatory for General Aviation, this serial failure might have been detected and have been proactively addressed. This data if had been processed, through SMS, might have saved Dr. Lowell Glenn Daun, the owner/operator of the CESSNA 182 with certain defective oil-filter adapters for Continental engine. Here is the NTSB list of prior failures.

NTSB oil filter history

The absence of required SMS reflects a realistic recognition that some of the administration associated with this discipline would be beyond the means of the average GA operator. To attempt to capture the needed data, both AOPA and NBAA have created  SMS programs easier for their Members to utilize.

These voluntary programs should be immediately adopted by these Part 91 operators with the same intensity as though SMS was mandatory.


To quote AOPA,

With SMS, "That's an accident waiting to happen," may be forever removed from aviation jargon.”

AIR SAFETY INSTITUTE DEBUTS SCALABLE SAFETY FRAMEWORK

AOPA ASI logo

March 1, 2019By AOPA Air Safety Institute staff

The AOPA Air Safety Institute has released a Scalable Safety Framework (SSF), a PowerPoint presentation with a supporting PDF, that can be downloaded by aviation organizations like public benefit groups, flying clubs, and more to help them formulate, implement, and sustain a safety culture that is geared and scaled to their specific organization.

The institute’s Scalable Safety Framework is based on the FAA mandated Safety Management Systems in use by air carriers and other large operations. The Air Safety Institute focused the framework on five main components and steps to success.

  1. Leadership….
  2. Accountability…
  3. Risk…
  4. Reporting…
  5. Culture…

 

Safety is everyone’s responsibility—help your aviation group by developing your own Scalable Safety Framework. Download the presentation from our Safety to Go portal.


NOTE: ASI SAFETY NOTICE: 2020-2 STRATUS STC OIL FILTER ADAPTER ASSEMBLY LINKED TO LOSS OF ENGINE POWER

 

striped warning


Safety Management System (SMS) Overview

nbaa ibac isbao

Through the use of SMS, business aircraft operators can proactively identify and manage risks. Under a formalized SMS, operators identify potential hazards and ensure that a process is put in place to effectively manage them. NBAA advocates that flight departments of all sizes implement a SMS for aircraft operations….

The International Standard for Business Aircraft Operation (IS-BAO), developed by the International Business Aviation Council (IBAC) and its member associations (such as NBAA), is a code of best practices designed to help flight departments worldwide achieve high levels of safety and professionalism. At the core of the IS-BAO is a scalable SMS tool for business aircraft operators, from single aircraft/single-pilot operations to large multi-aircraft flight departments.

NBAA in cooperation with IBAC is also offering two additional resources to assist operators with SMS implementation. The first is a Toolkit that will help operators develop and implement a SMS that meets ICAO SARPS. The second resource is a SMS e-Learning course developed by IBAC and FlightSafety International.


NTSB To FAA: Do Something About Oil Filter Adapters for Continentals

oil filter adapter gasket

Citing a recent fatal accident of a Cessna 182 in California, the National Transportation Safety Board (NTSB) has renewed efforts to get the FAA to issue an Airworthiness Directive for certain oil-filter adapters for Continental engines. The adapters are made by Stratus Tool Technologies (part of the Tempest Aero Group) but are often referred to by their original designer and manufacturer, F&M Enterprises. Some 11 accidents over the last 15 years have been linked to this filter adapter vibrating loose and allowing a loss of engine oil. Stratus has published a Mandatory Service Bulletin addressing the issue, but FAR Part 91 operators are not required to comply with this guidance.

CESSNA 182 N7302

The NTSB says the safety recommendation “is derived from both preliminary findings of ongoing investigations and our review of investigations and reports of airplane accidents in which the airplane was equipped with an oil filter adapter assembly installed under a supplemental type certificate (STC). In each of these accidents, oil leaked from the assembly, resulting in oil starvation to the engine and a subsequent total loss of engine power.”

The Stratus adapters are designed to fit a wide range of Continental engines, from the small six-cylinder models (C-145 and O-300), certain of the larger IO and TSIO-360 engines, and a wide swath of the big-bore O-470, IO-520, TSIO-520, and IO-550 engines. These relatively early Continental engines were designed with a simple brass screen instead of a paper-element canister oil filter, and the adapter allows installation of a full-flow filter. The adapters screw into the space originally occupied by the brass screen. “Two gaskets were used in the oil filter adapter assembly kit: a fiber gasket located between the oil pump bore and the oil filter adapter and a copper crush gasket located between the oil filter adapter and the bolt used to secure the adapter housing to the oil pump bore,” according to the NTSB. “The fiber gasket’s purpose was to create a seal between the oil pump and oil filter adapter, and the copper gasket’s purpose was to create a seal at the top of the oil filter adapter housing.”

At issue is the likelihood that the filter adapter loosened and dumped the engine’s oil overboard. The NTSB notes that the manufacturers have changed maintenance guidance over time. “In May 2011, F&M [the original STC holder] modified the installation instructions to specify that the oil filter adapter must be installed using new gaskets,” says the NTSB. “In October 2013, F&M added a new section on gaskets to its ICA that directed the installation of new gaskets anytime the oil filter adapter is removed and re-installed, and the replacement of gaskets at 300 hours or 3 years whichever occurs first. More recent installation instructions have removed that requirement and instead specify, ‘There are no mandatory replacement times for any components.’”

The NTSB wants the FAA to act. “Although a SAFO [Safety Alert for Operators] that directs operators to inspect, correctly install, and maintain oil filter adapters would provide this important information to operators of airplanes with these oil filter adapters, compliance with a SAFO is not required. The NTSB therefore determines that because owners who operate airplanes under Part 91 are not required to comply with an SB or SAFO, Stratus’ SB-001 and the FAA’s proposed SAFO may be insufficient to address all affected airplanes, which could result in a gasket rupture, oil starvation, and a subsequent engine failure.”

Issue an Airworthiness Directive to address the unsafe conditions of F&M Enterprises Inc. or Stratus Tool Technologies (Stratus) oil filter adapters that have led to oil starvation and loss of engine power by requiring owners of airplanes equipped with the adapters to repetitively inspect and, if necessary, reinstall the adapters in compliance with Stratus’ service bulletin SB-001. (A-20-39)

Dr. Daun

Dr. Lowell Glenn Daun,

THE PILOT FATALITY