Carbon monoxide (CO) poisoning

Carbon monoxide (CO) poisoning

At this time, this airworthiness concern is not considered an unsafe condition that would warrant an
airworthiness directive action under Title 14 of the Code of Federal Regulations (14 CFR), part 39.
3. Use CO detectors while operating your aircraft as recommended by SAIB CE-10-19R1,
dated March 17, 2010.
Aviation Safety
May 7, 2010
SUBJ: Engine Exhaust
This is information only. Recommendations aren’t mandatory.
This Special Airworthiness Information Bulletin (SAIB) advises all owners and operators of
reciprocating engine powered airplanes of an airworthiness concern.
The Federal Aviation Administration tasked Wichita State University to conduct research that
focuses on carbon monoxide safety issues as they apply to general aviation products. A technical
report titled “Detection and prevention of carbon monoxide exposure in General Aviation Aircraft,
Document No. DOT/FAA/AR-09/49, dated October 2009” is available from the National Technical
Information Services using the contact information noted below and is also available electronically at
The report shows that after researching National Transportation Safety Board (NTSB) accidents
related to carbon monoxide (CO) poisoning, the muffler system was the top source of CO. For the
CO-related cases where the muffler was identified as the source of the CO leakage, 92 percent had a
muffler with more than 1,000 hours of service.
When developing this SAIB the FAA considered the NTSB investigation of an accident on December
17, 2000, where a Beech Model BE-23 aircraft impacted terrain killing the commercial-rated pilot,
the sole occupant of the airplane. The NTSB determined the probable cause of the accident was in
part “the pilot’s incapacitation due to carbon monoxide (CO) and a fractured muffler.”
The FAA recommends that you do the following:
1. Replace the mufflers on reciprocating engine-powered airplanes with more than 1,000
hours on the muffler and at each 1,000-hour interval, unless the manufacturer
recommends or FAA regulations require a more frequent replacement.
2. Review and continue to follow the guidance for exhaust system inspections and
maintenance in SAIB CE-04-22, dated December 17, 2003, and Aviation Maintenance
Alert (AMA), All Powered Models, Carbon Monoxide Poisoning Potential, October 2006
issue of Advisory Circular 43-16A.

For Further Information Contact
Sarjapur Nagarajan, Aerospace Engineer, FAA Small Airplane Directorate, 901 Locust, Kansas City,
Room 301, Missouri 64106; phone: (816) 329-4145; fax: (816) 329-4090; email:
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
For Related Information on the Technical Report, Contact:
U.S. Department of Commerce
National Technical Information Services (NTIS)
Alexandria, Virginia 22312
(703) 605-6000 or 1-800-553-6847
4. Continue to inspect the complete engine exhaust system during 100-hour/annual
inspections and at inspection intervals recommended by the aircraft and engine
manufacturers in accordance with their applicable maintenance manual instructions.

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