Engine Exhaust (SAIB: CE-10-33R1)

Engine Exhaust (SAIB: CE-10-33R1)

    Aviation Safety    INFORMATION BULLETIN
    SAIB:    CE-10-33R1
    SUBJ: Engine Exhaust    Date:    August 16, 2010
    This is information only. Recommendations aren’t mandatory.
    This Special Airworthiness Information Bulletin (SAIB) communicates an airworthiness concern to
    all owners and operators of reciprocating engine-powered airplanes that use an exhaust system heat
    exchanger for cabin heat. This revision clarifies the airworthiness concern is for aircraft that use an
    exhaust system heat exchanger for cabin heat.
    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.
    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
    http://www.tc.faa.gov/its/worldpac/techrpt/ar0949.pdf    .
    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
    The FAA recommends that you do the following:
    1.    Replace the mufflers on reciprocating engine-powered airplanes that use an exhaust
    system heat exchanger for cabin heat 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 Advisory Circular 43-
    16A, Aviation Maintenance Alert (AMA), issued October 2006, All Powered Models,
    Carbon Monoxide Poisoning Potential.

    3.    Use CO detectors while operating your aircraft as recommended by SAIB CE-10-19R1,
    dated March 17, 2010.
    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 following their applicable maintenance manual instructions.
    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

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