Another maintenance release destroyed in GA crash. Same old story..

[A37575]

ATSB have released their accident investigation report on a Chieftain VH-OPC that crashed at Bathurst on 7 November 2008.

AO-2008-076 (http://www.atsb.gov.au/publications/investigation_reports/2008/aair/ao-2008-076.aspx)
Final ATSB Transport Safety Report AO-2008-076 into the Collision with terrain 3 km N Bathurst Airport, NSW, 7 November 2008, VH-OPC Piper Aircraft Corp. PA-31-35 Chieftain.

Seems the pilot lost control after take off at night and speared in. The report stated the Maintenance release issued at the time was not found at the accident site, so the total time in service and defect endorsement status were not available.

In other words if there were any defects recorded on the maintenance release ATSB haven't a clue what they were or if they would have had any bearing on the cause of the crash.

Time and again in general aviation crashes the maintenance release is destroyed, and thus possible vital defects recorded in between the last 100 hourly and the next, are lost. CASA will never learn, will they?

It is well known that in many instances general aviation pilots refuse to enter defects in the maintenance release because they perceive this may be prejudicial to job security if they are working for charlatans. Other pilots show marked reluctance to write up defects when hiring another operator's aircraft for a similar reason. Don't tell me it doesn't happen because from bitter personal experience I know it does in GA.

So it is quite possible that a maintenance release shows a clean defect sheet from one 100 hourly to the next. I know of one flying school that has this policy.

But what gets me is the CASA head-in-the sand policy with general aviation operators, that for decades has required by law that the original of the maintenance release is to be carried on each flight. There could have been several defects recorded in that maintenance release between 100 hourly inspections that may have been of significant interest to an ATSB investigator if that aircraft had had an accident which resulted in aircraft destruction.

The obvious solution is to leave a copy of the maintenance release at each port of call - similar to passenger manifests and a copy of the servicing sheet, left at each port of call by airline companies. At least that way, ATSB investigators could check on recorded defects entered since the last flight. While a record of the latest 100 hourly maintenance release is kept by the maintenance organisation once the aircraft leaves the hangar after the 100 hourly, that is not much good to investigators if other defects recorded after the inspection are then destroyed in a prang.

I can only guess that the attitude of CASA is that general aviation accidents mean nothing compared to a high capacity RPT accident, and if a vital maintenance release is destroyed in a GA accident -who cares? As the statement made by ATSB investigation in the Chieftain Bathurst accident said: "the defect status was not available".

Oh - that's alright then....

[dudduddud]

Yes I've always been curious about that ever since they first told me 'no no, you take that with you.'

What are the practical arguments against keeping the releases on the ground out of harms way?

[eocvictim]

Well the basic reason is unscheduled stops or overnighting in different locations with different crews using the aircraft the next day. It happens all the time so it would be impossible to implement.

The simplest answer to your question is what you will find most reputable operators do and that is to fax a copy of the MR or at least an area on your manifest/deck log/daily log to note any U/S's written up.

I know its beside the point but I think you'll find OPC would not have fit into the above dodgy operators. It was meticulously maintained.

[rmcdonal]

As soon as you write anything on an IFR MR the aircraft is U/S (Unless you have a MEL). Hence there is often hesitation to write anything up, particularly if the pilot feels that it would not effect to the safety of the flight eg rear seat lap restraint broken, would U/S the aircraft, even if no one was sitting in the seat.
As far as perfectly clean MRs go, I do know of some CASA guys who targeted aircraft with clean MRs. They figured every acft has something break on it once in a while and it’s a bit sus if nothing goes wrong.

[43Inches]

It is well known that in many instances general aviation pilots refuse to enter defects in the maintenance release because they perceive this may be prejudicial to job security if they are working for charlatans. Other pilots show marked reluctance to write up defects when hiring another operator's aircraft for a similar reason. Don't tell me it doesn't happen because from bitter personal experience I know it does in GA.

So how is CASA going to stop this? And how is a copy of the MR going to help if its blank anyway? What if your on a flight to the middle of nowhere with no phone or copying facilities, must you then depart illegally if you can not leave a copy pinned to a tree nearby.

At the last few GA companies I worked for we used to get ramp checked a few times a year with a few spot checks thrown in by CASA to check for defects on aircraft. Usually just an error on MR TT calcs, faded exit signs or other minor items. If you know of dodgy operators report them to CASA and it does get investigated.

As rmcdonal replied any defect on the MR makes the aircraft unairworthy unless it has an MEL condition invoked. The MR is carried with the aircraft as with your licence and medical to prove on request whether the aircraft is airworthy. The MEL will not allow departure into conditions which would preclude safe flight and should not be a contributing factor.

Any defects fixed during the 100 hour interval will have a record of maintenance carried out also.

[bentleg]

As soon as you write anything on an IFR MR the aircraft is U/S


I think it is a matter for pilot judgement. What about an unserviceable navaid, that does not affect minimum equipment requirements?

[43Inches]

Two other points relevent to this discussion from the report;


After extensive examination, the investigation found there was no evidence of any aircraft unserviceability and that airworthiness was not likely to have been a contributing factor in the accident


and;


The maintainer reported that the owner-pilot of the aircraft insisted on a high standard of aircraft maintenance and would not operate the aircraft with any defects.


If you have any further information sugesting the ATSB have got it wrong then you should contact them.

[Horatio Leafblower]

43"

I'm pretty sure that isn't A37575's point or intention :suspect:

[VH-XXX]

For this thread to succeed and be of value it should not reference the Chieftain crash but rather how the MR goes with the aircraft.

[Charlie Foxtrot India]

When I was doing GA in the Channel islands we had a tech log which was kept at base. Defects were entered onto it, "Nil defects"or "nil further"for allowable ones, filled in each time the aircraft returned. This meant that ops and engineering could keep track of things and schedule maintenance even though the aircraft were often out all working hours. I found it very strange that the MR had to be carried in the aircraft here.

I've seen some things on MRs that mean that in the hands of the unscrupulous, it worthless anyway.

[43Inches]

Horatio - A37575's point is quite clear in having a go at CASA for forcing a pilot to bring an aircraft maintenance release along with the aircraft.

The crash referenced has a paragraph which clearly states that without such a document the ATSB was able to ascertain that aircraft defects were not a distinct factor in this accident.

If the point is to prove that a copy of the MR would have been of benefit then an accident where the ATSB have stated this would have been more appropriate.

The MR is like a pilots medical certificate, you have to carry it with you and proves the aircraft was healthy at its last check, and when the next one is due. This is an easy, workable way for each pilot or engineer who comes across the aircraft to check its status.

There are numerous things which could be added to aviation which in practicality would increase the complexity of each flight, with negligible increase in flying safety. Airlines do it due to the operation of much larger aircraft with much greater loss of life at stake. They have dedicated engineers and support structure with aircraft specific systems of maintenance and central document control. On a private flight why do we need to add to the complexity of the system with more rules which would not have changed the outcome in this scenario?

Do you have to carry a running defect sheet for your car or boat with copies left at home in case you go missing? However you must have your licence and rego.

[Chadzat]

Slightly off the original topic, but valid for a point raised in this thread about pilots very reluctant to enter defects on an IFR MR.

Could this be solved with an Australian fleet-wide MEL? I realise it would be a big job for CASA (too big) but why not introduce an Australia specific (not company) MEL for the common types in service with operators who due to not operating RPT do not have MEL's? Ie PA31's, BE58s, C310's etc......

There would already be a quite few company MEL's applicable to the bigger piston twins as they would have operated RPT-although sadly piston RPT is a dying art.

Having flown for a company without an MEL and also one with an MEL, although I hate to admit it, your attitude towards defect reporting does change quite markedly. As a previous poster said, how many "little" things are U/S on these 30 year old aircraft that are not critical to the safety of the aircraft? HEAPS!

[bushy]

You are right. If the clock does not work you cannot fly the aeroplane.

[rmcdonal]

justapplhere
Roger, Just looking for it, not had my head in the books for a while so is taking a bit longer then usual. :ok:

[av8trflying]

I dont know where it mentions the MR, but in CAO 20.18.10.1 it states that all equipment fitted to an IFR charter or RPT aircraft must be serviceable prior to take off.

So I suppose if you have something on the MR it is no longer serviceable.

[rmcdonal]

Ok so my memory of the item was not exact (has been a few years) and it’s not all IFR aircraft just aircraft operating in Charter or RPT

10 Serviceability
10.1 In the case of a charter or regular public transport aircraft, all instruments and
equipment fitted to the aircraft must be serviceable before take-off, unless:
(a) flight with unserviceable instruments or equipment has been approved by CASA,
subject to such conditions as CASA specifies; or
(b) the unserviceability is a permissible unserviceability set out in the minimum
equipment list for the aircraft and any applicable conditions under subregulation
37 (2) of the Regulations have been complied with; or
(c) CASA has approved the flight with the unserviceable instrument or equipment
and any applicable conditions that CASA has specified in writing have been
complied with; or
(d) the unserviceable instrument or equipment is a passenger convenience item only
and does not affect the airworthiness of the aircraft.
10.1A A private or aerial work aircraft must not be operated:
(a) under the V.F.R., unless:
(i) all instruments and equipment required to be fitted to the aircraft under
subsection 3 are serviceable before take-off; or
(ii) CASA has approved the flight with the unserviceable instrument or
equipment and any applicable conditions that CASA has specified in writing
have been complied with; or
(b) under the I.F.R., unless:
(i) all instruments and equipment required to be fitted to the aircraft under
subsection 4 are serviceable before take-off; or
(ii) CASA has approved the flight with the unserviceable instrument or
equipment and any applicable conditions that CASA has specified in writing
have been complied with.
Civil Aviation Order 20.18

http://www.casa.gov.au/wcmswr/_assets/main/download/orders/cao20/2018.pdf

:ok:



Justapplhere
Sorry I may have misinterpreted your question.
The above CAO was what I was referring to. I just made the logical leap from there being a defect on the aircraft and it then being written up on the MR. Technically as soon as there is any defect the aircraft would be US with or without writing it up.

[Kulwin Park]

So in other words, if a seat belt is U/S in the rear seat on an IFR aircraft, and as you say above that it is equipment fitted, then ....
That seat belt must be removed prior to flight, the seat signed DO NOT USE,
or...
The affected seat be removed from the aircraft prior to flight!
Yes???!!!

I recently flew on Virgin where they had a row of seats U/S marked, loose on the track attach point, but they had labels already pre-made, attached to seats, and of course they would have an MEL that would cover this :ok:

[rmcdonal]

Kulwin Park, Yes.
Normally just signed DO NOT USE/ UNSERVICEABLE.
If you pull the seat out you have to account for it in the wt and balance.
And you then write it up in the MR, and then clear it on the MR with the reference to the MEL.

[Socket]

I refer you all to Aviation Ruling 1/2004:

http://www.casa.gov.au/wcmswr/_assets/main/rules/rulings/2004/ar0104.pdf

The Instruments and Equipment mentioned in CAO 20.18 are limited to those listed in Para 9.


9 For the purposes of CAR 207 (2), the following instruments and equipment have
been approved or directed to be fitted or carried by CASA in accordance with the
relevant CAO:
9.1 oxygen and protective breathing equipment as set out in CAO 20.4; and
9.2 emergency and life saving equipment as set out in CAO 20.11; and
9.3 seats, seat belts and safety harnesses as set out in CAO 20.16.3; and
9.4 instruments and equipment set out in CAO 20.18; and
9.5 all instruments and equipment of the kinds referred to in paragraphs 9.1,
9.2, 9.3, and 9.4, which are in addition to the minimum required by the
CAOs referred to in those paragraph.

[Tee Emm]

Well do I remember the case of the Partenavia fatal accident at Wagga a good few years back. Seems the aircraft descended below the DME steps to Wagga from Albury in cloud and clipped a hill four miles from Wagga. The aircraft had a load of defects at the time but nothing in the maintenance release. During the Coroners Inquiry it was revealed the pilot was required to fax details of defects to company head office interstate but not to record details of said defects in the maintenance release until permission granted to do so. To those present in the Coroners court room who were experienced professional pilots, there was amazement when a CASA FOI called as a witness stated that the pilot should have had no problem with no cockpit night lighting as this sort of thing was "tested" during a pilots instrument rating test! Of course that was rubbish but the Coroner accepted that as official CASA advice...

Defects included failure of windshield demisting system, pilots seat loose on rails and subject to excessive movement at all times. Pilots shoulder harness removed to allow for cargo net attachment. All cockpit instrument lighting inoperative - this required the pilot to fly with torch in his mouth in IMC night - I kid you not as he used a passenger to hold the torch for him and same passenger continually wiped the condensation formed inside the windscreen. Cockpit heating inoperative with pilot forced to use derro gloves at altitude when it was very cold. Witness to all this were non-paying passengers. When the maintenance organisation for the operator was asked by pilot to fix seat and other unserviceabilities during a short stop-over at maintenance organisation's base in NSW, request was refused citing non-payment of money owing for previous maintenance.

The maintenance release was destroyed in the crash. If the pilot had recorded the defects on previous legs, ATSB would not have known. If a copy of the maintenance release had been left at each port of call as per HC RPT flights (assuming the pilot would have recorded them of course) then ATSB would have more information that may have helped trace the reason why the pilot was flying below the DME steps - for example distraction of rocking seat, no instrument panel lights, no demisting etc.

When the list of defects was presented to the Coroner by a relative of the dead pilot (the pilot kept a list at home), the Coroner who of course had no aviation experience, nor had his policeman assistant, dismissed them as trivial, saying that as it was an old aeroplane, defects could be expected just like an old car could expect defects. There was no shortage of people running for cover during that Inquest. All to no avail as only two unfortunates lost their lives and the crash was soon forgotten.

It wouldn't surprise me if 50 percent of GA maintenance release documents - particularly in the flight training field of operations - are clean between 100 hourly's - no recorded defects. When CASA during an audit on one particular twin engine aircraft used for charter and training some years back, the airworthiness people found 20 defects on the aircraft and a clean maintenance release. While there is truth in that legally some aircraft may be grounded with even just one item entered, it also serves as a convenient excuse to keep flying with other major and minor defects to be "fixed" at the next 100 hourly OR when the owner deems he can afford to get the defects rectified.