Output Number
Approval Date
Published Date Time
Recommendation type
Mode
Date released

The Bureau of Air Safety Investigation recommends that Raytheon
Aircraft examine and implement methods of preventing incorrect
passenger oxygen system mask container door fitment as installed in
Beech King Air B200 series aircraft, and other Raytheon aircraft
similarly equipped.



As a result of the investigation into this safety deficiency, the
Bureau simultaneously issues the following interim
recommendations:



IR19990088



The Bureau of Air Safety Investigation recommends that Raytheon
Aircraft issue a directive for an immediate check of the fitment of
passenger oxygen system mask container doors on all Beech King Air
B200 aircraft, and all other Raytheon aircraft similarly
equipped.



IR19990084



The Bureau of Air Safety Investigation recommends that the Civil
Aviation Safety Authority issue a directive for an immediate check
of the fitment of passenger oxygen system mask container doors on
all Australian Beech King Air B200 aircraft, and all other aircraft
similarly equipped.



IR19990089



The Bureau of Air Safety Investigation recommends that the Federal
Aviation Administration issue a directive for an immediate check of
the fitment of passenger oxygen system mask container doors on all
Beech King Air B200 aircraft, and all other aircraft similarly
equipped.

Organisation Response
Date Received
Organisation
Beech Aircraft Corp
Response Status
Response Text

RAC will make a production design change to the B200 oxygen mask
containers to provide a method of preventing the doors from being
installed incorrectly. RAC will make available through spares, and
announce via a Recommended Service Bulletin, the same change to all
delivered airplanes. The production design change is tentatively
scheduled to be completed by the end of the second quarter of
2000.



RAC has investigated to determine whether the condition referenced
in the Interim Recommendation might exist in other Raytheon King
Air model airplanes:



* The Model C90A does not have an auto-deploy or drop-down system.
It is totally passenger operated (i.e., the passenger opens the
door and plugs in the mask).

* The Model B300 is an auto-deploy system made by Puritan Bennett.
The lid is permanently attached to the box with two metal lanyards.
The lanyards are not long enough to allow the door to be rotated
and installed improperly.

* Model 200 serials BB-1 through BB-54 (excluded from the
applicability of the B200 system) use the same system as the Model
C90A.

* The Model F90 has an oxygen system design similar to the B200.
The Interim Recommendation therefore applies to the Model F90 as
well. RAC will address the F90 in all corrective actions.

* The Model 100 has an oxygen system design similar to the C90A. It
does not have an auto-deploy or drop-down system. It is totally
passenger operated (i.e., the passenger opens the door and
plugs



In addition to the King Air Models, RAC has investigated to
determine whether the condition referenced in the Interim
Recommendation might exist in other Raytheon model airplanes. The
investigation revealed that the condition does not exist.
Specifically:



* The Commuter Airplane Series (Model 1900, 1900C, and 1900D)
oxygen box door design does not allow the door to be installed
backwards or in any other manner which would prevent the plunger
from releasing the door.

* The Beechjet Airplane Series (Model 400, 400A, 4001) design does
not permit the oxygen doors to be installed backwards.

* The Starship (Model 2000) does not have the same cover design and
cannot be installed backwards. The hinge tabs are on one side, and
the plunger interface is on the other. The plunger interface is
part of the door. There are no slots for the hinge tabs on the
other side of the box, so that the door cannot be installed 180
degrees out. Also, the plunger cannot be inserted into the valve
body if the door is backwards.



The Hawker Airplane Series design does not permit the oxygen doors
to be installed backwards.



This information has also been supplied to the U.S. FAA.



(* Letter to FAA:)



RAC has reviewed the Safety Recommendations submitted in FAA's
letter dated September 16, 1999, regarding the oxygen mask
container and its door. RAC agrees that the door can be installed
incorrectly, causing the masks not to deploy as intended.



Design applicability and description

Models B200, 300, and 200 (except BB-1 thru BB-54) use an
auto-deploy system from Puritan Bennett. Puritan Bennett provides
the box with plungers and masks. RAC provides the lids and plastic
lanyards that are attached to the RAC escutcheon.



Recommendation 99.301:

The Bureau of Air Safety Investigation recommends that the Federal
Aviation Administration issue a directive for an immediate check of
the fitment of passenger oxygen system mask container doors on all
Beech King Air B200 aircraft and all other aircraft similarly
equipped.



RAC Response:

RAC does not have an objection to FAA issuing an AD on this subject
matter. However, RAC has issued sufficient information on the Model
200 Series regarding repetitive inspections and functional tests on
the system that should be adequate to ensure their proper operation
(copies of the Maintenance Manual pages are enclosed).



Specifically, the Model 200 Maintenance Manual requires that an
oxygen system functional test be performed at Phase 1 and Phase 3
(initially at 200 and 600 hours, and every 800 hours thereafter for
both phases.) During the oxygen system test (Model 200 Series
Maintenance Manual, in Chapter 35-00-00, Page 217, paragraph d) the
operator is required to ensure that the doors on the mask
containers open and the masks drop out.



Additionally, the Model 200 Series Maintenance Manual cautions
operators that the oxygen "Container door can be positioned 180'
off. If this happens, the plunger cannot push the door open when
activated." This Caution note appears in Chapter 35-00-00, Pages
215 and 216, in Step 1 (Page 215) and Step i (Page 216).



The Model 300 Series Maintenance Manual requires that an oxygen
mask pressure test be performed at Phase 1 and Phase 3 (initially
at 200 and 600 hours, and every 800 hours thereafter for both
phases.) During the oxygen mask pressure test (Model 300 Series
Maintenance Manual, in Chapter 35-00-00, Page 6, paragraph f) the
operator is required to ensure that the doors on the mask
containers open and the masks drop out. This manual, however, does
not provide a Caution note regarding improper door installation
that might prevent the door from opening when activated. Therefore,
the Model 300 Series Maintenance Manual will be revised at the next
scheduled revision to add the caution note and the similar safety
information provided in the 200 Series Maintenance Manual.



Recommendation 99.302:

The Bureau of Air Safety Investigation recommends that Raytheon
Aircraft issue a directive for an immediate check of the fitment of
passenger oxygen system mask container doors on all Beech King Air
B200 aircraft and all other Raytheon air-craft similarly
equipped.



RAC Response:

RAC has published an article regarding this subject in a King Air
Model Comununique. The Communique is being mailed this month.
Additionally, RAC is preparing a Safety Communique against all
airplanes with auto-deploy oxygen masks to ensure that all
operators are aware of the importance of properly installing the
doors on the oxygen mask boxes.



Recommendation 99.303:

The Bureau of Air Safety Investigation recommends that Raytheon
Aircraft examine and implement methods of preventing incorrect
passenger oxygen system mask container door fitment as installed in
Beech King Air B200 series aircraft and all other Raytheon aircraft
similarly.



RAC Response:

Raytheon Aircraft will make a production design change to the B200
oxygen mask containers to provide a method of preventing the doors
from being installed incorrectly. RAC will make available through
spares (Recommended Service Bulletin), the same change to all
delivered airplanes. The production design chance is tentatively
scheduled to be completed by the end of the second quarter of
2000.



Applicability on other Models

RAC has investigated to see if the condition referenced in the
Safety Recommendation may exist in other Raytheon King Air Model
Airplanes:

* The Model C90A does not have an auto-deploy or drop-down system.
It is totally passenger operated (the passenger opens the door and
plugs in the mask).

* The Model B300 is an auto-deploy system made by Puritan Bennett.
The lid is permanently attached to the box with 2 metal
lanyards.

* Serials BB-1 through BB-54 (excluded from the applicability of
the B200 system) use the same system as the Model C90A.

* Model F90: RAC is still investigating and will provide a complete
response to FAA by November 30, 1999.

* Model 100: RAC is still investigating and will provide a complete
response to FAA by November 30, 1999.



In addition to the King Air Models, RAC has investigated to see if
the condition referenced in the Safety Recommendation may exist in
other Raytheon Model Airplanes. The investigation revealed that the
condition does not exist. Specifically:

* The Commuter Airplane Series (Model 1900, 1900C and 1900D) oxygen
box door design does not allow the door to be installed backwards
or in any other manner which would prevent the plunger from
releasing the door.

* The Beechjet Airplane Series (Model 400, 400A, 40OT) design does
not permit the oxygen doors to be installed back-wards.

* The Starship (Model 2000) does not have the same cover design and
cannot be installed backwards. The hinge tabs are on one side and
the plunger interface is on the other and is part of the door.
There are not slots for the hinge tabs on the other side of the box
so that the door cannot be installed 180 degrees out. Also, the
plunger cannot be inserted into the valve body.

* The Hawker Airplane Series design does not permit the oxygen
doors to be installed backwards.

ATSB Response

The following email was sent to Raytheon Aircraft Corporation on
29 May 2002:



To enable the ATSB to finalise our report on the incident, could
you please provide details of the production design changes,
including any IPC references, that have been made by Raytheon to
prevent the doors from being installed incorrectly.