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View Full Version : ATSB Report Failed landing gear struts 21Jun04 tech analysis + pictures


Time Out
6th Jun 2005, 10:57
FACTUAL INFORMATION

At about 0630 Eastern Standard Time on 21 June 2004, a MD Helicopters MD520N helicopter, registered VH-MPI, took off from Gladstone, Queensland, to transport a marine pilot to the deck of a bulk carrier ship that was preparing to enter Gladstone harbour. During the landing on the ship, the right landing gear struts fractured. The helicopter collapsed onto its right side and the main rotor blades struck the ship’s deck. The helicopter was substantially damaged and the pilot and passenger exited the helicopter uninjured.

The pilot satisfied Civil Aviation Safety Authority (CASA) recency requirements and was familiar with both the helicopter and the mission to be flown. He reported that he had conducted over 100 deck landings and was familiar with landing on ships of the type involved in the occurrence.

The pilot reported that weather conditions were fine with a clear sky, temperature about 17 degrees Celsius, wind from the south-west at about 25 knots, and a slight sea state.

The ship had a number of large hatches aligned longitudinally along the deck. The pilot was using one of those hatches as a landing area. The hatch was of a suitable size to accommodate the helicopter and there were no obstructions in the vicinity of the landing area. The pilot reported that the ship was underway and steaming at about 10 knots. The ship sustained minor damage to the hatch from main rotor blade impact.

The helicopter was fitted with a fixed utility float installation system on the landing gear. The floats had been fitted to the helicopter in July 2001 in accordance with the instructions contained in a CAR 35 engineering approval. The helicopter manufacturer was not able to provide engineering advice on the effect that the float installation would have had on the helicopter.

The primary damage to the helicopter was confined to the landing gear; in particular, the right front and right rear struts, and the main rotor assembly. A metallurgical examination of the landing gear components identified an existing fatigue crack, emanating from the drag brace attachment lower hole in the strut, as an initiation site for the failure of the right rear strut. The fatigue crack was due to the fitment of a non-standard drag brace bushing to the rear landing gear strut. The drag brace bushing also was not fitted using protective coating material and would not have been provided with corrosion protection from the marine environment. The right front strut failed in gross overload. A copy of the technical analysis investigation report, BE200400015, is at Appendix A.

Examination of the helicopter’s maintenance documentation revealed the following:

The helicopter had a valid maintenance release for the flight.
The landing gear fairing fillets were removed and the landing gear was visually checked for cracks and damage during 100-hourly/annual inspections. The last 100-hourly inspection prior to the occurrence was conducted on 3 June 2004.
Every 300 hours a landing gear inspection was carried out in accordance with the helicopter’s maintenance manual. Those inspections required that the helicopter be jacked and the landing gear checked. Any elongated, enlarged or worn holes in the strut were to be repaired. The last 300-hourly inspection prior to the occurrence was conducted on 3 June 2004.
There were no CASA or US Federal Aviation Administration Airworthiness Directives applicable to the 520N helicopter that would have required an inspection of the affected area to check for defects such as cracking of the strut.
All required landing gear periodic and special inspections were carried out.
Other than routine inspections, no maintenance action had been conducted in the region of the failure.
No record could be found to indicate when the non-standard drag brace bushing had been fitted to the rear landing gear strut.

ANALYSIS

It is likely that the right rear strut fractured due to fatigue cracking. As a consequence, the right front strut failed due to overload.

There was no evidence in the helicopter’s maintenance documentation to indicate when the non-standard bushing was fitted to the helicopter.

SIGNIFICANT FACTORS

The drag brace bushing did not comply with the helicopter manufacturer’s specifications.
The drag brace bushing hole had a rough-surface finish.
The drag brace bushing was not fitted using protective coating material.
Fatigue cracking initiated in the bore of the drag brace bushing hole.
The right rear strut fractured during the landing.
source (http://www.atsb.gov.au/aviation/occurs/occurs_detail.cfm?ID=644)

Technical analysis report with pictures (http://www.atsb.gov.au/aviation/tech-rep/200402243/200402243.pdf)

flymech
4th Jul 2005, 14:15
Come on guys what your opinions on this one....?
The sig factors say it all....... Maybe??

Flingwing207
4th Jul 2005, 18:43
It seems to come down to the non-standard bushing on the drag brace - the question being, how did it get there?

up and go
4th Jul 2005, 23:13
Seems to me to be another incident involving a large company breaking the law and expecting to get away with it.

Is the responsibility squarely with engineering or is it more a problem within the company culture? Is this an example of short term thinking of management wanting the aircraft to be serviceable at all times?

Why was there no paper trail for the repair? Surely the modification should have been submitted for approval.

Was the safety of the marine pilot considered when making the decision to use an unapproved modification? I think not. My understanding is that the marine pilot was lucky to be inside the aircraft and not exiting or entering the deck.

Was the increased gross weight of the MD500N considered as opposed to the MD500 also used on the contract when carrying out the repair?

This company has large government contracts and carry large volumes of passengers and or essential crew, is this how they carry out their day to day operations?

Is this not the ultimate in compromising the safety of both pilot and client?

justanothernumber
6th Jul 2005, 02:44
Whoah there Mr up-and-go horsey!

What's to say this was done after they took delivery of the helicopter? Is there a requirement to check the bushings on the drag brace as part of any scheduled maintenance? No?

The short answer to your question "is this how they carry out their day to day operations?" would have to be a resounding NO!

Don't be so quick to point the finger here - next time you take delivery of an aircraft that appears to be 110% structurally sound, remind yourself of this incident and ask "has every single nut and bolt and hole been checked on this aircraft?"

up and go
6th Jul 2005, 14:18
Not pointing fingers justanothernumber. The aircraft was definitely not delivered in this condition.

Something to consider is that the MD500N involved was first of type to be fitted with fixed floats. Wouldn't this require a reasonable inspection of landing gear?

In reply to your comments regarding scheduled maintenance I think the excerpt below from the report says it all -

"Every 300 hours a landing gear inspection was carried out in accordance with the helicopter’s maintenance manual. Those inspections required that the helicopter be jacked and the landing gear checked. Any elongated, enlarged or worn holes in the strut were to be repaired. The last 300-hourly inspection prior to the occurrence was conducted on 3 June 2004."

The incident occurred 21 June 2004, just 18 days after the last inspection.

And yes I would expect my aircraft to be airworthy, what does 110% mean? It's either airworthy or not, structurally sound or not.

Me thinks your comments are overly defensive, could it be that you have a vested interest in this fine company?

justanothernumber
6th Jul 2005, 23:34
could it be that you have a vested interest in this fine company?
Just sick of people coming down on a company with comments bordering on libel when there are huge numbers of hours flown totally incident free, with what seems like one of the best safety records in the industry.

The aircraft was definitely not delivered in this condition
You are much closer to this than I then. I am merely a speculating outsider.

My comment about the scheduled maintenance related to the line:There were no CASA or US Federal Aviation Administration Airworthiness Directives applicable to the 520N helicopter that would have required an inspection of the affected area to check for defects such as cracking of the strut.

If the requirement at the 300-hourly is that this specific thing should have been checked, then someone is going to get their a$$ fried, and rightly so.

To make this a whole-of-company corporate attitude thing though seems a little excessive. If it was a corporate attitude, or "the way they carry out their day to day operations", then surely there would be more evidence of this, and their safety record wouldn't be what it is.

Didn't they get some safety award last year?

up and go
7th Jul 2005, 00:28
I am not close to the source, However I have researched the Incident being discussed. There are in fact Ad's applicable to the Landing gear, not specific to the area in question you are correct there.

The scheduled 300 hour inspection calls for an inspection of this area...there is no question about that.

I am merely pointing out that a company who touts themselves as being accident free, operating with a safety culture second to none, Has infact broken the rules and paid the consequences...they are still able to procure large government contracts that our tax money pays for.

Isnt it fair to question their integrity, the basis for covering up illegal modifcations is usually based on a company culture towards maintenance, this is a proven fact.

To discuss this in an open forum is the only way people are able to gauge for themselves the intregrity of a company.
These guys are not at the lower end of helicopter flying they are at the top...their standards and practices should reflect this.

spinwing
7th Jul 2005, 05:37
Q. Is this the same company that is about to show CHC how to do EMS and suchlike in Adelaide???

:eek: :eek:

vetskone
7th Jul 2005, 06:59
Would that be the same CHC that had a door depart in flight in Timor on a 212 due to a fatigue crack in the roller. Lucky it was not through the tail or main rotor. Why wasn't it picked up? And the same CHC that has had three majors in the last 2 years?
Get a life folks. Things like this happen, even to good companies. We can all learn from such incidents but please, leave the slander at the door.

up and go
7th Jul 2005, 09:09
I must apologise to those whom I have offended, I have only just started posting on this site but have viewed it for a number of years. i thought we were free to express our opinions, create debate and try and improve the safety of our own operetions and that of others.

Vetskone,you dont obviously believe in your own principles...as you have just shown in your last post.

Discussion and debate brings about change.

Zero accident rate is what we should aspire to and ultimately not to compromise the safety of ourselves or our Pax

wishtobflying
7th Jul 2005, 10:26
"Seems to me to be another incident involving a large company breaking the law and expecting to get away with it. "

I think you kind of set the tone with that line, and I think the responses have been along the lines of that.

Discuss the incident, sure, but if it descends into the sort of statement that you started with then I don't think it's too good.

MPT
12th Jul 2005, 09:28
G'day All,

Scary that they crack up at the top too! I've experienced a number of cracks on the rear legs, especially on the "new" 2-bolt attachments. The old 4-bolt ones didn't seem to give as many problems. Interesting that most cracked the RH rear ones. Landing technique perhaps?

Cheers,

MPT:O