I need help for current research!
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I need help for current research!
I am once again appealing to the excellent maintenance engineering crew on PPrune who have helped me in the past.
I am gathering data specifically on aircraft related incidents or accidents which have led to changes in Part-66/Part-147 basic or type training or JAR equivalents.
There are many of you who have been LAMEs for up to four decades if not more, and I would like to pick your brains regarding the above: any particular incidents or accidents which prompted changes to JAR or EASA regulations with respect to basic or type training and/or delivery thereof.
Although there is always Google, I prefer to ask people who have been there and done that as a starting point, and then if you can tell me of any particular incident or accident you can recall, then hopefully I can find more data about in on the internet or through aviation archives.
I am gathering data specifically on aircraft related incidents or accidents which have led to changes in Part-66/Part-147 basic or type training or JAR equivalents.
There are many of you who have been LAMEs for up to four decades if not more, and I would like to pick your brains regarding the above: any particular incidents or accidents which prompted changes to JAR or EASA regulations with respect to basic or type training and/or delivery thereof.
Although there is always Google, I prefer to ask people who have been there and done that as a starting point, and then if you can tell me of any particular incident or accident you can recall, then hopefully I can find more data about in on the internet or through aviation archives.
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Pretty much every type rating I've done, I've been lucky enough to have a decent instructor who has been "hands-on" on the aircraft being taught, with the exception of A320.
If ever there was a serious or famous incident the, instructors focused on it and went into depth about the cause of the problem. Examples that come to mind for me are A330 Air Transat glider into the Azores and the BA 777 glider into Heathrow.
The A330 was caused by a maintenance error when the technician installed an L shaped fuel pipe the wrong way round, causing it to chafe on an adjacent hydraulic pipe.
The B777 lead to a re-designed fuel/oil heat exchanger.
If ever there was a serious or famous incident the, instructors focused on it and went into depth about the cause of the problem. Examples that come to mind for me are A330 Air Transat glider into the Azores and the BA 777 glider into Heathrow.
The A330 was caused by a maintenance error when the technician installed an L shaped fuel pipe the wrong way round, causing it to chafe on an adjacent hydraulic pipe.
The B777 lead to a re-designed fuel/oil heat exchanger.
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Cockpit windows all redesigned so they are installed as plugs, ie from the inside and screws pull them up, due to someone installing one with the wrong diameter screws and the window popping out in flight.
Can't remember the type but FO and cabin crew did extremely well held on to captain and landed safely.
Can't remember the type but FO and cabin crew did extremely well held on to captain and landed safely.
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RAPID ENGINE-OIL loss on both engines forced a British Midland Airways Boeing 737-400 crew to make an emergency landing at London Luton Airport on 23 February.
UK Civil Aviation Authority records show that blanking plates had not been replaced after borescope inspections of the two engines, and that this led to oil loss.
The UK Air Accident Investigation Branch is to conduct a "formal investigation". The airline says that it has temporarily suspended three maintenance engineers while an internal probe is completed.
The incident started as the aircraft climbed out from East Midlands Airport for Lanzarote, Canary Islands, with 177 passengers and six crew. When low-oil-pressure warnings for both engines were received at 12:08, the crew declared a full emergency and landed the aircraft safely at 12:14, shutting down the engines immediately upon stopping. Each engine is said to have had 1.5litres (0.3gal) of oil remaining of the normal 22litres.
UK Civil Aviation Authority records show that blanking plates had not been replaced after borescope inspections of the two engines, and that this led to oil loss.
The UK Air Accident Investigation Branch is to conduct a "formal investigation". The airline says that it has temporarily suspended three maintenance engineers while an internal probe is completed.
The incident started as the aircraft climbed out from East Midlands Airport for Lanzarote, Canary Islands, with 177 passengers and six crew. When low-oil-pressure warnings for both engines were received at 12:08, the crew declared a full emergency and landed the aircraft safely at 12:14, shutting down the engines immediately upon stopping. Each engine is said to have had 1.5litres (0.3gal) of oil remaining of the normal 22litres.
Additionally, it is a requirement to plan maintenance to stagger engine servicing or inspections where possible, for example carry out boroscope inspections at separate intervals.
Maintenance Organisations should have critical task control policies, these should require a second Duplicate Inspection on tasks that are deemed to require a further safety check, these may include tasks carried out during the small hours at night, listed tasks such as windscreen changes, gear changes and so on.
Despite these precautions I am aware of several incidents that have occurred during the past couple of years,
Citation take off with elevator trim reverse rigged.
Bombardier Global windscreen bolts not correctly torqued and water ingress to the cockpit.
Citation off maintenance with speed tape over static ports.
Cessna Mustang take off with NACA duct taped over following aircraft washing, negative pressure in fuel tanks and engine flame out due to fuel starvation, following emergency landing aircraft written off due to structural damage.
Challenger engine cowling not properly fitted and leaves aircraft after take off.
Rubber wing walk mat left on Challenger wing and goes down intake during take off and damages engine.
Despite MROs recognising the safety situation there are still maintenance related incidents.
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To the extent that almost every civil aviation regulation is written in blood, you'll find a long and rich seam to mine here.
To put it another way, almost every regulation, maintenance and otherwise, that governs civil aviation was introduced after an accident or incident of some sort. You could start with each regulation and work back to the original reason it was brought in. When you get there, you'll probably find some dead bodies.
Sometimes it takes a major catastrophe to do this; TWA 800 is a case in point. The whole range of changes to procedures and training that sprang from SFAR 88 was brought about by that terrible accident. But there had been several fuel tank explosions before then. It took the horror of TWA 800 to get the regulators (and constructors) off their backsides.
It is only relatively recently that Safety Management has introduced the notion that you look for hazards and remove them before they cause the crash, rather than finding out what caused it after the event and regulating to prevent another one.
Date 12/Oct/14; Afterthought; I would hope that the near-disaster that was G-TCBC/MT 6107's go-around at Newcastle and diversion to Manchester will be analysed ruthlessly to discover why a perfectly competent Captain and F/O with a perfectly serviceable aircraft committed a series of errors that could have ended in a smoking hole. Human error is caused by human factors, and stress was clearly a factor. But not the only one, and I hope that the investigation triggers changes in regulations and procedures that would reduce the risk of it happening again. Because it could, if nothing is done; the only evidence needed for that assertion is that it did happen.
But with the UK CAA being in the dysfunctional state it's in, and with EASA being what it is, I will not be astonished if little or nothing positive comes out of that incident, in terms of improved aviation safety.
I realise that this was not a maintenance problem, and is thus off-thread. But I think it's pertinent to your study.
To put it another way, almost every regulation, maintenance and otherwise, that governs civil aviation was introduced after an accident or incident of some sort. You could start with each regulation and work back to the original reason it was brought in. When you get there, you'll probably find some dead bodies.
Sometimes it takes a major catastrophe to do this; TWA 800 is a case in point. The whole range of changes to procedures and training that sprang from SFAR 88 was brought about by that terrible accident. But there had been several fuel tank explosions before then. It took the horror of TWA 800 to get the regulators (and constructors) off their backsides.
It is only relatively recently that Safety Management has introduced the notion that you look for hazards and remove them before they cause the crash, rather than finding out what caused it after the event and regulating to prevent another one.
Date 12/Oct/14; Afterthought; I would hope that the near-disaster that was G-TCBC/MT 6107's go-around at Newcastle and diversion to Manchester will be analysed ruthlessly to discover why a perfectly competent Captain and F/O with a perfectly serviceable aircraft committed a series of errors that could have ended in a smoking hole. Human error is caused by human factors, and stress was clearly a factor. But not the only one, and I hope that the investigation triggers changes in regulations and procedures that would reduce the risk of it happening again. Because it could, if nothing is done; the only evidence needed for that assertion is that it did happen.
But with the UK CAA being in the dysfunctional state it's in, and with EASA being what it is, I will not be astonished if little or nothing positive comes out of that incident, in terms of improved aviation safety.
I realise that this was not a maintenance problem, and is thus off-thread. But I think it's pertinent to your study.
Last edited by Capot; 12th Oct 2014 at 17:52.
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Thanks Capot, Om15, plasticmerc and winglit
Thanks to the four of your so far. This gives me plenty to read up on this coming week. I was aware of the obvious Aloha one and the TWA 800 but I know that there are plenty more, and it could take a long time to plough through reports, google, etc. I will look into all the ones mentioned so far and find the accident report etc.
Capot, you have helped me a number of times before and I see that you are very helpful to other members of the forum, so thank you. And om15 too. I am aware that things are certainly not ideal with EASA and CAA at the moment, having had my own recent experiences with them.
But I would still prefer to try to do something about it, rather than do nothing and moan. I feel that helpful engineers like yourself and the others above are certainly rendering a great service in passing your knowledge down to people like myself coming newly into this industry and discovering the many good things as well as the not-so-palatable nooks and crannies.
Capot, you have helped me a number of times before and I see that you are very helpful to other members of the forum, so thank you. And om15 too. I am aware that things are certainly not ideal with EASA and CAA at the moment, having had my own recent experiences with them.
But I would still prefer to try to do something about it, rather than do nothing and moan. I feel that helpful engineers like yourself and the others above are certainly rendering a great service in passing your knowledge down to people like myself coming newly into this industry and discovering the many good things as well as the not-so-palatable nooks and crannies.
