Helicopter engineer cleared of manslaughter after crash

[swashplate]

There was some gibberish on teletext yesterday about a Helicopter engineer being prosecuted over a crash last march. 3 people died, apparently.
Anyone know any facts about this?

[The Nr Fairy]

I think, from hearsay knowledge, that this may be related to the H300 crash near Reading last year that claimed the life of Dennis Kenyon's son and two companions.

The snippets I've heard about this incident aren't really substantiated enough to warrant an airing.

[Lu Zuckerman]

Although I am not aware of a mechanic being charge criminally in regards to a crash it is within the realm of possibility in the United States. Whether you agree or not with the lawyers looking for deep pockets I would think in a case like this they want to affix blame and in some cases, get the maintenance organization or the operator involved as they have the deep pockets (read insurance). I do know of a specific case where Boeing suffered the loss of a commercial CH 47 in Scotland several years ago. The crash was traced to internal corrosion resulting from a design change made in the gearbox. They not only got Boeing involved but they also sued the manager of the design section and one of the designers directly involved in creating the change. No one is immune from prosecution.

On the reverse side of a US A&P certificate it says,” The holder hereof shall not perform or approve alterations, repairs or inspections of aircraft except in accordance with the applicable airworthiness requirements of the federal aviation regulations or such method, techniques and practices found acceptable to the administration”. If something goes wrong and the problem can be traced to the mechanic making an error his ass is grass and the FAA and the trial lawyers are the lawnmower.


------------------
The Cat

[lmlanphere]

A general lawyer tactic is to advise the client to go for broke - try to get as much as you can, then settle for something less. I wouldn't doubt that this is the case. With a bigger, more threatening lawsuit, the plaintiff has better odds at a big settlement.

[Te_Kahu]

There have been two or three prosecutions in New Zealand over the last 2/3 years involving engineers and bogus parts. If my memory serves me right two of these prosecutions have been successful - one on the West Coast of the South Island and one in the Bay of Plenty region in the North Island. In the later, the engineer was found guilty of manslaughter.

This prosecution followed the crash of an R-22, which killed two, because the 'home repaired' tailrotor fitted to the machine delaminated in flight. The blade had been sourced from a Californian junk yard. An American father and son where charged over selling bogus parts - I think that case was concluded recently also.

PAC ROTORS - can you remember more details??

[willy the one]

There has been a lot of talk/rumour on this matter in the last year. I understand the cheif eng lost his licence or it has been suspended. I am also led to beleive the servicing documents of all the helis maintained by the company where gone through by the CAA. Sensative subject as now going to court

[Ewan Whosearmy]

Swashplate,

Given that the case is ongoing i'll limit what i'll say: the prosecution is being brought against the individual on the basis that he performed incorrect maintenance which resulted in the tailboom seperating and impacting with the MR. Willie is correct in that the CAA grounded all helicopters serviced by the company until it had reviewed maintainence records for each heli.

On a side note, and this has no bearing on the case as it was always going to prove fatal, it is likely that there were 3 individuals sat in the front, and that 2 of them were not belted in. They were thrown through the plexiglass on inital failure and subsequent impact of the tailboom with the rotor disk.

[Flying Lawyer]

Fellow Pruners
'Willy the one' is right. This is a now an extremely sensitive subject. The engineer is being prosecuted and the matter is now going to Court.

The Facts:
The Engineer has been charged with three counts of Manslaughter, and some associated ANO offences.
He will appear in a Magistrates Court on Monday. This is a formality in the judicial process; Magistrates are not qualified to deal with serious cases.
The case will be transferred to the Crown Court where it will be heard by a Judge and jury later this year.
As with all cases sent to the Crown Court for trial, the Press are restricted to reporting the name of the accused, the charges which he faces, and the fact that his case has been committed to the Crown Court for trial.
There is a very good reason for that rule. It is to ensure, so far as possible, that a defendant has a fair trial in which the jury tries the case on evidence which is properly produced in Court, uninfluenced by what they may have read in the Press - which may or may not be accurate.

If this thread continues, it is inevitable that people will speculate, repeat rumours they've heard, give "the facts" as they understand them to be, comment upon the pros and cons of the case, relate the facts of "similar" cases. As we can see from just a few posts, that has already begun.

Although PPRuNe is not part of the Press, it is (despite its name) a public forum read by many thousands of people who are interested in aviation, but not involved in it. It is not beyond the bounds of possibility that one of those will be called for jury service later in the year, and will be on the jury which tries the case.

This is a tragic case for EVERYONE concerned: Firstly, and obviously, for those who were killed and their families. Secondly, and perhaps less obviously, for the Engineer and his family - whatever the eventual outcome.
This is entirely different from the more common 'low flying' cases where what is at stake is a heavy fine and licensing action by the CAA.

May I ask you, please, to defer any further comment about the case until the trial is concluded.

For completeness, I should declare my interest in the case:
I have been asked to represent the Engineer. I would make precisely the same request if I had been asked to prosecute. Both sides in any criminal trial share one common interest, namely that there should be a fair trial.

[SPS]

Fair enough. Too much trial by newspaper and TV going on these days and trial by internet is no more suitable.

[swashplate]

Thanks a lot chaps, v. informative.

I just wanted to know the background info into this incident, having read the confusing piece on teletext. Totally agree with Mr Flying Lawyer re discussion, and I will now close this thread so that there no possiblity of 'trial by web'.

However, I look forward to a post from Flying Lawyer when the trial is over (if he is allowed to do so).

[swashplate]

Ahhh, can't close my own thread down, 'cos I'm not a moderator. I have e-mailed helidrvr about this.

Please everyone, no more posts. Read 'Flying lawyers' post about this.

[Seaking]

Just saw in the Telegraph about this crash.
Witnesses say they saw the tail rotor/tail come off just before an "explosion"! Anyone know anything about this???

[SPS]

Was it a story or report on an accident that occurred last year?

If so it might be one that we have agreed not to discuss whilst a Court case is in progress.

Don't think this is a rebuff, it's not.
Just info.

[Heliport]

from Ananova News .....


Helicopter engineer cleared of manslaughter after crash


An aircraft engineer has been cleared of three charges of manslaughter after a helicopter crashed to the ground killing everyone on board. Paul Kenward, 47, from Biggin Hill, Kent, was cleared at Oxford Crown Court after the accident involving a Hughes 269C helicopter.


The aircraft plummeted to the ground on March 8, 2000, at Twyford, Berkshire, when the tail boom broke away and became entangled in the rotor blades. Kenward had ignored manufacturers' instructions to replace a cracked part which supported the tail boom and had it welded instead.


Brendan Loft, 38, Dennis Kenyon, 18, and Jane Biddolph, 23, all died instantly when the helicopter smashed into the ground and burst into flames minutes after taking off on a pleasure trip from the Booker airfield in High Wycombe, Bucks. Pilot Mr Loft of Reigate, Surrey, and his companions, from Shoreham in West Sussex, were pronounced dead at the scene of the crash.


Kenward, a trained aircraft engineer, licensed by the Civil Aviation Authority and with years of experience, pleaded guilty before the trial to three separate charges in connection with the fatal accident. He admitted allowing an aircraft to fly without a valid certificate of authority, a further charge of endangering an aircraft and failing to make an entry into an aircraft log book.


Sentencing has been adjourned for reports and will be held at a date to be fixed. The judge Mr Justice Aitkens told Kenward that he was considering all possibilities including a term of imprisonment. The maximum sentence Kenward can face is an unlimited fine, two years in prison or both.


Outside the court, Brendan Loft's father, Walter, 74, said: "We are very disappointed with the result. I feel terribly frustrated with the court system. This verdict sends out the wrong message to those involved in the maintenance of aircraft. We have lost a wonderful, wonderful son."




Edited - original formatting didn't survive the 'new look' PPRuNe.
Content unchanged.
Heliport

[G-WIZZ]

The last two years have been tragic for all involved, having flown heli's out of Biggin I have been associated with the engineer in question and was extremely surprised as everyone else who has known him of the allegations and court case. . .. .My thoughts are with the family of the deceased.. .. .My feelings are that the eventual verdict is not a negative message towards engineers and quality of work, the very idea of waiting two years for the verdict in a manslaughter case must be the biggest reason ever not to cut corners!. .. .I believe the message is very clear 'stick to the rules or this could happen to you'. .He has served his two year sentence.

[B Sousa]

Two Years for three Fatals and the loss of an Aircraft.......Hmmmm, not to bad. Just shows what a good lawyer can do for you.... .Sometimes Pilots put too much faith in maintenance. Not being familiar with the case, Im wondering if the pilot was aware. Might have made a difference....... .Anyway, sad day all around.

[The Nr Fairy]

Bert :. .. . I suspect the accident report on this one will be published in a few days, now the legal side of things appears to be finished.. .. . Check the <a href="http://www.aaib.detr.gov.uk/whatsnew/news.htm" target="_blank">UK AAIB What's New</a> web page about 10th - 12th April.

[LGW Vulture]

Sousa... .. .Have to question your pilot / awareness quote....Surely there comes a time when a pilot has to put his faith in the staff that support the on-going operation.. .. .Every input to an aircraft operation is vital....that's why so many checks + balances are in place...... .. .That poor engineer....he's learnt by experience the hard way....Let's hope the whole of the industry can learn from such a mistake....Horrifying.

[B Sousa]

Agree pretty much with all the above. My experience has been as a pilot to get all the mechanical knowledge of the aircraft as I possibly can. Thats what I meant "was the pilot aware." I can guarantee I wouldnt settle for a weld job on a tailboom.... .Im sure the engineer/mechanic has a heavy load on him to carry for some time..... .Things are different here, they are throwing away the key on some for vehicular manslaughter cases.. .I also agree, there but for fortune....

[Lu Zuckerman]

On the reverse side of my Airframe and Powerplant certificate it says among other things the following: . .. . REPAIRMAN OPERATIONAL RESTRICTION. .. .The holder hereof shall not perform or approve alterations, repairs or inspections of aircraft accept in accordance with the applicable airworthiness requirements of the federal aviation regulations or such method, techniques and practices found acceptable to the administration.. .. .If a mechanic did otherwise, and an aircraft crashes, and it is determined that an illegal procedure was performed the mechanic can be held liable. He can be fined around $10,000 by the government and be held culpable in any legal action taken by the survivors of those killed or injured in the crash. He will also lose his ticket.

[The Nr Fairy]

As an aside, the CAA held a small helicopter safety seminar last year, and part of the trip involved a visit to the AAIB in Farnborough.. .. .The wreckage of this particular machine was still there. Sobering thought for a helicopter pilot, almost as much as the imposing wreckage of the Lockerbie Pan Am 747.

[Heliport]

Things are different here, they are throwing away the key on some for vehicular manslaughter cases.

Presumably they still have to be found guilty first?. .The jury cleared this engineer of Manslaughter.

[Hone22]

There was accident here in Oz a couple of years back due the lower cluster/tailboom support failing.. .. .We had a H300 with the same fatigue type crack appear in the lower cluster. Options as told to us were to weld in a whole new cluster, or have an "approved" weld repair carried out.. .. .Having a little knowledge about these members and how welding can effect them, we elected to forgo the cheaper weld repair and replace the whole cluster.. .. .If an "approved" repair is undertaken you can only rely on the procedures to get it past the "approval" process.. .. .Even then you as the Pilot ought to keep a damn good eye on it.. .. .A very Sad case all round.. .. .fly safe. .Hone

[Greg Baddeley]

Sounds like what's needed is an AD for this particular problem - one accident's more than enough to justify it. Anyone know if any such action is forthcoming?

[md 600 driver]

As far as i know Flying Lawyer defended him

g whizz
you must be a engineer. young dennis kenyon died because someone did not stick to the rules. you want to ring denis kenyon senior and tell him paul kenward has served his sentence of 2 years.

b sousa. pilots have to put there faith in engineers and the pilot did not know about it.
lu. the engineer is a caa not a faa.
nopaxthanx. apparently there has been seven accidents the same as this. ido hope that denis kenyon senior puts his point of view forward as there is lots to this that did not come out in court that the procicution lawyer omitted .

steve atherton my name as i do not want to be annon.

[Flying Lawyer]

There were no 'winners' in this case. It was a tragedy for the three people who lost their lives, a tragedy for their families and friends, and a tragedy for the engineer whose life has been shattered by one mistake.

The news report is inaccurate in one important respect. The engineer did not 'ignore' the manufacturer's instructions. He did what many of us do from time to time - he relied on his memory instead of going to the books to check. There but for the grace of God go many of us.
The clevis lug was already welded in course of manufacture, and further repair welds are permitted to one side of the cluster. Sadly, the engineer's memory re which side could be welded was incorrect.

It may not be generally known that, to his great credit, the engineer contacted the AAIB when he heard the crash was caused by a failed aft cluster, and told them he had authorised a weld repair. He provided all the evidence which led to him being charged with Manslaughter.

The engineer always admitted he was negligent. That was not in dispute. He pleaded Guilty to ANO offences which included negligently endangering the helicopter and its occupants. The sole issue for the jury to decide was whether his negligence was an so great that it amounted to Gross Negligence - Manslaughter.
The jury heard all the facts and considered the arguments by both sides. They found him Not Guilty of Manslaughter.

In addition to the engineer, who admitted what he had done, a number of other people behaved with great integrity and dignity.
The engineer's employer, Mr Chris Stepto, supported him throughout the long period between the crash and the trial - in circumstances where many employers might have distanced themselves.
Mr Rex Parkinson, the Senior AAIB Investigator who investigated the crash, remained totally professional and independent throughout, providing information fairly to prosecution and defence as required. (The CAA assisted the prosecution.) I have had extensive dealings with the AAIB over the years, and I never fail to be impressed by their impartial approach.

Above all, Mr Dennis Kenyon, a highly respected instructor and display pilot and father of one of those who died. Under cross-examination, Mr Kenyon told the jury he had known the engineer professionally for some years, and had always regarded him as conscientious and trustworthy. When asked whether he would trust him again despite the loss of his son, he paused to think about the question, and replied: "Yes. I suppose I would."

MD 600 driver
That may surprise you, given your comments. Let me surprise you a little more.

Mr Kenyon approached the engineer outside the court room. It was the first time they'd seen each other since the accident. He put his arm around the engineer's shoulders, asked him how he was bearing up under the strain, and wished him good luck with the manslaughter charges.
Dennis Kenyon is a far, far bigger man than you give him credit for, and earned the respect of those who heard him give evidence.

[B Sousa]

"Presumably they still have to be found guilty first?. .The jury cleared this engineer of Manslaughter. ". .. .Heliport.....Get Real.....I understand what the jury did. Thats why I mentioned about having a good lawyer. OJ was cleared also.... .Time to dump this thread.

[Whirlybird]

Flying Lawyer,. .. .Thanks for filling in all the gaps. I feel inclined to agree that there but for the Grace of God go any of us.

[On the skids]

Sousa:. .You're beyond the pale.. .When you know nothing, say nothing.

[HeliEng]

Flying Lawyer,. .. .Thank you for your post. It has changed my feelings somewhat towards Mr Kenward, and from what you say I think that Dennis Kenyon Seniors' strength is to be admired and respected.. .. ."Some days you are the statue, some days you are the statue!"

[swashplate]

V interesting post from Mr Flying Lawyer!!!

. .. .Look forwards to AAIB report....

[Nick Lappos]

For my two cents, sit down and strap in.. .. .This issue of criminal penalty for honest mistakes is the issue. Who among us wants to go to prison for overshooting an approach and landing hard? How about getting a bit lost and putting down in a rough spot?. .. .Consider that about 2/3 of all accidents are pilot error should make us think about this in a different way. The mechanic in this case flew his family in the machine after the repair, he stepped up to his mistake without hesitation, and he has expressed nothing but regret.. .. .He is no criminal, and retribution is not justice. Let he who has not made a mistake cast the first stone.

[helmet fire]

Hats off to Mr Dennis Kenyon snr, you are an inspiration sir.. .. .FL's article again demonstrates the appalling accuracy and use of emotive language of some (most!) sections of the media. Yet it still seems to suck some of us into believing the drivel.. .. .Cap'n Sousa, it's hard not to sympathise with your viewpoint on a "heat of the moment" emotive level of outrage at the loss of life, but after you consider the reality of the situation from FL's post it is clear that justice has indeed been achieved. . .. .Have I ever relied upon memory in making decisions only to find the book said something different? Yep. As said by many above - there, but for the grace of God....

[B Sousa]

On the Skids. .Heliport. . Its an Analogy. I have nothing against the guy whatsoever..... .You can equate the two trials. The man was charged criminally and found not guilty. So was OJ....No Difference.. Again, Im not talking of all the particulars, only the fact that one was "Charged Criminally" and found "Not Guilty". .Nick also mentioned "Criminal Penalties" for "Honest Mistakes".. Its a way of life here. Look for example of DUI in the states. A few years ago it was but a simple fine, or worse if someone was killed......maybe, just maybe probation and a fine....Today Prosecutors are seeking the Death Penalty/Life without Parole for the same offense. . .As with most similar situations the "Civil Process" not the "Criminal Process" resolves most of it in the old fashioned way......Money.. .Dont get so uptight...its a discussion not a fight.

[DennisK]

Not sure if the correspondence on the Hughes 300C manslaughter case is still open, but I have just been directed to the site.

It is sad but understandable that there appears to be so little accurate information out there on this case. As the parent of the pilot, I have taken it upon myself to know every fact.

Yes a top lawyer represented the engineer and he didn't 'get him off' He accurately laid out the difficulties all engineers faced over this cracking proble, Even the CAA;'s own surveyor failed to detect the welded repair as he signed off the Certicate of Airworthiness four months before the accident. I believe the jury said to themselves. If the safety regulatory authority's own engineer made a mistake, why are we trying this engineer for manslaughter?

My son's accident was the eighth, yes the eighth failure of the centre frame, aft left hand cluster. You might think a more responsible regulatory authority would have mandated the fitment of the later redesignerd cluster after the firstt occurence. They still have not done that even now, so fellow 300C pilots, there are perhaps 400 helicopters out there wthat may have the same defect. The AD's, SB's and LTO's are already there to guide engineers, but in one case in England the crack could not be detected with paint on or WITH PAINT OFF!!

The airframe broke in two allowing the M/R blades to disentegrate the ship in flight, so please make 100% checks on this suspect component on your future flying of the type.

Two more factors. Had the CAA's own inspector been made aware of the previous history of the type, he may well have conducted a more specialist inspection, lives would not have been lost. Had the welder been required to inspect a conformity, lives would not have been lost. Had I been made aware of the type's history, I would have required fitment of the later 'dash three' cluster or not purchased the model at all.

Unfortunately these sad facts go on and on.

I believe what has happened is an object lesson in lack of information and over reliance on the CAA strategy of repetitive inspections. They did not work and I won't fly the pre dash three type until the authorities mandate the obvious modification.

I also believe the engineer was only some 20-30% responsible. You judge where the balance of the blame lies. The AAIB report should be out in the next few weeks.

Thanks for all your interest. Dennis Kenyon Snr.

[sprocket]

Thank you for sharing that information DennisK.

There are no winners in these situations, but we can use what has been learnt in this case to help eliminate future tragedies of this kind.

[alapt]

The main question on my mind is "Did the unauthorized repair directly cause the crash"? If it did then he should be jailed and the key thrown away. If the repair failed due to circumstances say, beyond flight parameters, then he is a "scapegoat".
Hard to judge without further details.....

[Heliport]

The failure of the welded cluster fitting was the direct cause of the helicopter crashing.
But the CAA don't come out of it smelling of roses either.

[Old cynic]

I fail to see how sending the guy to jail could make him feel any worse than he does already, or what benefit a custodial sentence can bring to the community at large. We have already heard from those in the know that he put his hand up and cooperated fully with AIB and others. His personal grief and pain will be with him forever and 8 months inside will be as nothing to the ongoing nightmare for him. I understand it was a simple mistake and, as said many times before, there but for the grace etc.

[Helinut]

A very difficult but important question. Obviously affected by the facts of the case, and we only have a brief idea of these. I don't disagree with the sentiments of the last two posts exactly, but I am not sure that nothing should be done, and that the error should go unmarked by the authorities.

The aspect that concerns me is the need for a deterrent for others in the future.

It is, of course, complicated because there is at least an argument that part of the problem lay with the regulator (i.e. the CAA) according to previous posts. I am worried if there is a suggestion that an individual is being used as a fall-guy or scapegoat.

I tend to agree with the view that a prison sentence would be of little point (in respect of the individual). Like in so many legal areas it is often difficult to find a suitable "punishment".

But I think that something probably needed to be done.

[CRAN]

Helinut,

I agree with your sentiments and those of several of the other posts on this subject. Maybe we should try to be a little more constructive.

The real problem is that helicopters are extremely complicated machines in which hidden forces and destructive mechanisms exist in great numbers. Such mechanisms are not properly understood by specialist design engineers employed by the helicopter manufacturers, let alone maintenance technicians.

The tragedy here is that this individual's experience has almost certainly worked against him. What has happened is that he has tried to extrapolate a procedure to situation that is only subtly different to repairs he has carried out many, many times before. Tragically in this case, subtle differences in helicopters frequently have disproportionately significant effects that cannot be predicted without substantial prior knowledge and understanding of complex engineering science.

Knowledge that it is unreasonable to assume a maintenance technician could ever posses (in the necessary volume) - if they did they would be design engineers!

I think what we should learn from this tragedy is that while aircraft maintenance is covered by procedure, attention must be paid in the future to explaining during training why a maintenance engineer should never carry out a repair without an exact manufacturer approved procedure. i.e. They do not have the expertise to accurately predict the consequences of there actions. Then possibly go on to explain some of the processes at work in a helicopter to adequate detail.

What I have said here is of course a generalisation as to the capabilities of helicopter maintenance technicians. Obviously some helicopter technicians will be superior to others and to those individuals I mean no offence, however by regulating for the lowest common denominator we can achieve a safety net that nobody can legitimately slip through.

“As an Engineer, it is more important to know what you don't know than what you do. - Be aware of the limits of your capability.”

The technician in question should not be in jail, but he should certainly have lost he license and be prevented from being an aircraft technician in the future.

I wish to express my sincerest condolences to the families of those lost and to the technician and his family. This is a terrible tragedy and we should take a moment to consider that is could just as easily have been any of us. Though the technician has shouldered the blame in this case it is the system that has failed – there is no way he would have carried out the repair had he been equipped with the knowledge that I’ve suggested.

:(

CRAN

[Old cynic]

Agree completely that something should be done, just that I don't think a custodial sentence is always the right action. Believe that loss of license, precluding his right to practise (earn), is entirely appropriate as it has been for both engineers and pilots in the past. Whether more should be done is another question.

[diwai]

After reading the above, we still do not know the whole story, was the engineer told the full story or was he just asked to recert a repaired component?. As I've aways said the jockeys are paid for something that might never happen and we are paid less than car mechanics to know an degreed engineers job, call me cynic but its true.
We are all in the same boat, keeping the flying public safe and the jockeys too, but the poor old engineer is treated like a second class citizen and payed as such.
I hope the engineer's rights and judgement isn'ts going to effect the public image of the industry as the media does...:confused: :confused: :confused:

[Heliport]

As I undertand it the engineer saw a small hairline crack, called in a specialist aviation welding firm who said it could be repaired by welding. They didn't ask if a weld repair was allowed. He thought it was, and without checking the books, gave the go-ahead.


Heliport

[Genghis the Engineer]

There but for the grace of god go many of us, who can truly say that they checked every possible thing available to be checked, every time they make an Engineering decision.

However, this is not a new instance. There was a case where the engineers who designed a walkway that collapsed killing about 20 people were charged with, and convicted of, manslaughter. This is not a dissimilar case.

I think it's inevitable than any Engineer or technician whose decision has led to a death can expect at the very least a very robust investigation. If somebody has failed to perform to the very highest standards, they can expect reprisals. It's the form and source of the investigation and reprisals that are key.

I'd argue that the legal system jumped, inevitably because the Engineering profession is so poor at policing itself. If this was a medical cock-up, the offender would be up before the BMA (or equivalent outside the UK) - in other words a jury of his peers. They have the power to regrade, or even disqalify somebody. In extremis, they'd of-course refer something to the public prosecuting authority (Harold Shipman is an extreme example of just this).

I think we'd all rather our own mistakes, if (god forbid) we make any that cause death or injury, are judged by our peers than a criminal court. One might conject that a jury of Engineers would have removed the chaps license, and required a strenuous plan of education and supervision. Painful and humiliating, and probably should be, but far more constructive than 8 months inside (and may I make a point, he'll probably still have his license when he comes out - is that wise? for anybody?).

G

[Bus429]

Some guys & gals defer snags or carry out repairs without due reference to approved manuals/tech services/TC holder etc (something I'm sure we've all done to some degree in our careers). Any unapproved repair invalidates the C of A (as does an unapproved modification). If there are no published limits or repairs, that means there are probably none and your next step is to call Tech Services. Let them assume the problem. If the company has limited or no design authority, they go back to the TC holder/OEM and ask their advice. Hopefully, the TC holder/OEM will come back with an NTO, which, depending on your company procedures, should be covered by a concession. Don't forget, an NTO only implies that there is no technical reason why the situation could not exist - it does constitute an airworthiness approval. It is ultimately up to the certifying engineer (in consultation with the NAA if required) to determine acceptance.
In my experience, commercial pressure, or perceived notions of helping the company (an accident certainly doesn't help), are factors in occurences such as these. There have been cases where engineers have not even referred to the manual, thinking that the defect is trivial, only to find, after consulting the MEL or the TC holder/OEM, that the situation is a no-go. Such perceptions sometimes have, as demonstrated here, tragic or potentially tragic outcomes.
Don't forget that, as demonstrated by this topic, it is the certifying engineer who carries the can, despite the fact that corporate failings have probably generated the situation in which he finds himself. Commercial considerations are secondary, safety is the number one priority.
I have some sympathy with the engineer involved with the helicopter repair and doubt jail is the right punishment. It is likely he is absolutely mortified by the accident and may not be inclined to continue his career.
On a related point, all the human factors training in the world is not going to help. You could spend two days on the course, identifying and agreeing with the situations described, only to get back to work and find yourself in the situation. Systems create situations. A good system can create an atmosphere conducive to safety, a bad system could hurt someone.:(

[Young Paul]

I have no comment on the wrongs and rights of this case. I'd like to point out that you don't send people to jail to make them feel bad, though. It's because they have offended society and are therefore being withdrawn from it. Or maybe it's to rehabilitate them. But what they feel is not really connected with it.

I'll shut up now, as that remark was not about this case.

[Weight and Balance]

Just my 2 cents worth...

First cent: I agree that the sentence for the engineer involved probably won't make him feel any worse, and he will probably be the most cautious mechanic in the world now (assuming he gets to be a mechanic again), but can we be absolutely sure? Will we bet more lives on it? From what I know of this case (very little, I admit), I can't say 100% yes or no on either question, so I think we must err on the safe side.

Second cent: Like most jail sentences, the intent here is not only to punish and/or reform the jailed person, but to also dissuade others. From the volume of discussion here, that part seems to be working.

[ShyTorque]

I have a great deal of sympathy for all involved, especially the families of the deceased, but including the engineer who appears to have made a terrible error of judgement. Jail sentence or not, he will live with the awful knowledge of his part in this fatal accident.

Personally, I would have thought that although justice must be seen to be done, a jail sentence was perhaps not really appropriate.

My condolences to all. :(

[john_tullamarine]

Thanks to Heliport for noting this thread in another place ....

More than a few questions implicit in this thread.

The enthusiasm with which the police pursue a case in a specialist arena ? .. plenty of similar cases around (eg the Ansett Dash crash in NZ not all that long ago, and the various efforts to acquire CVR data for prosecutions in a variety of jurisdictions) where we all are left wondering why the police spend such effort in going down a "not very useful to safety" pathway... "eye for an eye" considerations aside ... I suppose much of the problem derives from the legal system's endeavours to view life in black and white, rather than real world shades of grey.

The question as to the technician's losing his ticket ? What would that achieve ? Presuming, as seems reasonable, that he is a very experienced and basically competent fellow .. he made a mistake (more specifically a wrong call), apparently due to pressure of work, and the mistake on this occasion proved to have disastrous consequences. He is most unlikely to act without due diligence in the future and, more importantly, one could envisage that he will become a great advocate to his junior colleagues in respect of the need for doing things in a disciplined manner. I, for one, would see little, if any, necessary benefit to be had in taking away his livelihood ... would it not be more useful for his professional competence to be reviewed and any appropriate retraining undertaken ? Had the events been associated with demonstrated and persistent wilful recklessness (ie entrenched cowboy behaviour) one might take a contrary view ...


There are several major engineering points, not at all limited to the rotary community, to be made.

(a) the manufacturer's team puts a lot of dollars into developing a safe-for-flight product. The Type Certification procedure attests that the system's best reckoning is that this has been achieved... not a guarantee ... only a best guess assessment.

Usually, as we see, operational experience points out various flaws in the product which were not detected or foreseen during the initial program and the continuing airworthiness programs are there precisely to address these sorts of problems. When it works well, it works very well ...

The way we get around in service problems involves for the manufacturer or, more correctly, the holder of the Type Certificate .. which may not necessarily be the OEM ..

(i) in some cases, revisiting the certification .. which, in the extreme, can result in the TC's being cancelled or subject to quite onerous restrictions .. at times this avenue results in great cost for the manufacturer only to demonstrate that the original design is fine and that some other gremlin was as work ... eg an operational technique which was inappropriate.

(ii) the manufacturer's internal review processes will review accident/incident/occurence details with a view to figuring out what went on and whether some change(s), either in the design (eg a new part, modification, operational technique, or fatigue limit), maintenance (eg a new procedure or inspection), operations(eg handling guidance to pilots) or whatever is required to maintain TC compliance. Sometimes the perceived significance is so great that the change will be mandated, by AFM/MM change, SB and/or AD. ADs can be initiated either by the manufacturer, in concert with the regulatory authority, or the regulatory authority sometimes will act unilaterally.

In the main, this is taken very seriously by the manufacturer's systems for all the usual commercial reasons .. to which I can attest, having chaired such a group in a previous life.

It is a matter for regret that, sometimes, a manufacturer will lose sight of the safety raison d'etre and try to avoid acknowledging that a problem does exist or delay taking hold of the problem and fixing it. For instance, blow out panels in the widebodies to get around deformation problems following a cargo hold explosive decompression took a little while to filter through.

The matter of fatigue assessment and damage prediction is, to some extent, still a black art and is based very heavily on presumptions as to the way in which the operator is going to operate the aircraft and, quite importantly, the operational environment within which the aircraft is to be operated. Problems which might arise in this arena could include consistent operations rather different to the typical flight profile presumed by the manufacturer's fatigue engineers .. eg extensive operations at low level when the fatigue assumptions were based on a typical flight cycle involving a significant period of cruise above low level mechanical turbulence. Some readers may recall a number of inflight failures when low level pipeline inspections first became popular ... For some aircraft, the manufacturer will endeavour to address this type of problem by specifying different fatigue retirement criteria for different typical flight profiles.

One very significant difficulty in the fatigue area is that of non-terminating damage assessment inspections for damage tolerant designs. The presumption is that the development of a crack (and, despite whatever you might think ... aircraft, being highly loaded structures .. especially in the rotary world ... are going to suffer cracks in all sorts of places) will be predictable over time and that, if we inspect with sufficient frequency, we will detect and be able to correct before the crack gets to a size where the basic airworthiness of the beast deteriorates significantly. Often these inspections are extremely difficult and critical. If either the operational scenario or maintenance procedures change in a way that is unconservative, then the basic assumptions in the inspection process are invalidated.

If a field repair is made which compromises these presumptions, then the whole fatigue design process might just as well be thrown into the circular filing cabinet.

I know nothing more about this specific accident other than what I have read in these threads, but it appears, in this case, that the technician, after seeking specialist advice (which may or may not have been entirely appropriate to the task), made an unfortunate (and consequently tragic) wrong call.

It is a basic requirement in procedures adopted by the signatory States that the technician operate in accordance with approved data .. if he/she doesn't do so for any reason, then there is a breakdown in the protections developed by the system with an increased potential for mishap. It appears that this may have been the root cause of this specific accident.

(b) the manufacturer's published data is the final output of the design/manufacturing process and, invariably, gives precious little detailed information as to what went into the process. The principal consequence of this is that the end user has to be fairly careful in ensuring that the published procedures are, in fact, followed sensibly and accurately. Several consequences of this system are ...

(i) the regulatory systems provide for the approval of in-service modifications (and a weld process different to what the manufacturer specifies .. such as appears to have been involved here.. would definitely be included) following appropriate assessment. The US DER style of system, which is echoed in other countries, establishes a network of specialist professional engineers to provide in-service certification design services either via or external to the manufacturer. In many cases the manufacturer has a lot of data which cannot be obtained by other means other than at great expense .. it follows that the DER type of chappie moves very cautiously ... which would have been the case for this sort of welded structure.

(ii) the usual requirement imposed on the technician is that he/she must work in accordance with approved data (manufacturer's data, DER style approved information, ADs, etc). The question, in this case, of whether the manufacturer specified that the weldment not be rewelded is not the point .. that sort of problem can often be got around by consideration either of how the weld is done or post weld treatment ... the main problem is that the defenses built into the system break down when people make wrong calls.

The question of wrong calls is not exclusive to the technician fraternity in any way .. it applies across the whole spectrum of activities ... what it comes down to is a simple test ... as an appropriately skilled and trained person, in respect of this particular decision/operation, do I know so much about it and is it so basic to my discipline that it is a fundamental skill ? If the answer is yes .. then do whatever is required with appropriate skill and care. If the answer is no .. then go look up some information to resolve whatever the potential problem may be ...

For the techician, we don't expect that he look up a book before spinning a nut onto a bolt .. but we do expect that he refers to approved data to check the torque load to which the nut is to be tightened ...

For the pilot, we don't expect that he look up a book to find out the mechanics of shooting an ILS .. but we do expect that he refers to the plate to check frequencies, courses, minima and the like ...

.. and one can generate similar examples in each and every discipline involved in the aviation game ...

This sort of event, and the consequences of it, should highlight to each and every one of us the need for disciplined and cautious conduct of our various aviation activities ..... as one who has made his fair share of mistakes and wrong calls over the years ... may I echo the sentiment that .. "there, but for the grace of God .. "

[Heliport]

B. Sousa
My US Co-Moderator's decision to close the previous thread was a kind and sensitive gesture with which I agreed entirely.

I understand your concern but, since that time, it has been brought to my attention that Captain Kenyon feels there are many lessons which need to be learnt from this tragedy, including by the regulatory authorities.

Far from wanting people to hold a respectful silence, which inevitably means the crash soon becomes just another statistic, he does not wish this tragedy to be forgotten. He is determined that it should not be forgotten until changes are made ro prevent a similar tragedy happening again. If he succeeds, it will mean that some good will have come out of his son's death.

Captain Kenyon can rest assured that he may use Rotorheads to obtain publicity for his cause so long as we are the Moderators.

[Flight Safety]

I find myself in complete agreement with John_tullamarine.

The "system" as it's set up in the aviation world, is in the main a very safe system. Deviation from the regs or procedures of that system, without very expert advice, and manufacturer and governing body approval, can have very tragic consequences.

I had very similar thoughts regarding this accident and intended to post them, but John did it 10 times better than I could have.

[Rob_L]

MODERATOR

I think all I said was that in my opinion you were out of order. I must admit that I have no idea why you should ask people to give opinions on the legal process, when probably only flying lawyer has all the facts at his disposal or the necessary knowledge of the UK legal process. Inviting ill informed comment of this type has little value.

My thoughts rest with the ex BA captain who commited suicide not so long ago. The legal process is a very blunt instrument and the end results are often unforeseen. In this case inviting people to second guess the decision of a judge who has listened to the whole case seems rather odd.

To turn this tragedy into a quiz question seems to me to be inapropriate.

[Whirlybird]

Rob L,

I for one am finding this discussion useful and informative. Quiz question? No, discussion. The two are different. Exactly WHY do you object to other people discussing it? Nobody's forcing you to read this thread. The people involved, ie Dennis Kenyon, have no objection. So what's it to you?

You don't have to agree with any of us, but we have a right to our opinions. So lay off the moderators, and if you want to make your reasons clear, do so.

Because at the moment all you're doing is effectively yelling that you don't like it.

[Captain Stable]

Perhaps a non-whirly pilot could be permitted to enter the discussion...

The engineer concerned did not fail to check whether a weld could be performed. He knew it could. The problem was, on which side it could be performed, and he got that wrong.

He made a mistake, and had not checked.

He was not jailed (in my understanding) for making the mistake. He was considered negligent in not checking the details of what welding could be performed, and he was jailed for that negligence.

You will not stop people making mistakes by threatening to lock them up. But you may persuade them to be as thoroughly diligent as anyone might wish in the performance of their duties.

This is, as has been expressed many times, a thoroughly tragic case. The engineer concerned has expressed his total and genuine remorse for what happened, and the consequences.

I am not in favour of punishing him further by taking away his licence. What he did was an error of judgement that he (and anyone he trains) will never, ever repeat.

I would prefer to have him working on my aircraft than someone who has yet to learn the same lesson.

[Heliport]

I agree. Taking away his licence is a pointless exercise, for the reasons you give.

[OFBSLF]

Genghis:

I was a Civil Engineering student at the time of the walkway collapse at the Hyatt Regency Hotel in Kansas City, MO. There are many places on the web that you can find information about it. Here's one:

http://www.uoguelph.ca/~ajenney/webpage.htm

That collapse was quickly used as a case study in our classes. The web site shown above has sketches of the joint in question, with the original design and the as-built. There were two walkways, one above the other. The original design had both walkways supported by one 30' long (IIRC) rod. Quite rightly, the contractor did not like this design, because it would require threading the support beam for the upper walkway (and its nut) 20' feet up the rod. It was essentially unbuildable.

The as-built redesign had two rods: 1) one rod from the ceiling to the beam supporting the upper walkway, and 2) one rod from the beam supporting the upper walkway to the beam supporting the lower walkway. The box beams in the as-built design were basically unchanged from the original design.

Any structural engineer type (whether civil or mechanical) worth his or her salt will immediately recognize that the as-built places approximately double the load on the box beams supporting the upper walkway. In the original design, the upper beams support only the weight of the upper walkway itself (plus anyone standing on it) -- the load of the lower walkway is supported by tension in the rod. In the as built, the lower walkway is supported by the lower rods. The lower rods are supported by the upper box beams. Thus, in the as-built, the upper beams are now supporting both the upper walkway and the lower walkway.

And then there's the details of the joint itself...

Yes, a number of engineers lost their licenses. There was plenty of blame to go around, however. The original design wasn't great. The redesign was done by the structural fabricators, who should have caught the problem. The designers should have caught the problem when reviewing the redesign. The constructors should have recognized the problem with the redesign as well.

My point ("yes, get to the point!" I hear you say...) is that this was an incredibly obvious error, immediately obvious to most junior year undegraduates.

OFBSLF
(who is no longer a civil engineer and now drives keyboards for a living)

[Genghis the Engineer]

Oh dear, I was actually talking about a completely different walkway collapse, the one at http://www.hse.gov.uk/press/e00013.htm two years ago.


Somebody once said to me that there were two differences between a Doctor and an Engineer. One was that a Doctor could bury his mistakes and an Engineer had to live with his. The other was that Doctors can only kill one person at a time.

Yet more evidence, as if it were needed, as to the need for rigour and crosschecking in our profession!


G

[Roofus]

I have been following this thread with interest. I share Whirlys sentiments, in that it is very informative.

On the 21st of April 2000 an engineering error caused the tail rotor on the twin squirrel I was flying to fail. The result was a well publicised Police helicopter in the roof of a house in Cardiff.
Thankfully there was no physical injuries to the house occupants or crew.

Mentally it is a different matter. The occupants of the house, the two police officers onboard & the engineers involved have all suffered, as did I, to some degree or other. The occupants of the house & the engineers particularly.

The engineers were suspended, debriefed, retrained & returned to work.

Lessons were learnt by all.


The engineer jailed in this tragic accident made a mistake, a mistake with tragic consequences. But he stood up & admitted his mistake.
The family of all concerned must have suffered terribly & my heart goes out to them.
But make no mistake, the engineer will have suffered too.

How does a prison sentance serve any purpose at all. Obviously steps must be taken to minimise & hopefully eradicate mistakes within the aviation world....but jailing a man? It serves no purpose to further punish a man, who will already have punished himself far more severly than anyone else can & he will continue to do so.

& what of the regulatory body that failed to regulate? Are we jailing CAA inspectors too for signing the C of A? Please don't forget that these regulatory bodies were involved aswell.

Are we to further compound this tragedy by learning nothing?

Capt. Stable you said it well, I would rather have the gentleman concerned servicing my aircraft than someone yet to learn by mistakes.

For the record.
I feel that all of us who are involved in aviation take upon ourselves a vast responsibility... be we pilots, engineers, ATCOs or otherwise. We pride ourselves on our professionalism, and are right to do so.
I have accepted the responsibilty of flying the machine, but I would not wish to bear the burden placed upon our engineers.

I feel for all concerned.
Mr Kenyon.... I salute you.
My heart, thoughts & prayers are with you & your familly.

[Nick Lappos]

Unfortunately, OFBSLF and Ghengis are quite off base in the walkway analogy, and roofus perpetuates it in his post.

The Engineer in the helicopter case is not an engineer, he is a mechanic, authorized to follow repair guidelines and fix aircraft. He can change the oil. He can use nuts and bolts to change a part. He can conduct authorized repairs using maintenance procedures and common aerospace techniques.

He is not educated or trained as a true professional Engineer, and is not capable of originating or approving a design in any sense. He is not paid to originate a new design or repair technique, he cannot change the maintenance manual that a professional engineer wrote.

It is unfortunate that British usage of "engineer" blurs this important destinction. Most of the world uses a different title for mechanic than for engineer, to avoid this error. British usage stems from the fact that the terms were in use before the profession of engineer was differentiated, and before engineering schools were created.

[john_tullamarine]

Nick,

If I have misread your post, then may I apologise in advance.

I get the impression that you perceive PEs to be a cut above the technician (mechanic in the US).

Might I advance the thought that such a view is the height of parochial and blinkered vision ? ... not to mention just a little bit arrogant ...

Might I suggest that the two disciplines are complementary rather than a master and servant relationship. As a PE of many years standing (and an absolute menace with a spanner), I have seen numerous examples where an experienced technician has saved a PE - including me, in ignorance or self-serving worship, from making a prize idiot of himself ... likewise the PE can help the technician in areas outside of the latter's expertise.

In the design arena, of which I have a lifelong experience, the PE who doesn't seek the relevant input of appropriate technicians can end up with a design which has unfortunate aspects ..... maintainability, access, ease and cost of manufacture and repair come to mind .....

Often, the practicalities dictate that the two disciplines function apart .. but I have yet to be convinced that this is the best solution ...

I have always held in high regard the old UK practice of PEs coming up via an apprenticeship ... far superior, I think, to the sort of out of school, into university, into the workforce system through which I was processed ...

Just a parochial thought from a parochial PE pilot who, nonetheless, appreciates the value and contribution of technicians..

[Nick Lappos]

john_tullamarine,
I did not infer (I hope) an above or below into the relationship between a mechanic and an engineer, because I am not sure it is germain to the discussion, but there is a hierachy nontheless, not of better worse, but of planner and executer.

The skills necessary to maintain a machine are those of craft, and require training, mechanical prowess and experience. They are little academic, and those who are expert as mechanics are very often not particularly scholarly. This is not a put-down.

It is not arrogance to suppose that a mechanic can not know the mathematics and material science needed to design that fitting in question, it is fact. It is also quite the law that a mechanic must pass his designs to an engineer for approval, should a mechanic try to design a part of a flying machine.

This is simple fact.

That being said, I know many mechanics who would have, given a different set of circumstances in their youth, made great engineers. I know engineers who are great mechanics. The best engineers I know are great mechanics (Paul Martin, the program manager on the F-117 and F-22, rebuilds cars in his oversized garage as a hobby).

I know poor engineers who could cross-thread a mayonaise jar!

In this thread, the spin is on what mistakes people make, and how they should pay for them. I think the real errors here are in the design, and that the mechanic was only the last guy in the chain who was easiest to grab.

I have contended that an engineer/designer is responsible when he sets up circumstances that are likely to lead to a mistake. That about 8 such fittings have failed in flight is testament to that class of mistake.

Some examples of the relationship between mechanic and engineer:

nurse - doctor; machinist - engineer; carpentor - architect; boatswain - naval officer; cinimatographer - director

There is not above/below here, I don't think.

[smiles]

I'm sure your comments may be true when it comes to the A&P mechanic, but think you will find the standards and training requirements in the UK are quite different as they are for pilots!

[Nick Lappos]

smiles,

Now there is arrogance! Smiles, you are too much.

If you tell me that your mechanics take calculus and differential equations, and know how to program a NASTRAN model to determine the strain distribution, and that they go to University for four years to learn how to change your oil, then I would agree with you. They are better.

I have flown lots in the UK, and in many other cultures, and it is all roughly the same. Mechanics are trained in how to do procedures, engineers are trained in how to design stuff and how to write the procedures that mechanics perform. If your mechanics are all able to design things, you are wasting good talent by making them change oil!

BTW, any time you would care to stack up "How things are done" on this side of the Atlantic against how much "better" they are done on your side, let me know.

[Genghis the Engineer]

Nick, you are digging a hole for yourself here.

I've been an active participant in the Engineer .v. Technician debate many times (for the record, in the class of aircraft I work on mostly I'm a design signatory, self certifying technician and a test pilot so am probably as qualified as anybody to do so). I routinely verbally abuse companies who send what they call an "Engineer" to repair my dishwasher and much prefer the term technician for somebody who builds and fixes rather than designs and analyses.

But, what we're talking about here is professionalism and what to do when it breaks down. If I authorise a mod which doesn't take proper account of stresses and material properties, or approve a repair that goes against the requirements in the servicing manual, or decide not to worry about an aircraft with a divergent oscillatory mode because *I* can fly it okay - I am being unprofessional in each case and to a similar degree. In each case, I probably need careful supervision, possibly second check on my work for some time, and a black mark on my professional records.

None of this is at-all dependent upon what job title I'm using at the time. The debate anyway is a daft one, because we can only change the job titles in our own organisation and nothing's likely to change the title "Licenced Engineer" (even the Engineering Council use the title "technician engineer" - probably a good compromise!).

G

N.B. 5 years to do an Engineering apprenticeship, 4 years to do an Engineering degree, considerable years after either to be trusted out on your own!

[Nick Lappos]

Genghis,
No hole here, I think we agree. The issue is who made the biggest mistake - the mechanic who got caught in the wheels of the system or the engineer who made the real error to begin with througfh his poor design. I opt that the biggest mistake was the engineer's one.

[Genghis the Engineer]

Frankly old chap, these are real people with a family and things discussed in public will get back to them. I don't think I want to go there in a public discussion. Talk about how not to let it happen again, but blame is not helpful.

G

[Nick Lappos]

It is not blame but understanding that we all seek. This is a public forum, and I try to be sensitive to the personal nature of the topics that we discuss. As with only a few professions, our mistakes are layed out for all to see, mechanics, engineers and pilots alike. It is healthy to discuss them, and I make my comments in the light of one who does not believe in punishment for honest mistakes. See my first post in this thread. Here is what a famous engineer said about it:

"The great liability of the engineer compared to men of other professions is that his works are out in the open where all can see them. His acts, step by step, are in hard substance. He cannot bury his mistakes in the grave like the doctors. He cannot argue them into thin air or blame the judge like the lawyers. He cannot, like the architects, cover his failures with trees and vines. He cannot, like the politicians, screen his shortcomings by blaming his opponents and hope that the people will forget. The engineer simply cannot deny that he did it. If his works do not work, he is damned." Herbert Hoover

[John Eacott]

Nick,

Interesting discussion. Long time since I operated in UK, but your comments regarding an "engineers" ability is well covered down here, where a modification of this nature would be cleared under CAR 35. Reg 35 approvals are delegated to approved engineers, who are allowed to sign out a modification after taking into account any stress calculations, electrical load analysis, etc., depending on the nature of the modification. Nonetheless, many of the initial design calculations for modifications on my aircraft are often done by our chief engineer, who then has them checked by a Reg 35 signatory.

Usually adds about $3-600 to the job, even when the modification is paperwork only, but it has streamlined the system and taken the onus away from the regulatory authority (CASA) and allowed more "hands on" approach to local modifications and fixes.

[OFBSLF]

Nick:

Hold on there. All I did was to explain in more detail the walkway collapse that I thought (incorrectly) that Genghis was referring to. If you reread my post, you'll see that I did not try to say that the walkway incident should be used as a model or analogy for the helicopter incident. Genghis brought up the walkway incident (er, a different one) as an analogy, not I.

I was once a Civil Engineer, so I'm semi-qualified to comment on the walkway collapse. I'm not a helicopter pilot or mechanic, nor do I play one on TV. I'm just a wannabe who should be working...

I don't know enough about helicopters and their maintenance to have an opinion about the helicopter incident in question.

OFBSLF