Should EASA hold its head in Shame?

[Beeline]

This is a recent press release from Aircraft Engineers International regarding the legal investigation into Span Air MD80 accident Flight JK5022.
I apologise in advance if this subject has been covered already please point me to the relevant thread.

http://www.airengineers.org/docs/news/spanair_investigation.pdf

Background

I hold a current EASA Part 66 Maintenance Licence; reading this release and the final report makes my spine shiver. The two engineers in question made one mistake, which was to trust an unregulated, deceivable and ambiguous MEL. Scary still this is not the worst thing I have ever seen or heard about being despatched incorrectly.

I have read the CIAIAC report numerous times now and cannot see how placing an inoperative sticker by a RAT gauge lands them with 154 acts of involuntary manslaughter and 18 counts of negligence. Even if the engineers had made the decision to inop the whole system instead of just the Probe heat it still would not have highlighted the u/s Take off warning system.

Safety recommendation

I am quite surprised at this response from the investigators and AEI. I see erroneous intermittent failures of systems all the time. If you cannot reproduce the fault on the ground you cannot fix it; I am sure flight crew appreciate this concept as well. How deep into the system must we go on each defect; time is always a factor and I cannot look at a system schematic every time I am called to an aircraft just to make sure it doesn’t affect a vital system such as TOWS. We rely on the MEL to tell me these links where someone has had time to go through the systems vitals and double check. In some respect the MEL is our QRH and should be as concise.

View on report Scenarios

The report is obviously written by somebody unfamiliar with the processes on the Line and the pressure what are upon you when you are called to an aircraft full of people wanting too fly. How can you have an infinite knowledge of an aircrafts system in your head using experience and intuition? Hindsight is 20:20; shame on you investigators.

Wash up

I do not hold a rating on the MD80 so it will be interesting hearing the views of MD80 typed Pilots and Engineers and the common drills with this snag. If it is fairly common don’t attack these guys actions that have landed them in the slammer, they may work up to 5 types of aircraft a day; that is why the MEL must be black and white, with no grey!


CIAAIC Report A-032-2008
www.fomento.gob.es/NR/rdonlyres/EC47A855-B098-409E-B4C8-9A6DD0D0969F/107087/2008_032_A_ENG.pdf

[Kitbag]

As a lay person (I have a military aviation maintenance background) my reading of the report was that the investigators,, with the benefit of hindsight were unable to come to a definitive conclusion on the correct remedial action for the reported fault.
I also noted that the recommendations had been rejected by the FAA.
There certainly appears to be grounds for duty holders to be held to account for not ensuring their duties were upheld.
I know nothing of the Spanish judicial system; is it independent or political? There were several passages implying certain recovered components were examined in the prescence of the judge, is this level of oversight normal in similar investigations outside Spain? How well were the engineers able to explain their situation?

[Fargoo]

The primary cause of the accident was taking off with an incorrectly setup aircraft by the flight crew.

I couldn't find the extract from the MEL within the report - did it say that part of making the RAT INOP that you need to pull this circuit breaker? If not then I think the Engineers may have left themselves wide open.

It is a design fault that fails to provide redundancy to such a vital safety system and the same scenario could occur were the c/b to trip on taxi out without the crew noticing!

View on report Scenarios

The report is obviously written by somebody unfamiliar with the processes on the Line and the pressure what are upon you when you are called to an aircraft full of people wanting too fly. How can you have an infinite knowledge of an aircrafts system in your head using experience and intuition? Hindsight is 20:20; shame on you investigators.

Scrub the pressure bit Beeline, that is irrelevant. All lineys know the pressure, all flight crew know it too but good Engineers and Crew deal with the pressure without rushing or bodging things. If you need to consult the MM and your line office is 10 min drive away so be it, a delay is better than an incident or accident.

Don't blame the investigators , I think they did an excellent job with this report. Blame instead the judiciary who are looking to find some living breathing scapegoats to pin the whole thing on to.

Have a proper read of the report again, page 5.

[boogie-nicey]

General EU culture and that of it's self appointed regulatory bodies is to be unanswerable. As for shame they are far too high and mighty for that kind of honourable conduct.

[woptb]

Scrub the pressure bit Beeline, that is irrelevant. All lineys know the pressure, all flight crew know it too but good Engineers and Crew deal with the pressure without rushing or bodging things. If you need to consult the MM and your line office is 10 min drive away so be it, a delay is better than an incident or accident.



FARGOO if you've always felt able to play the red card,more power to you,but having been subjected to almost intolerable pressure in the past, sadly during my career I've made some bad choices.

The implication that "good" engineers 'always' deal with the pressure is well wide of the mark. There really are those occaisions where many (most?) have felt the pressure to get the job done is overwhelming.
If there is anyone out there who has 'always' followed the procedures,then your a better man than me!
Without recognising that pressure applied by organisations forces people into rule breaking,(not just bad people say yes?) we mask the issues.
The regulators are gutless & unfortunately the judiciary are partial - they don't care why the engineers sign off a job,just that they did.
Just culture,my ar5e !!

[ABAT4t2]

G,day guys

from my understanding of events it seems most of you have missed the point.

Techs went on board a defective aircraft and started troubleshooting. As time passed pressure was applied to depart, troubleshooting stopped and the item defered as per the MEL.

The judge has criticised the techs for paying more attention to avoiding a delay than fixing the fault. Regulations covering MEL use are full of loopholes and most of us are aware of commercial pressure.

So what do you want, leave things as they are and should you take the quickest route, defer according MEL end up in court or should the regulations surrounding the use of the MEL be tightened.

All manufacturers out of interest inform operators that the MEL is a tool to be used after the cause of a fault has been determined. Now ask yourself, do you really get to the cause of a fault before applying the MEL or do you ask whether the fault can be deferred before troubleshooting?

Most take the latter and leave themselves wide open. Beeline I am sorry but some of your coments come across as a joke. You are clearly unaware of your responsibilities as a certifier.

[mono]

Not rated on this type, but for me, if there's a probe(s) heated on the ground, then there is the possibility of an air/ground sensing fault and this should be checked. I've had similar faults myself and have always investigated further (one was a failed relay, the other a faulty probe)

Having said that, the report does state that for every eventuality with the MEL written as it was then (not sure if it has since been amended), a defect in the TAWS would not have been detected by the maintenance crew as there was no requirement to check it.

However, the maintenance crew did make some mistakes the main one being that having pulled the probe heat CB they didn't cross refer to any MEL refs for RAT sensing (i.e the inoperability of the auto throttle system, which appears to have concerned the FO somewhat). The report specifically states that pulling the RAT probe heat would not affect normal operation of the TAWS in a correctly functioning a/c.



This terrible tragedy occured mainly because the flight crew missed several cues and had not correctly set their flaps/slats, the TAWS was inoperative for a reason undetermined by the investigation and the Spanair Ops manual diverged from the Boeing/Douglas recommended procedure and didn't call for a TAWS check prior to each flight.

The maintenance crew are in for a torrid time but any decent lawyer will throw the charges out of court.

[ABAT4t2]

G,day guys

mono I believe you are still missing the point. Troubleshooting can require x amount of time to complete. How long is a piece of string?

Should commercial pressure force troubleshooting to be broken off before completion and the link to the TOWS system has not yet been established as part of the troubleshooting process and the regs allow for MEL use without troubleshooting, who takes the rap?

Well we now know, the techs.

As an engineer I would have thought your instincts would kick in to support your fellow colleagues in need and not kick them in the groin.

However, the maintenance crew did make some mistakes

The techs in my opinion after reading the report many times did nothing wrong. They went on board a defective aircraft, commenced troubleshooting in a genuine and honest manner, yet were let down by regulations designed to keep the commercial machine moving.

There is NO requirement in the regulations to troubleshoot prior to using the MEL. Pilots can use the MEL without troubleshooting. Therefore there is no requirement to be a hotshot and come directly to the cause of a defect in a short period of time whilst under pressure.

Those techs were in the middle of their troubleshooting actions, were put under pressure break off the troubleshooting to get the aircraft under way. Their mindset at the time, in the middle of the troubleshooting process was that the probe heating was defective. There was no regulatory support for the techs to keep that aircraft on the ground as the MEL allowed an escape route.

99% of you would have done exactly the same under the same circumstances without the benefit of hindsight.

And the icing on the cake is that when a body apparently representing engineers raises the issue, you criticise them too (not u mono).

I am quite surprised at this response from the investigators and AEI.

How about this for a scenario?

Forget the actual defect. Aircraft manufacturers inform the operators that the MEL should only be used after troubleshooting has traced the defective item.

Real life is completely opposite as we all know and the MEL is the first port of call for most defects and this is supported by the operator. The regulations are vague and you as a tech are going to get slaughtered in a court of law for your actions because as the judge said "you were more concerned about avoiding a delay rather than finding the cause of the defect"

Under those circumstances I support anybody or organisation calling for tougher regs and I absolutely support my fellow colleagues in what must be a bloody awful experience for them.

Sorry if this is a bit rantish but similar thing going on here with the sunstate engineers.

[mono]

ABAT!

Read my post again please. I didn't say THEY should have investigated further I said that I would have. I certainly don't condemn them for applying the MEL and may well have done so myself.

Their mistake was not to cross refer to RAT sensing! It makes sense that if you de-activate the probe heat then the sensing for that system may be affected. It is after all, calibrated to indicate correctly when heat is applied.

In effect they should have applied 2 MEL refs. One of which would have indicated that the TMS was (or should be considered) inop.

The report indicates that the FO was pre-occupied with the fact that the TO would be with manual thrust. Had he known this from the onset he MAY have realised that the flaps/slats were not set.

[ABAT4t2]

G,day guys

mono, nobody made any mistakes. If it takes on average 10 mins to troubleshoot and get to the TOWS but you are only given 5, nobody made any mistake.

Hindsight is a wonderful tool when used correctly but can make you look an ass otherwise.

[Beeline]

ABAT

All manufacturers out of interest inform operators that the MEL is a tool to be used after the cause of a fault has been determined. Now ask yourself, do you really get to the cause of a fault before applying the MEL or do you ask whether the fault can be deferred before troubleshooting?
Most take the latter and leave themselves wide open

There is NO requirement in the regulations to troubleshoot prior to using the MEL.

You have answered you own question.

If it takes on average 10 mins to troubleshoot and get to the TOWS but you are only given 5, nobody made any mistake.

Do you actually have a concise opinion on this post.

Beeline I am sorry but some of your coments come across as a joke. You are clearly unaware of your responsibilities as a certifier.

Do I need to quote your posts again?

I raised this post to obtain objective opinions from fellow professional Licensed engineers on this subject of dispatching aircraft i.a.w the MEL and approved documentation.

In a nutshell, minus my opinion on the report, the MEL should be black and white and thoroughly researched before issue.
I use the Airbus MEL every day and the thing is a ambiguous false vs actual warning, MSN applicability etc.

I am lucky that I do know my responsibilities and know my aircraft types well so know the implications if I inop a system because I have worked with the aircraft at great depth; but other people are not so fortunate. I know a guy with 12 type ratings and can work up to 7 different types a day!!

I really do feel for these guys in Spain as I can relate and many I presume can relate to the situation they were in, we have (but for a few posters probably) been in this scenario and that is what makes it frightening. We have no room for error and the approved documents we sign our CRS too should be accurate.

FARGOO
MEL extracts are right at the bottom of the report in the appendices.

Cheers I think

Beeline

edited due typo