The aircraft was not fitted nor required to be fitted with a crash-resistant fuel system under the current standards or those in place at the time of manufacture. As a result, post-impact fire presents a significant risk of fire-related injuries and fatalities to aircraft occupants.
Response by the United States Federal Aviation Administration
The Federal Aviation Administration is forming a cross-organisational team to review the topic of post-crash fires and identify potential risk mitigations.
ATSB comment
The ATSB acknowledges the Federal Aviation Administration’s plan to review the issue of post-impact fires. However, as there is no commitment to safety action addressing standards for crash-resistant fuel systems or timeframe, the ATSB is issuing the following safety recommendation.
The FAA assessed that additional crash-resistant fuel system rulemaking for fixed-wing airplanes is not warranted at this time.
The ATSB recommends that the United States Federal Aviation Administration take action to address certification requirements for crash-resistant fuel systems for fixed wing aircraft to reduce the risk of post-impact fire.
The Federal Aviation Administration (FAA), Aircraft Certification Service, has received and is assessing the ATSB’s final report to develop an appropriate action plan. The FAA anticipates providing an updated response to this safety recommendation by March 31, 2024.
The ATSB appreciates the FAA's initial response and looks forward to further response in March 2024.
As a result of this recommendation, a team of FAA specialists was formed to review the ATSB’s report and, in addition, initiate a study of all National
Transportation Safety Board (NTSB) accident reports involving general aviation post-crash fire accidents that occurred between January 1, 2012, and December 31, 2021. The study was completed on November 1, 2023. Currently, the results of the study are being reviewed to determine the FAA’s next actions in addressing this safety recommendation. The FAA anticipate providing an update to this safety recommendation by March 31,
2025.
The ATSB appreciates the work being done by the FAA regarding post-impact fire accidents. We look forward to hearing the results of the study and FAA's next actions.
The FAA formed an internal team of specialists to review the ATSB accident report as well as NTSB accident reports related to post crash fires (PCF). The team completed their PCF review and study on November 1, 2023 (available at https://rosap.ntl.bts.gov/view/dot/77378). The results of the study were consistent with earlier studies conducted regarding this subject, including the results from studies conducted prior to the Notice of Proposed Rulemaking (NPRM), Notice 85-7A, Airworthiness Standards; Crash Resistant Fuel Systems, published in the Federal Register on February 28, 1990 (55 FR 7280). The NPRM is available at the following website: https://archives.federalregister.gov/issue_slice/1990/2/28/7176-7287.pdf#page=105.
The Notice 85-7A proposed changes to Title 14, Code of Federal Regulations Part 23 airworthiness requirements to improve crash resistance of select fuel system components by limiting fuel spillage near ignition sources and thus allow additional time for survivors of the impact to evacuate the airplane. However, Notice 85-7A was withdrawn (64 FR 250) on December 30, 1999, because the costs of the proposed change did not justify the potential safety benefits. The results of the FAA’s 2023 study were consistent with previous studies showing most fatalities in PCF accidents were due to occupant blunt force trauma injuries. Therefore, increasing evacuation times by delaying the PCF event would have had limited impact to survivability outcomes in a majority of PCF fatal accidents. This Notice is available at the following website: https://www.govinfo.gov/content/pkg/FR-1999-12-30/pdf/99-33801.pdf.
The benefits of aftermarket safety equipment, such as passenger restraints, and their ability to reduce the severity of general aviation (GA) accidents has been documented both by the FAA and GA industry advocates. The FAA will continue to communicate the benefits of safety enhancing equipment available to the industry and encourage aircraft owners and operators to incorporate such technologies voluntarily.
FAA documentation related to aftermarket safety equipment is available at the following website: https://www.faa.gov/sites/faa.gov/files/2022-01/Aftermarket%20Safety%20Equipment.pdf.
Industry documentation related to aftermarket safety equipment is available at the following website: https://www.aopa.org/news-and-media/all-news/2021/august/flight-training-magazine/what-am-i-seat-belt.
Therefore, we believe the cost/benefit data from the FAA’s study prior to Notice 85-7A combined with our more recent 2023 study and its assessment does not warrant additional crash-resistant fuel system rulemaking for fixed-wing airplanes at this time.
I believe the FAA has effectively addressed this safety recommendation and consider our actions complete.
The Office of Accident Investigation and Prevention convened a Safety Recommendation Review Board to review the attached response to your FAA Safety Recommendation 23.027. As a result, the Review Board classified this recommendation as Closed Not Adopted (CAN).
The ATSB notes that the FAA's recent study concluded that the presence of post-impact fire and its effect on survivability has remained constant since the 1970s, with minimal changes made to small aeroplanes and their fuel systems over that time. Without a change to the certification standard to mandate crash resistant technologies for fuel systems, manufacturers are unlikely to incorporate such systems in new aircraft designs. As the FAA does not propose to take any action to amend certification requirements for crashworthiness of fuel tanks and systems to reduce the risk of post-impact fire, disappointingly the ATSB has closed the safety recommendation as unaddressed.
