casa, atsb and the whyalla accident
While we are at it, it is worth a review as to the Coroners Report for this:
http://www.courts.sa.gov.au/Coroners...20Airlines.pdf
In part it says:
On 14 December 2001, only five days before the ATSB final report was published, the right engine in an aircraft identical to MZK failed.
Upon inspection of the engine, it was established that the crankshaft had fractured, and the appearance of the fracture was strikingly similar to that of MZK’s left engine crankshaft.
The ATSB did not examine the fracture in detail, so the aircraft owner commissioned an examination by an engineer who concluded that the failure was caused by a material flaw, and not by thermal cracking.
A scientific investigation conducted for this inquiry has thrown doubt on a number of ATSB conclusions: - Professor King, an expert in chemical engineering and Dr Zockel, an expert in mechanical engineering, both agreed with the ATSB that the damage to the right engine was due to end gas detonation;
- Professor King concluded that there was considerable doubt about the ATSB conclusion that lead oxybromides were present in sufficient quantity to be a significant factor in the failure of the left engine;
- Dr Zockel concluded that the damage to the left crankshaft was not caused during the combustion stroke of the engine and so abnormal combustion was irrelevant anyway;
- Dr Zockel also concluded that the failure of the left crankshaft was not caused by bearing failure or thermal cracking as suggested by the ATSB;
- Dr Powell and Mr McLean, both experts in metallurgy, found iron oxide inclusions at the nearby No.5 journal of the left crankshaft of sufficient size to constitute a material defect capable of affecting the tensile and torsional strength of the crankshaft. Although similar inclusions were not found at the fracture site, they could have been lost during the fracture process;
- Mr Braly, an aeronautical engineer, aviator and manufacturer of aircraft components, also disputed that lead oxybromides were relevant to the failure of MZK’s left engine, that the crankshaft could have remained ‘dogged’ as the ATSB suggested, that the aircraft could have maintained 167 knots groundspeed on one engine after 1847:15, and hence that the left engine failed first. He argued that the right engine suffered a partial loss of power at 1847:15, and that it was not until after 1858 or so that the left engine failed;
- Mr Braly also said that the mixture settings adopted by Whyalla Airlines for the climb phase of flight were too lean, and these settings may have caused or exacerbated the damage to the right engine;
- Mr Hood, a metallurgist with McSwain Engineering Inc. in the United States of America also confirmed that the left engine crankshaft in MZK did not fail due to thermal cracking initiated fatigue fracture, that bearing failure was not relevant, and that the crankshaft failure was due to a ‘manufacturing-related material condition’. Like Dr Powell and Mr McLean, they were unable to identify an inclusion in the metal at the fracture site, but he found a ‘pocket’ there, from where an inclusion may have fallen during the fracture process.
Remind us of the PelAir report??? by atsb and the "downgrading" by casa with the use of the MoU??