R22 washup from May 2004 crash
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R22 washup from May 2004 crash
The following was posted about May 2004:
In March 2014, the following emanated from the Court action:
R22 helicopters, LAME?s, Owners and legal actions | Assistance to the Aviation Industry
and:
Helicopters | Assistance to the Aviation Industry
Robinson R22 helicopter crashed
ONE man is dead and another in hospital with serious burns following a helicopter crash near the Queensland-Northern Territory border.
Alice Springs police today said a Robinson R22 helicopter crashed on Tobermorey Station about 450km north-east of Alice Springs.
The pilot died in the crash which occurred about 11am yesterday.
Another man in his 50s, who was in the helicopter, was taken to Mount Isa and flown by the Royal Flying Doctor Service to hospital in Townsville.
ONE man is dead and another in hospital with serious burns following a helicopter crash near the Queensland-Northern Territory border.
Alice Springs police today said a Robinson R22 helicopter crashed on Tobermorey Station about 450km north-east of Alice Springs.
The pilot died in the crash which occurred about 11am yesterday.
Another man in his 50s, who was in the helicopter, was taken to Mount Isa and flown by the Royal Flying Doctor Service to hospital in Townsville.
In March 2014, the following emanated from the Court action:
R22 helicopters, LAME?s, Owners and legal actions | Assistance to the Aviation Industry
and:
Helicopters | Assistance to the Aviation Industry
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Conclusion
I am satisfied that the instructions in the Maintenance Manual relating to the
inspection of the flexplate, particularly the instruction to verify its security, were, in
light of the provisions of the Manual relating to torque stripes, adequate to address
the risk of failure of the flexplate from an inadequately torqued bolted joint.
It follows that Robinson took reasonable care to address that risk; and that neither the
helicopter nor the Maintenance Manual had a “defect”, for the purposes of s 75AD
and s 75AE of the TPA. The plaintiffs’ claims accordingly fail.
inspection of the flexplate, particularly the instruction to verify its security, were, in
light of the provisions of the Manual relating to torque stripes, adequate to address
the risk of failure of the flexplate from an inadequately torqued bolted joint.
It follows that Robinson took reasonable care to address that risk; and that neither the
helicopter nor the Maintenance Manual had a “defect”, for the purposes of s 75AD
and s 75AE of the TPA. The plaintiffs’ claims accordingly fail.
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NOT the Final Conclusion.
The judgement of Justice Lions was appealed against and heard on the 9th September, 2014. Anyone with knowledge of this case was astounded at Justice Lions ruling (including the defendants). He was way out of his depth and his reasoning demonstrated that. Hopefully the court of appeal will set matters straight, but courts are not about justice or right, they are about the law.
BP
BP
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Queensland Court rules against Robinson
Supreme Court Library Queensland | Court of Appeal
A passenger in an R22 helicopter that crashed as a result of an untorqued flexplate nut sued RHC on the basis that the Maintenance manual was inadequate to inform LAMES as to the processes necessary to ensure flexplate security. The trial judge in the Qld Supreme Court found against him and bought the RHC line that it was slack LAMES who were to blame.
However yesterday two Appeals Court judges set aside that judgement and ruled in the plaintiffs favor.
"Secondly, the Robinson manual was otherwise found by the learned trial judge to be
inadequate in a number of other important respects concerning the detection of
fretting dust,48 cracks in the flexplate,49 and the failure of the bonding on the
washers meant to be bonded to the flexplate.50 There was no challenge to those
findings. While there can be no dissent from the learned trial judge’s conclusion
that the manual must be read ‘as a whole’51 it is compelling that the exercise, at least
in regard to what the manual said about proper inspection of these critical parts –
the flexplate, and the bolts through it – gives rise to suspicion, not comfort, about
the sufficiency of the instructions in it."
The appeal judges found that the toque stripes : "useless as
indicators of bolt movement or slippage.52"
and
"The evidence and the weight of
evidence pointed to only one possible finding about the condition of the torque
stripe on Bolt 4: that, whatever its actual state, it was not such as to alert any LAME
(or any pilot) to the fact that the bolt was loose, and rotating."
"Once that is appreciated, the evidence that the stripes could deteriorate or slip means
that reliance upon them, for inspection purposes, is insufficient. It was the reliance,
in the manual, upon torque stripes as a method of verifying security that was
inadequate – the stripes were not, in light of the weight of the evidence,
a trustworthy or reliable indicator.
[99] The manual said nothing to the effect, or on the lines that, a deteriorated torque
stripe might indicate looseness. Nor did it counsel checking the torque on a bolt
with a deteriorated stripe. The later changes to the manual manifest an attempt to
remedy this apparent deficiency – albeit one which, in light of the critical nature of
these parts of the machine, seems less than adequate or ideal."
This has been a mammoth case costing many millions of $s and fought tooth and nail all the way by RHC. It it had not been for the tenacity and guts and huge monitary risk made by Graham McDermott (terribly injured in the crash), in fighting this case, the RHC would again be trumpeting their usual "its not our fault" mantra.
Its a great win for LAMES and owners and passengers alike, and will through the hip pocket nerve, force Robinson to fix up what the courts have found is a substandard set of maintenance instructions. It will also open up a can of worms for RHC in that there have been a number of other flexplate failures on R22 and R44 helicopters since McDermotts crash.
In the meantime folks, get out a spanner and make sure those flex bolt nuts are tight. The court and expert evidence stated that that is the only way to know. Forget the fretting dust, the tourque stripes, the visual inspection, THE SPANNER IS THE ONLY WAY!
BP
A passenger in an R22 helicopter that crashed as a result of an untorqued flexplate nut sued RHC on the basis that the Maintenance manual was inadequate to inform LAMES as to the processes necessary to ensure flexplate security. The trial judge in the Qld Supreme Court found against him and bought the RHC line that it was slack LAMES who were to blame.
However yesterday two Appeals Court judges set aside that judgement and ruled in the plaintiffs favor.
"Secondly, the Robinson manual was otherwise found by the learned trial judge to be
inadequate in a number of other important respects concerning the detection of
fretting dust,48 cracks in the flexplate,49 and the failure of the bonding on the
washers meant to be bonded to the flexplate.50 There was no challenge to those
findings. While there can be no dissent from the learned trial judge’s conclusion
that the manual must be read ‘as a whole’51 it is compelling that the exercise, at least
in regard to what the manual said about proper inspection of these critical parts –
the flexplate, and the bolts through it – gives rise to suspicion, not comfort, about
the sufficiency of the instructions in it."
The appeal judges found that the toque stripes : "useless as
indicators of bolt movement or slippage.52"
and
"The evidence and the weight of
evidence pointed to only one possible finding about the condition of the torque
stripe on Bolt 4: that, whatever its actual state, it was not such as to alert any LAME
(or any pilot) to the fact that the bolt was loose, and rotating."
"Once that is appreciated, the evidence that the stripes could deteriorate or slip means
that reliance upon them, for inspection purposes, is insufficient. It was the reliance,
in the manual, upon torque stripes as a method of verifying security that was
inadequate – the stripes were not, in light of the weight of the evidence,
a trustworthy or reliable indicator.
[99] The manual said nothing to the effect, or on the lines that, a deteriorated torque
stripe might indicate looseness. Nor did it counsel checking the torque on a bolt
with a deteriorated stripe. The later changes to the manual manifest an attempt to
remedy this apparent deficiency – albeit one which, in light of the critical nature of
these parts of the machine, seems less than adequate or ideal."
This has been a mammoth case costing many millions of $s and fought tooth and nail all the way by RHC. It it had not been for the tenacity and guts and huge monitary risk made by Graham McDermott (terribly injured in the crash), in fighting this case, the RHC would again be trumpeting their usual "its not our fault" mantra.
Its a great win for LAMES and owners and passengers alike, and will through the hip pocket nerve, force Robinson to fix up what the courts have found is a substandard set of maintenance instructions. It will also open up a can of worms for RHC in that there have been a number of other flexplate failures on R22 and R44 helicopters since McDermotts crash.
In the meantime folks, get out a spanner and make sure those flex bolt nuts are tight. The court and expert evidence stated that that is the only way to know. Forget the fretting dust, the tourque stripes, the visual inspection, THE SPANNER IS THE ONLY WAY!
BP
Last edited by bush pelican; 20th Dec 2014 at 02:06. Reason: additional information
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Good report BP,
But one Swallow don't make a summer, I would think the Robinsons Corp wont just roll over and accept this, without some come back, but it is however a good set of points and judgements from the QL Judges.
But one Swallow don't make a summer, I would think the Robinsons Corp wont just roll over and accept this, without some come back, but it is however a good set of points and judgements from the QL Judges.
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From the accident report it sounded like someone was fitting a bolt with incorrect parts after delivery from the factory, causing the crack which lead to loss of control. But since that guy was never identified, it's obviously easier to sue RHC.
http://www.atsb.gov.au/media/2786447/aair200401917.pdf
http://www.atsb.gov.au/media/2786447/aair200401917.pdf
Last edited by jymil; 20th Dec 2014 at 09:35. Reason: Typo
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The learned Judge is an idiot. One doesn't need a detailed explanation to properly inspect the flex plate bolts. And at the risk of being flamed, the so called LAME was incompetent if not lying
And for a dumb sh1t mechanic like me, what the fcku does a broken torque stripe indicate if not to inspect further?
And for a dumb sh1t mechanic like me, what the fcku does a broken torque stripe indicate if not to inspect further?
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Queensland Court rules against Robinson
Graeme McDermott has won an appeal in the Queensland Supreme court where he claimed that an R22 accident where he suffered severe burns was caused as a result of the failure of the RHC to provide adequate instructions to LAMES to ensure the continuing airworthiness of R22 helicopters.
http://www.sclqld.org.au/caselaw/QCA/2014/357
The judges stated that "torque stripes were useless as
indicators of bolt movement or slippage.52".
The judges also found that "the Robinson manual was otherwise....inadequate in a number of other important respects concerning the detection of fretting dust,48 cracks in the flexplate,49 and the failure of the bonding on thewashers meant to be bonded to the flexplate."50
This has been a mammoth case costing many millions of $s and fought tooth and nail all the way by RHC. If it had not been for the tenacity and guts, and huge monitary risk made by Graham McDermott (terribly injured in the crash), in fighting this case, the RHC would again be trumpeting their usual "its not our fault" mantra.
Its a great win for LAMES and owners and passengers alike, and will through the hip pocket nerve, force Robinson to fix up what the courts have found is a substandard set of maintenance instructions. It will also open up a can of worms for RHC in that there have been a number of other flexplate failures on R22 and R44 helicopters since McDermotts crash.
In the meantime folks, get out a spanner and make sure those flex bolt nuts are tight. The court and expert evidence stated that that is the only way to know. Forget the fretting dust, the tourque stripes, the visual inspection, THE SPANNER IS THE ONLY WAY!
BP
http://www.sclqld.org.au/caselaw/QCA/2014/357
The judges stated that "torque stripes were useless as
indicators of bolt movement or slippage.52".
The judges also found that "the Robinson manual was otherwise....inadequate in a number of other important respects concerning the detection of fretting dust,48 cracks in the flexplate,49 and the failure of the bonding on thewashers meant to be bonded to the flexplate."50
This has been a mammoth case costing many millions of $s and fought tooth and nail all the way by RHC. If it had not been for the tenacity and guts, and huge monitary risk made by Graham McDermott (terribly injured in the crash), in fighting this case, the RHC would again be trumpeting their usual "its not our fault" mantra.
Its a great win for LAMES and owners and passengers alike, and will through the hip pocket nerve, force Robinson to fix up what the courts have found is a substandard set of maintenance instructions. It will also open up a can of worms for RHC in that there have been a number of other flexplate failures on R22 and R44 helicopters since McDermotts crash.
In the meantime folks, get out a spanner and make sure those flex bolt nuts are tight. The court and expert evidence stated that that is the only way to know. Forget the fretting dust, the tourque stripes, the visual inspection, THE SPANNER IS THE ONLY WAY!
BP
Last edited by bush pelican; 20th Dec 2014 at 10:23. Reason: link
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P6 Driver. that wasn't the point of my post, more a summation of his lack of knowledge about aircraft maintenance.
If I happened to know the Judge(s), I would tell them, perhaps not in a court room, contempt of court and all that.
If I happened to know the Judge(s), I would tell them, perhaps not in a court room, contempt of court and all that.
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Robinson case - McDermott's win on appeal
I have been following this with interest, as the person relied on for McDermott is an AWI - Barry Ogier.
The appellant relied on field based LAME's for evidence.
The following summarises the case:
R22/ R44 matter goes on - Robinson manual found defective | Assistance to the Aviation Industry
The appellant relied on field based LAME's for evidence.
The following summarises the case:
R22/ R44 matter goes on - Robinson manual found defective | Assistance to the Aviation Industry
Last edited by Up-into-the-air; 21st Dec 2014 at 06:05. Reason: correction
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Queensland Court rules against Robinson
Up-into-the -air.
Ogier was an expert witness acting for McDermott, not Robinson. He left CASA a few years ago and has been very supportive of industry ever since.
Other expert witnesses well known in Australia for their aviation expertise and impartiality also supported this case against RHC.
The LAMEs concerned were the ones that actually conducted the work on the helicopter and were the ones being impugned by Robinson as being negligent. One other expert LAME supporting McDermotts case was from the USA.
The court found for a whole range of reasons that EVERY indicator that Robinson gave in it's Instructions for Continuing Airworthiness, for the detection of loose fasteners on an R22 flex plate was deficient and could not be relied on.
This is of great assistance to LAMES and Robinson helicopter owners as it exposes a critical error and omission in the R22 maintenance manual, and clarifies the simple action needed to ensure flexplate fastener integrity.
Other evidence given at the trial exposed further critical deficiencies in the manual to the extent the appeal judges stated,
"it is compelling that the exercise, at least in regard to what the manual said about proper inspection of these critical parts –the flexplate, and the bolts through it – gives rise to suspicion, not comfort, about the sufficiency of the instructions in it."
There were other comments of a similar nature.
This is a case that needed to happen, and it wasn't pursued on the basis of 'easy targets' or 'CASA culture'. It was pursued because of the dire consequences that had been suffered, the failure and arrogance of a large company that refuses to listen to anyone, and that for example was prepared to issue instructions to R22 and R44 passengers that they should wear fireproof clothing if they were to contemplate traveling in these machines.
BP
Ogier was an expert witness acting for McDermott, not Robinson. He left CASA a few years ago and has been very supportive of industry ever since.
Other expert witnesses well known in Australia for their aviation expertise and impartiality also supported this case against RHC.
The LAMEs concerned were the ones that actually conducted the work on the helicopter and were the ones being impugned by Robinson as being negligent. One other expert LAME supporting McDermotts case was from the USA.
The court found for a whole range of reasons that EVERY indicator that Robinson gave in it's Instructions for Continuing Airworthiness, for the detection of loose fasteners on an R22 flex plate was deficient and could not be relied on.
This is of great assistance to LAMES and Robinson helicopter owners as it exposes a critical error and omission in the R22 maintenance manual, and clarifies the simple action needed to ensure flexplate fastener integrity.
Other evidence given at the trial exposed further critical deficiencies in the manual to the extent the appeal judges stated,
"it is compelling that the exercise, at least in regard to what the manual said about proper inspection of these critical parts –the flexplate, and the bolts through it – gives rise to suspicion, not comfort, about the sufficiency of the instructions in it."
There were other comments of a similar nature.
This is a case that needed to happen, and it wasn't pursued on the basis of 'easy targets' or 'CASA culture'. It was pursued because of the dire consequences that had been suffered, the failure and arrogance of a large company that refuses to listen to anyone, and that for example was prepared to issue instructions to R22 and R44 passengers that they should wear fireproof clothing if they were to contemplate traveling in these machines.
BP
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It is indeed a can of worms, more so a Pandora's box.
Will every maintenance manual by every OEM have to be rewritten to explicitly state what the mechanic has to do to check the integrity of every nut and bolt on every machine?
Are we now dealing with such incompetence on the shop floor and in the field that the mechanic cannot be trusted to carry out the most basic of tasks unless the maintenance manual tells him exactly what is required?
And By the By, the bolt in question was assembled incorrectly without the bonded washer or palnut fitted, Robinson had photos of assembly showing it assembled correctly at the factory
Having worked on R22 and R44, I dispute that their instructions for continuing airworthiness was/is deficient
Will every maintenance manual by every OEM have to be rewritten to explicitly state what the mechanic has to do to check the integrity of every nut and bolt on every machine?
Are we now dealing with such incompetence on the shop floor and in the field that the mechanic cannot be trusted to carry out the most basic of tasks unless the maintenance manual tells him exactly what is required?
And By the By, the bolt in question was assembled incorrectly without the bonded washer or palnut fitted, Robinson had photos of assembly showing it assembled correctly at the factory
Having worked on R22 and R44, I dispute that their instructions for continuing airworthiness was/is deficient
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Queensland Court rules against Robinson
owen meaney.
Your comments show you have no grasp of the subject in general, nor the case in particular.
Your statement that, 'the bolt in question was assembled incorrectly without the bonded washer or palnut fitted', is entirely incorrect, and also shows you have no understanding of the construction of an R22 flex-plate.
Perhaps your problem is as you previously described yourself?
BP
Your comments show you have no grasp of the subject in general, nor the case in particular.
Your statement that, 'the bolt in question was assembled incorrectly without the bonded washer or palnut fitted', is entirely incorrect, and also shows you have no understanding of the construction of an R22 flex-plate.
Perhaps your problem is as you previously described yourself?
BP
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The bolted joint at the flex plate failure location was found to have a single thin washer under the bolt head and nut, and no spacer washer between the yoke and flex plate. This spacer and washer combination was different from that specified by the manufacturer for use with a NAS6605-6 bolt.
http://www.atsb.gov.au/media/2786447/aair200401917.pdf
I stand corrected, the pal nut was fitted
Further reading says the pal nut MAY have not been fitted
Last edited by owen meaney; 22nd Dec 2014 at 01:00.
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So heres the thing Bush Pelican, another R22 in the Hangar for annual 100 hour, third one and it's only 7 January, open for Business since Monday.
Spoke with all the Gingerbeers reference this report about torque stripe being no good, BS was the retort from them all. apart from that I paid particular attention to access for inspection of the forward drive flange on these machines; with the centre and side panels off I am nonplussed how a mechanic would not see the loose flange bolt and nut.
Spoke with all the Gingerbeers reference this report about torque stripe being no good, BS was the retort from them all. apart from that I paid particular attention to access for inspection of the forward drive flange on these machines; with the centre and side panels off I am nonplussed how a mechanic would not see the loose flange bolt and nut.
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Queensland Court rules against Robinson
I guess we all don't know what we don't know Owen. That is certainly demonstrated in the case of The RHC Maintenance Manual and the comments you and your 'Gingerbeers' are making.
The torque required on the R22 flexplate NAS fasteneres is 240"lbs. no more, no less. Would you like to take a guess as to what torque would be required on these fasteners for them to feel 'tight'? 100"lbs? 50"lbs?
Amazingly it is only 1-3"lbs, depending on whether the belts are fully engaged or disengaged. So tell me, without using a spanner, how do you know they are tight?
So you look at the plate, feel the fasteners, yeh bewdy, "no cracks, nuts tight", touch up the torque stripes (if you're lucky), and shes good. Don't tell me that's not what you do, because after looking at a lots of operational R22s some just out of maintenance, (probably some of yours), and talking to some honest CEs, that's a fact.
Hundreds of photographs were taken to demonstrate the complete uselessness of torque stripe, and it was found that the average LAME knew SFA about how torque stripe should be applied, what their limitations were, and what the real significance of what they were looking at might be. Military and other experts in the helicopter field were adamant that torque stripe was useless for the purposes the RHC was advocating it be used for.
I can tell you, if you want to confirm the fact that the average LAME servicing helicopters is mentally challenged, then keep arguing the way you are. But save your $s for that multimillion $ law suit that will come your way if you don't take notice of these findings, and do more than just run your eyes and fingers over an R22 (or 44) flexplate, when you do your 100hrly inspections. You will be held accountable.
http://209.203.9.244/resource%20cent.../2010/8777.pdf
BP
The torque required on the R22 flexplate NAS fasteneres is 240"lbs. no more, no less. Would you like to take a guess as to what torque would be required on these fasteners for them to feel 'tight'? 100"lbs? 50"lbs?
Amazingly it is only 1-3"lbs, depending on whether the belts are fully engaged or disengaged. So tell me, without using a spanner, how do you know they are tight?
So you look at the plate, feel the fasteners, yeh bewdy, "no cracks, nuts tight", touch up the torque stripes (if you're lucky), and shes good. Don't tell me that's not what you do, because after looking at a lots of operational R22s some just out of maintenance, (probably some of yours), and talking to some honest CEs, that's a fact.
Hundreds of photographs were taken to demonstrate the complete uselessness of torque stripe, and it was found that the average LAME knew SFA about how torque stripe should be applied, what their limitations were, and what the real significance of what they were looking at might be. Military and other experts in the helicopter field were adamant that torque stripe was useless for the purposes the RHC was advocating it be used for.
I can tell you, if you want to confirm the fact that the average LAME servicing helicopters is mentally challenged, then keep arguing the way you are. But save your $s for that multimillion $ law suit that will come your way if you don't take notice of these findings, and do more than just run your eyes and fingers over an R22 (or 44) flexplate, when you do your 100hrly inspections. You will be held accountable.
http://209.203.9.244/resource%20cent.../2010/8777.pdf
BP
Last edited by bush pelican; 10th Jan 2015 at 06:27. Reason: additional info
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Bush Pelican I can see we are in agreement about the requirement to maintain the drive train at the highest standard.
Our difference of opinion about the validity of the torque strip as an aid to inspecting the integrity of a fastener is of no import.
Our difference of opinion about the validity of the torque strip as an aid to inspecting the integrity of a fastener is of no import.
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Queensland Court rules against Robinson
Great if that's the case Owen..... so heres the thing,
The RHC ICA for checking the fwd flexplate is rubbish.
A 'visual' inspection of the flexplate is useless.
1. There will never be any 'fretting' dust that you can find.
2. A finger check will not find a crack because the glue squeezes out around the washer at the edge of the flexplate, and as well as its rough texture, it often extends right to the edge of the plate, not to mention the fact that the yoke covers a large percentage of the relevant area.
3. You will not find a crack under the bonded washers unless you remove the flexplate and examine the area around the bonded washers with a light and magnifying glass. Even then you won't find a crack if it's still under the bonded washer, and that alone makes the helicopter unairworthy according to the MM and RHC.
4.Torque seal has nothing to do with ongoing fastener integrity. It was also proved that it is hopelessly ineffective as a method of identifying bolt rotation. In fact the stuff barely lasts the time it takes you to fly it home after a 100hrly. Walk out on your field and have a look at a few. Not just on the flexplate, but the tail rotor assembly also.
However everyone agreed that if you see the palnut intact, and you stick a simple open ended spanner on either end of the fastner and you can't make it turn, chances are it's OK.
I think most LAMES should be able to get that. Pity Robinson couldn't, because its cost many lives, and they have known about the problem for a long time. Even in this case they had the opportunity to listen, learn and repent, but chose not to. Now they will pay the price.
BP
The RHC ICA for checking the fwd flexplate is rubbish.
A 'visual' inspection of the flexplate is useless.
1. There will never be any 'fretting' dust that you can find.
2. A finger check will not find a crack because the glue squeezes out around the washer at the edge of the flexplate, and as well as its rough texture, it often extends right to the edge of the plate, not to mention the fact that the yoke covers a large percentage of the relevant area.
3. You will not find a crack under the bonded washers unless you remove the flexplate and examine the area around the bonded washers with a light and magnifying glass. Even then you won't find a crack if it's still under the bonded washer, and that alone makes the helicopter unairworthy according to the MM and RHC.
4.Torque seal has nothing to do with ongoing fastener integrity. It was also proved that it is hopelessly ineffective as a method of identifying bolt rotation. In fact the stuff barely lasts the time it takes you to fly it home after a 100hrly. Walk out on your field and have a look at a few. Not just on the flexplate, but the tail rotor assembly also.
However everyone agreed that if you see the palnut intact, and you stick a simple open ended spanner on either end of the fastner and you can't make it turn, chances are it's OK.
I think most LAMES should be able to get that. Pity Robinson couldn't, because its cost many lives, and they have known about the problem for a long time. Even in this case they had the opportunity to listen, learn and repent, but chose not to. Now they will pay the price.
BP
