PPRuNe Forums - View Single Post - Korean Air B747 (Stansted crash) report out
Old 28th Jul 2003, 17:38
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eng123
 
Join Date: Oct 2002
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Ignoring all this media argument,I have skipped through it and not read it,I would like to pick up on the 'maintenance blunder' part of this.

To my mind,one of the most important parts of the report is the AAIB highlighting the existance of the 'partial maintenance support' [or whatever they called it in the report]. This agreement had a direct effect on the defect diagnosis at the time.The point they make about the division of responsibilities is crucial.I was working on the night it crashed and heard the thump as it hit the ground and exploded.

I personally know the two UK based engineers involved and remember speaking to them minutes after we heard the news.Hopefully I'm never in that situation.I would like to point out that they are both extremely experienced and competent engineers.

If Korean Air had given the contract to FLS on a full support basis,I have no doubt that the defect would have been correctly diagnosed and perhaps the accident would never have happened.

The trouble arises when you are tasked to support a foreign airline with a different culture and language when they are calling all the shots.I have experienced this myself.You seem to be immediatly kept out of the loop as soon as any defect occurs and you are relegated to a general dogs-body,doing as the airline engineer [and common language speaker] requests,often,as in this case,without knowing the full details.The report said that the inbound crew wrote in the log 'Capt ADI unreliable in roll',but the inbound flight engineer stated that he de-briefed the airline engineer [presumably in Korean] that selecting to alternate rectified the fault.This crucial part of the de-brief would be lost on the Fls engineer who,in all probability,was not even at the de-brief because it is the sole responsibility of the airline engineer.

Having had the de-brief,the airline engineer then asked the local engineer to remove the ADI,at which point the pushed back pin is found.As he is not an avionic engineer,he asks his colleague to attend to rectify the fault.The avionic guy turns up and carries out the task requested of him correctly,he re-seats the pin and functions the instrument,which works correctly.He asks the Korean guy if he is finished with him and when told yes he leaves.The Korean guy then signs the log.The rest is history.

Now,the different scenario is that FLS has the full support contract.What would have happened is as follows [if I was the meeting A&C engineer,and I'm sure would be the same with the engineer involved].

Upon de-brief [in english],hearing the defect was avionic based,an avionic engineer would have immediatly been called,had the proper de-brief from the F/E and,in all probability, have diagnosed correctly and the aircraft despatched with a seviceable ADI or correctly deferred IAW the MEL.

OK,it could be argued that there was a maintenance error but I just wanted to point out that it goes deeper than that.However,it must be said that the actual cause of the accident has to be crew error in failing to respond to multiple comparator warnings.The f/o should have reacted but I'm sure that having had the Captain already b@ll@ck him several times for trivial matters,it made him reluctant to speak up.
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