Scandal or not? CAA rejects AAIB criticism and safety recommendations!

[newswatcher]

Sadly it appears that the CAA do not wish to accept most of the recommendations from the report. :confused: There will now follow a bout of fisticuffs.

http://news.bbc.co.uk/1/hi/england/2786289.stm

[Flying Lawyer]

The AAIB's key findings include
15. During the investigation, other instances of cracking on the original standard of clevis lugs, associated non-approved welded patch repair, and a non-approved welding repair of the outboard flange area were found on other Hughes 269 helicopters in the UK, indicating that the non-approved welding repair found on G-ZAPS was not an isolated occurrence on this helicopter type.
16. Hughes Helicopters had previously responded to the cracking problem on the clevis lugs of these centre frame rear cluster fittings with additional periodic inspections and a re-designed –3 type of cluster fitting, but it became apparent during this investigation that there was confusion within UK personnel responsible for the maintenance of Hughes 269 helicopters regarding the difference between the original and re-designed -3 standards of these centre frame cluster fittings, and which inspections applied to which standard of fitting.
17. Six previous accidents to this type of helicopter were identified which had been caused by fatigue failure of clevis lugs on the original standard of centre frame rear cluster fitting; all six accidents had stemmed from fatigue cracking of the left clevis lugs. In addition, one fatal accident had occurred in Australia in 1995 due to fatigue failure of an upper clevis lug on a re-designed -3 centre frame rear cluster fitting. No previous accidents were identified which had occurred due to failure of a clevis lug that had been weld-repaired.
18. This accident, and those which had also occurred previously due to fatigue failure of these clevis lugs on helicopters of this type, demonstrated that such clevis lug fatigue cracking could remain undetected, despite frequent opportunities and requirements for in service inspections of these readily viewed fittings, until eventual failure of such weakened lugs caused accidents. Such findings questioned the regulatory reliance placed upon such inspections to detect fatigue damage of these clevis lugs before catastrophic tailboom separation occurred.
19. A lack of logical standardisation was apparent with respect to the timespans that maintenance records and associated documentation must be kept by aircraft operators and maintenance organisations. The ANO requires operators to retain aircraft Log Books for two years after related aircraft have been permanently withdrawn from service, but JAR 145.55 only requires maintenance organisations to retain work records for a minimum of two years after the aircraft to which they refer have been released on completion of related maintenance work. In effect, the potential advantages to investigations of retaining Log Books for the life of an aircraft can thus be nullified by the absence of the detailed maintenance records to which the Log Books refer, if the related work of interest has been completed more than two years before an aircraft suffers a maintenance related accident. and
4. Safety Recommendations

The following safety recommendations were made during the course of the investigation:

4.1 Safety Recommendation No 2001-80 The CAA should forward an information notice to all Licensed Aircraft Engineers, and all approved aircraft and component maintenance organisations, reminding them of the requirement that all repairs, including weld repairs, can only be carried out to an approved repair scheme and of their responsibilities to ensure that there is an appropriate repair scheme in the manufacturer’s maintenance or repair manual, or related approval is granted by the manufacturer, before any repair is authorised.

4.2 Safety Recommendation No 2001-81 The CAA should tighten the approval process for persons granted CAA Welders Approval Certificates to ensure that before they carry out any welding repairs to aircraft or aircraft components, written assurance is obtained from the authorising Licensed Aircraft Engineer that such repairs are in accordance with an approved repair scheme.

4.3 Safety Recommendation No 2001-82 The CAA should take early action to introduce a requirement that Welding Certificates of Conformity must state details of the applicable aircraft registration, type, component, part number, serial number and approval for the related weld repair.

4.4 Safety Recommendation No 2001-83 The CAA should remind all Licensed Aircraft Engineers and aircraft maintenance organisations that maintenance should not be undertaken on aircraft without access to the associated Log Books and Technical Log (if applicable) and that all work should be recorded as required.

4.5 Safety Recommendation No 2001-84 In order to better justify assumed airworthiness assurance arising from CAA Survey Reports the CAA should require, before any aircraft or helicopter is surveyed by a CAA Surveyor for the purpose of issuing a Survey Report, that the service history of the type be carefully audited by the Surveyor to identify any critical structural areas which have been the subject of special inspections / Airworthiness Directives to ensure that such areas are closely inspected, if reasonably accessible, during these surveys.

4.6 Safety Recommendation No 2001-85 The CAA should specify who is authorised to carry out and certify a Daily Inspection (A Check), in addition to describing the initial training and continuity training required for such authorised persons, how that training should be recorded and monitored, and where the authorised person should sign to certify that a Daily Inspection (A Check) has been carried out satisfactorily.

4.7 Safety Recommendation No 2001-86 The CAA should require that all pilots use a Pre-Flight Check List from the CAA approved Pilot’s Flight Manual whenever a flight is conducted for training, conversion or testing so that only approved and fully amended Check Lists are used.

4.8 Safety Recommendation No 2001-87 The Schweizer Aircraft Corporation should amend the Pre-Flight Check List contained within the Pilot’s Flight Manual for the Hughes/Schweizer 269 and 300 helicopters to include in the Pre-Flight Inspection a visual check of the right centre frame rear cluster fitting for cracks and damage, and to include the warning that if cracking of cluster fittings is suspected then dye penetrant inspection is required before flight.

4.9 Safety Recommendation No 2001-41 In view of the finding of non-approved welding repairs to the clevis lugs of the Centre Frame Rear Cluster Fittings on two Hughes 269 helicopters, failure of one of which caused a catastrophic in-flight separation of the tailboom assembly, it is recommended that the Civil Aviation Authority and the Federal Aviation Administration take early action to issue Airworthiness Directives to require immediate visual inspections of these fittings on all Hughes/Schweizer 269 and 300 helicopters in order to check for any non-approved welded repairs to the clevis lugs, and to ground any affected helicopters until such repaired Centre Frame Rear Cluster Fittings have been replaced with new fittings. (Safety Recommendation No 2001-41, made 11 April 2001)

4.10 Safety Recommendation No 2001-45 In view of the potential for catastrophic in flight tailboom detachment on Hughes/Schweizer 269 and 300 helicopters due to fatigue fracture of the clevis lug attachments on the Centre Frame Rear Cluster Fittings, and the difficulty in reliably detecting by dye-penetrant testing all such fatigue cracking in service before related lug fracture occurs, it is recommended that the Civil Aviation Authority issues an Airworthiness Directive requiring the mandatory replacement, on all affected helicopters of these types on the UK Register, of all original Centre Frame Rear Cluster Fittings, part numbers 269A2234 and 269A2235, with the manufacturer's re-designed Cluster Fittings, part numbers 269A2234-3 and 269A2235-3; it is further recommended that the Federal Aviation Administration should implement similar mandatory modification action for all affected helicopters of these types abroad. (Safety Recommendation No 2001-45, made 11 April 2001).

4.11 Safety Recommendation No 2001-88 The CAA should conduct a review of JAR 145.55 with the aim of proposing to the JAA the improved harmonisation of maintenance document retention time requirements with those specified in the ANO, so that maintenance Worksheets and component Certificates of Release that are referred to in Aircraft, Engine and Propeller Log Books are retained until the aircraft, engine or propeller has been destroyed or scrapped.

4.12 Safety Recommendation No 2001-89 In order to avoid inadvertent omission of manufacturer’s inspections during maintenance, it is recommended that the CAA withdraw the option to use the generalised CAA Light Aircraft Maintenance Schedule for Hughes/Schweizer 269 and 300 series helicopters so that they may only be maintained to the manufacturer's Handbook of Maintenance Instructions (HMI).

4.13 Safety Recommendation No 2001-90 The CAA should conduct a review of the manufacturer’s maintenance manual requirements for all helicopter types on the UK register which are currently maintained to CAA/LAMS/H/1999 issue 1 and where there are significant additional ‘specific-to-type’ maintenance requirements in the applicable maintenance manuals, require such helicopters to be maintained only to the manufacturer’s maintenance manual.

Click here for the Full Report. (http://www.aaib.dft.gov.uk/formal/gzaps/index.htm)

Tudor Owen

[headsethair]

Of all the things that astound me in this investigation, the delay in publishing is the worst. How many other lives have been put at risk by this delay ? If an AD is necessary, why wasn't the world told earlier ?

The only reason we have regulators (officially) is to make flying safer. Isn't it?

[Heliport]

I've been told, but don't yet have the details, that sadly there has been another fatal - in the United States - with same clevis lug fracture problem.

[Heliport]

CAA rejects crash report
Air accident investigators and the Civil Aviation Authority (CAA) have clashed over a report into a helicopter crash which killed all three people on board.

The CAA has rejected 10 of the 13 air safety recommendations made to it by the Air Accident Investigation Branch.

The AAIB report into the crash at Hare Hatch, near Twyford, Berkshire, in March 2000 says the CAA had not detected an illegal welding job on the Hughes 269 helicopter during a survey in 1999. As a result, the aircraft was granted a certificate stating it was fit to fly.

The helicopter crashed en route from Wycombe air centre in Buckinghamshire to Shoreham in West Sussex.
During the flight, the section of the helicopter that had been welded - linking the tailboom to the rest of the aircraft - failed and the aircraft broke apart and crashed.

Dennis Kenyon, 18, of Shoreham, Brendan Loft, 38, from Reigate in Surrey and Jane Biddulph, 23, of Lancing in West Sussex all died.

The report criticised the CAA for not listing in its surveys for inspection the area of structure that needed welding - despite a history of cracking in other similar helicopters.

The AAIB also said that non-approved welding "was not an isolated occurrence on this helicopter type".
The tightening up of procedures was recommended by the AAIB but only one was accepted by the CAA - two of the others were partially accepted.

A CAA spokesman said: "We normally accept around 80% of AAIB recommendations. But in this case we felt the AAIB have highlighted areas that we feel they do not understand.
"These types of helicopters are perfectly safe if they are properly maintained."

Paul Kenward, a licensed aircraft engineer from Biggin Hill in Kent, who authorised the illegal welding in 1999, was cleared of three counts of manslaughter last year.
He was later jailed for eight months for allowing the helicopter to fly without a valid certificate of airworthiness, endangering an aircraft and failing to make an entry in the aircraft's logbook.


Can it be right that CAA surveyors who inspect a helicopter may little or nothing about the type?

Or that they are not properly briefed to look for known problems relating to a particular type?

"The AAIB do not understand." ?? :rolleyes: :confused:
It seems like the AAIB understands all too well the dangers/weaknesses in the existing procedures.
And, the AAIB understands that this tragedy which cost three lives might not have happened if the procedures the AAIB recommends had been in place.
Is that the reason the CAA won't accept the AAIB is right?

Whose judgement do you accept?
The AAIB which helps pilots by finding out what caused an accident, and then tries to ensure the same thing doesn't happen to us? Or the CAA?

The CAA is entitled to reject safety recommendations which the AAIB makes for our benefit - but do you think it's right that they should?

[Genghis the Engineer]

I would venture that they should have that right, but I would dispute strongly in this case that they should. It certainly does not appear that they have made a good case why they should.

I've had AAIB findings "against" me, and in every case I can remember, the nearest to rejection CAA has ever accepted has been a staged plan of implementation. Whilst in retrospect, I think CAA was generally right, this tends in my view to suggest that they should take a similar line towards themselves.

So, from the view of a neutral but competent observer, I'd say this stinks. AAIB are incredibly competent, if they truly don't understand an issue it's not for want of making proper inquiries and can only mean that those who "do understand" (CAA) failed properly to explain the position. I have certainly never before heard of something as extreme as CAA rejecting such a large proportion of AAIB recommendations from an investigation. None of the recommendations are contentious from where I'm sitting, and it does read to me like a deliberate effort to protect their own backsides from a charge of CAA's own system being at fault, rather than the one individual who was jailed after making an open and honest admission of what he had done wrong.

You chaps have disagreed with me before and I said I wouldn't post again, but sod it. In my opinion, anybody who is sufficiently knowledgable in this case, and has even a tenuous relationship with the people directly affected, should in my opinion be writing to their MP about this. This reads to me as a serious failure of a safety system in the name of protecting somebody's career and that should not ever happen.

Incidentally, could somebody in the know post which three recommendations CAA DID accept, it would be interesting to know.

G

[Flying Lawyer]

I was involved in this case from the outset - I represented the engineer.

I have no doubt whatsoever that the AAIB investigators fully understood all the issues during the course of their extremely thorough investigation and that the AAIB as a body fully understands those aspects about which the Report makes formal safety recommendations.

The Report highlights problem areas: some are specific to the helicopter type, and some are of general application to CAA procedures.

In my opinion, until the AAIB's safety recommendations are implemented, there is a very real risk that there will be more fatalities.

[IanSeager]

I have the CAA press release in front of me. To make sense(?) of it you will need to refer to Tudor's post above.

The CAA have accepted safety recommendation 2001-86

The CAA have partially accepted safety recommendations 2001-82 and 2001-83

Safety recommendation 2001-87 is addressed to The Schweizer Aircraft Corporation

The CAA rejected the other safety recommendations

So the summary...

1 recommendation accepted
2 partially accepted
1 not addressed to the CAA
10 safety recommendations not accepted

Ian Seager, Flyer magazine

[Genghis the Engineer]

Lu is without doubt a loud and opinionated reactionary.

However, from my own experience of the same or similar authorities, which although probably less than Lu's is considerable - he is right. I could happily introduce several company Chief Engineers or CTPs who have beat their heads against an attitude which is far more to do with protecting the authority and it's staff than with achieving what should be the two sole goals of an aviation authority, which are (1) safety, (2) allowing aircraft builders, owners, operators, etc. to operate as efficiently as possible without compromising (1).

My only disagreement with Lu's post is naming any particular aircraft when giving past history, it only starts to point at individuals which gets hackles up.


As to the individual recommendations, I've been looking at them. It frankly staggers me that most of these were necessary at-all. I did start this post by making an individual critique of them, but why? - any suitably qualified aerospace professional can see the need if any of these issues are not already addressed for doing so. One can only conject as to why CAA has not accepted them, for the time being I shall hold with my previously posted theory.

G

[Heliport]

I've split this topic into two parts because I think the latest development in this curious affair deserves careful consideration.

http://www.ejectorseats.co.uk/walkstrp.gif

It is highly unusual for the CAA to reject so many AAIB safety recommendations made after such a thorough investigation.

http://www.ejectorseats.co.uk/walkstrp.gif

Many Rotorheads have been very suspicious about the delay in publishing the Report.
See the original thread started by Hoverman - under it's old title Something fishy going on? (http://www.pprune.org/forums/showthread.php?threadid=71785&referrerid=30158)

Has Genghis the Engineer hit the nail on the head?

Heliport

[Helinut]

Is the CAA Press Release on the web?? I could not find it on the CAA website. Perhaps they are too ashamed to make their press release public ? :(

I can only add to the other comments here, that having read the AAIB report carefully, it seems to be up to their normal high standard. The content of the report itself seems to me to demonstrate that the AAIB have a good grasp of the issues. To dismiss the AAIB recommendations in such a way seems pretty cavalier - although I have not been able to read the Press Releasee directly of course! :rolleyes:

If you realised you were on a very sticky wicket this is the sort of garbage, spun response that might be generated. Their hope must be that it will go away if they keep fairly quiet about it. There are loads of routine examples of the CAA engaging in back-covering exercises - avoiding their own liability (i.e. taking responsibility for nothing)

Certainly my confidence in the engineering system that we as pilots all rely upon is undermined by looking at this report. Obviously, the actions of the engineer are worrying, but far more so is the attitude of the CAA, and their inadequate systems.

I have been musing about what we could do about it. The only thing that might just make the CAA reconsider their position would be if politicians got involved. I may be unduly cynical about politicians, but I doubt that they would be much interested, unless they saw the connection to some big fixed wing accident (i.e. a threat to lots of non-aviating voters).

Does anyone have any ideas??

[Dantruck]

I doubt any politician would be of help, not least because they'd never want to get involved in such a complex issue, and because it would mean taking on a government entity - one which, if they aren't already connective with it, might be after the next election. As a journalist I can tell you the general media are also unlikely to handle this one well, not least because the CAA has every right to reject AAIB recommendations.
As a pilot I also agree the CAA's attitude is cavalier. I for one have great respect for the AAIB's work. I've never met anyone who grumbled about the AAIB, but the CAA?...

[Heliport]

Dantruck
I share your cynicism about politicians, but the CAA is not a government department.

I bow to your experience of the Press as a journalist, but wonder whether the Press would ignore the story if, as is widely believed, this is a cover-up with the CAA watching their own backs after a fatal crash in which three people lost their lives.
What, for example, would Joe Public think if they knew that CAA surveyors were expected to conduct surveys of aircraft types they know nothing about - and without a briefing to point them towards known problem areas?
The British Press is notorious for making 'scandal' stories and alleging cover-up when neither are true - would they not be interested if there was actually a basis for such a story?

[Dantruck]

Heliport
On a slow news week a serious weekly like the Sunday Times, a UK broadsheet newspaper, might just pick up your point and run with it. However, the problem we pilots would have in convincing a news editor of the worth of the storyline you suggest lies in the fact the crash involved a helicopter, and not even one operating a scheduled service. Had it been a 737 taking holidaymakers to Malaga - ie: an aircraft and type of operation understood by Joe Public - the reaction would likely be different. This is dumb given that the aircraft type and operation do not lie at the root of your suggested (and worthy) story idea, yet, that is how any news editor would weigh it up.
Bottom line is: complex issues of minority interest don't make popular reading, especially at a time when big issues like the probability of war have everyone's attention. In an earlier post someone made a similar observation about the involvement of an airliner being more likely to attract journalistic interest. That post was spot on.
Specialist magazines like The Engineer or Flight International could pick this one up, but that would not reach Joe Public.

Didn't mean to imply the CAA is a government department, more that it comes within ministers' sphere of influence.

[BlueEagle]

Well, having just read it right through I too agree with Genghis and think it stinks.
If it were possible it might answer a few questions to
find out who in the CAA gave the aircraft the 'all clear' in 1999, where are they now for instance, what position do they hold?
Flying Lawyer, you probably know what, if any, Professional Indemnity cover the CAA would have?
From a legal point of view if the CAA had agreed to the thirteen recommendations would they be laying themselves open to court action? (I would have thought they would).
Before even an interim report was published I imagine there
would have been considerable communication between the AAIB and the CAA behind the scenes so for it to have come down to this public showdown the CAA must be desparate to protect someone and/or themselves. A quick statement to
the effect that the CAA had accepted the bulk of the recommendations and had already implemented corrective action would have shown that they at least took a positive attitude towards righting wrongs, as it is, how many more unmodified -300s have fallen out of the sky since? How many more have to
before the CAA will admit changes are required?
I may not be adding anything new here, but yes, it does stink, the CAA are protecting themselves and possibly individuals and are afraid of a court case that might well cost them dear and set precedents.

[Genghis the Engineer]

BlueEagle asks, not unreasonably, who would have been responsible for approving the type. I'm sure I could guess a few of the key names, but if I did, I don't suppose the moderator would be as gentle to me as he is to Lu, so I shall refrain.

However, it's worth mentioning how the aircraft gets approved, which is probably transparent to most people.

The manufacturer, who are approved by their own authority as competent to do so will submit a series of reports to CAA. These consist of two parts. One is called the "compliance checklist", showing that the aircraft should comply with each paragraph of the relevant safety standard - in this case JAR-27. The second (and rather larger) part will be all the supporting structural, test, analysis, flight test, etc. reports referred to by the compliance checklist. The company will have various specialist "signatories", but the overall compliance checklist is signed by the top-level design signatory, usually the Chief Engineer or Chief Designer.

This initially goes to somebody at CAA called a "Design Liaison Surveyor" who will go through the compliance checklist, pick up any obvious problems, then distribute the supporting reports to various specialist departments - structures, flight test, powerplant, documentation, etc. These specialist surveyors each check in their specialist areas and report back to the DLS.

The DLS, who will usually be an aeronautical Engineer and supervised by a more senior Engineer ultimately makes the approval decision based upon the reports of their specialist departments. They then issue a provisional approval (called a Draft Airworthiness Approval Note) on the basis of which a regional surveyor will go and examine an example aircraft, and probably somebody from flight test will go and spend a few hours in the type if they haven't already. Finally, if everybody's happy, they report back to the DLS whose signature will give the final approval.

So, for there to be so many errors in the approval as AAIB appear to have found, I can't see it can be anything but a complete breakdown in the management system. Although one person ultimately signed it off, I can't see that any one person at CAA could be held responsible for the technical failings. Of-course, if it's a failing of the system, the finger inevitably points at managers senior enough to refuse AAIB recommendations :( Having said that, everybody in the business is well aware of the problems that arise from having a DLS who is a less than exceptional Engineer.

G

[Thomas coupling]

Not being familiar with the a/c type, and also not really involved in this latest debacle from the CAA, makes it that much harder to get my head round it.
However, from an outsiders point of view, I would make these observations:
1. There must be mitigation behind the CAA's response and if it was something which directly affected me, then I would do everything possible to find out why they responded the way they did..
2. As the a/c type operator, I would make damn sure I acted on the AAIB recommendations within reason, to safeguard my fleet and working practices, with or without the CAA's help.
3. If I felt very strongly about this issue, I would then take matters further by advising my insurance company of the outcome. I would write to my MP. I would write to the Chairman of the CAA and I would write to the local (where the accident happened) and national newspapers.
The debating can and probably will go on - ad infinitum, but action behind the scenes cannot wait on this one.....
:*

[Rob_L]

The CAA realised years ago that it was impossible for them to have type current surveyors for all types on the Uk register.
This was the reason why Cof A renewals became the resposibility of the operators/maintenance organisations. The CAA would otherwise have to employ hundreds of extra surveyors who would spend most of their time on the road going from airfield to airfield.

[t'aint natural]

The point here is that more than 500 early-model Hughes 269 aircraft are flying around the world today with a design fault that could cause them to break up at any time, and the CAA refuses to adequately address the issue.
Hughes recognised the fault and redesigned the component concerned in the early 1970s, incorporating the new design from s/n 570. Since then, there has been only one failure of the redesigned component, but that had suffered damage.
But the helicopters with the original component are steadily falling out of the sky. Since 1972 there have been eight such accidents, and14 people have been killed.
The CAA's case has always been that regular inspections of the component, coupled with periodic dye penetrant inspections, is enough. The trail of corpses, however, should lead them to a different conclusion.
In April 2001 the AAIB, investigating this accident, made an urgent recommendation to the CAA (and via them, to the FAA) that replacement of the original component with the redesigned one be mandated immediately. The CAA refused, clinging to the claim that inspections were adequate. In November 2002, a Hughes 269 crashed in Oklahoma when the original component gave way, and the occupants were killed.
There are a hundred other aspects to this sorry saga, but the key question is why, in the face of all the evidence, does the CAA stick to its discredited line? Perhaps Flying Lawyer could enlighten us as to whether this is merely a matter of loss of face, or whether there is some liability issue to be considered.
As to interesting the mainstream media, it may be possible, but there are other shoes to drop first.

[DennisK]

From Dennis Kenyon

To date, I have remained largely quiet on the G-ZAPS accident, since it seemed proper to await formal publication of the AAIB report even tho I received the draft over a year ago.
However in view of the very serious situation we now have as observed by many of my industry pilot friends and pprune contributors, I plan to raise the profile of my son's accident putting the spotlight where it belongs, ie the FAA/CAA. I have produced a piece that will shortly be published in aviation journals which I hope will bring the situation into the public arena. Since the AAIB report was published on 21st Feb 2003 I see the flack has been well and truly flying.

The accident history of the type is simple. A clevis component suffered a fatigue failure some thirty years ago, This was followed in succeeding years by a further five identical accidents until March 2000 when my son lost his life. Seven in thirty years so we can anticipate on an average basis - one every four years.
Following the earlier accidents, the Hughes factory produced a 're-designed' cluster commonly refered to by engineers as 'the thickwall cluster' being part no 2234 dash three. It was incorporated into all factory build helicopters after serial number 570. I have to emphasise that with the exception of a single incident for a special reason, there have been no failures to the thick wall dash three component, which includes all Schweizer built helicopters flying today.
As we know the 'regulatory authorities' ie FAA/CAA did not mandate the modification instead relying on a strategy of AD's, SB's LTO's SL's etc, being periodic inspections. to date thirteen in all !! Now one might be forgiven for thinking that a more responsible authority would have mandated the modification following say the second or third accident. But no, our CAA felt that the regular 'dye penetrant and eyeball' inspection route was sufficient. Now my view is that - yes the inspection route was correct - but patently it wasn't working for whatever reason.
So why the hell didn't someone in charge wake up, and say enough is enough. The fix is staring us in the face. Mandate the modification. Had the FAA/CAA done this my son and a few other pilots would not be dead. Had they even embarked on a programme of letting the aviation world know, I would not have purchased the early Hughes suspect type or as a minimum would have required it to be modified before putting it into service on my school.
Two years ago, I wrote a piece on the above lines, and ended by saying the CAA must do something now before we have an eighth accident. Sadly I must confirm that on Nov 1st Hughes 300 N8885F suffered an in flight break up at 500 feet in Oklahoma. How do my readers think I feel now. How will the USA relatives feel when they discover the truth.

In April 2001, one year after my son's accident, the AAIB recommended the FAA/CAA mandate the modification. The FAA said they would report back in the standard 90 days. In May 2002, the CAA replied refusing to accept the recommendation.
Yes, Paul Kenward was sent to prison for an illegal weld repair, no doubt allowing the CAA to think they were off the hook. But this was the only failure due to a weld repair. One might even argue the Kenward's repair extended the life of a clevis lug that was on its way to a failure anyway.

In October 1999, five months before the accident, a C of A was issued being overseen and routinely checked by the CAA surveyor. In my view one of the reasons, Paul Kenward was found not guilty by the Oxford Crown Court jury on three of the charges. The CAA have made a statement and I quote, the 1999 inspection was not a sign off for the safety of the helicopter. Ye Gods - and they call themselves the Safety Regulation Group !! Of course I understand the CAA's C of A involvement, but if the surveyor had only been made aware of the type's chronic history of failure, my son would be alive. If the welder had been made similarly aware of the proper procedure, my son would be alive. I'm afraid I have to find the CAA totally negligent in this matter and for them then to make a statement and I again quote. "The AAIB have highlighted areas they do not understand." How arrogant. The AAIB - with an army of the most experienced engineers and access to pilots in the world.
So to turn to some of the questions raised by Rotorhead contributors. The AAIB produced their draft on 20 th December 2001. I am advised that the report was delayed during extended legal representations by the CAA to change two of the six 'causal factors'
1. Failure to mandate the fitting of ... became, the decision NOT TO MANDATE, (my capitals) the fitting of ..........
2. Failure of the CAA surveyor ..... became, there being no requirement for the CAA surveyor ......
I plan to be constructive in a moment but must first refer to a third AAIB 'causal factor - ie the pilots failure to detect the cracked cluster in a pre flight/check A inspection.
Just to say that as a 13,500 hour rotary pilot/instructor/examiner I was last to fly the aircraft and did not detect the crack or knew about the illegal weld repair. Prior to my inspectionf, Mike Smith a higher qualified pilot inspected the aircraft five days before the accident. Leon Smith a 14,000 hour instructor/examiner flew the aircraft for twenty hours over a three week period and detected nothing. One might be forgiven for thinking the crack was not there to be seen. A view partially shared by AAIB.
So where does that leave us now. Simply that around 400 to 500 Hughes 300 helicopters are today flying around the world and if nothing is done now, accident number nine will happen in the next three to four years.
I am advising Gerald Howarth M.P (defence minister) of this situation and other persons in parliament who may decide to take things up. But no holding breath !

So what must I say to the CAA. They must do the following.

1. Mandate the fitting of the dash three component on all affected helicopters.

2. Accept the AAIB recommendation in all 14 areas, particularly those relating to authorisation of welders, access to type knowledge by surveyors, use of pilot check lists that are authorised by the manufacturer Scrapping of the usless LAMS. There are 17 early Hughes on the UK register, two of which were also found with clevis cluster cracks. I have made it my business to tell UK owners what they must do. Yes the CAA inspection system is working most of the time, but there are catastrophic consequences when it doesn't.

Finally to apologise for not being able to edit these words and my case simply due to the nature of this forum. The words come from my heart as they occur. I have tried hard to keep emotion out of this piece. Those who know me and knew my son, will appreciate how difficult it has been.

Please call on me at my Shoreham office if anyone wishes to discuss or participate in any aspects of my son's accident in an effort to stop this ever happening again.

Fly safely.

Dennis Kenyon

[Rob_L]

It seems to me that the option to modify these suspect aircraft has been there for a considerable amount of time with parts available. All aircraft operators have a duty of care. Do they really need an AD to force them to exercise it?
The FAA are responsible for this particular aircraft and unless a cluster broke in the UK it is unlikely that the CAA would have become involved, it would take it's lead from the FAA.
In the 70's 80's the CAA took quite a strong line on modifications to Hughes built helicopters, hence the large number of CAA additional directives. Why this particular modification was not made mandatory is a mystery to me.
However it is my view that the CAA did not carry out an independent engineering review of all service information and relied on operators and maintenance organisations to make recommendations. Given that they were the people with hands on experience this was not unreasonable. The cost of a full independent engineering review of every bulletin from every manufacturer would be astronomic and who would pay for this level of safety?

[handyandyuk]

The G-INFO register of UK a/c lists 48 Hughes 269 or Schweitzer 269 model aircraft. Would it not be an idea to contact the registered owners of these aircraft, inform them of the state of play and see how many would care to write to the CAA and voice their feelings as to why the CAA deems it unnecessary to ensure that all safety recommendations of the AAIB are implemented? I for one, would love to see the justification the CAA would come up with. Of course, should the CAA response manage to find it's way to the press, maybe they who would have us grounded as 'a threat to the safety of London' could actually do some good for once and bring to the public's attention the CAA's apparent disregard for aircraft safety.

I may only be a PPL with less than 100 hours TT, but I would like to think that there is an organisation looking out for my safety and that of all affected each time I take off. Will it take another 269 falling out of the sky and maybe landing on a village school before they do what needs doing?

[Hoverman]

Rob L says - "It seems to me that the option to modify these suspect aircraft has been there for a considerable amount of time with parts available. All aircraft operators have a duty of care.
Do they really need an AD to force them to exercise it?"

Answer - Obviously yes, because many haven't done it voluntarily. Unless we're content to allow people to go on being killed of course. :rolleyes:

[SASless]

A quick comment......

In the US FAA system, anyone may offer for consideration a change, amendment, removal, exemption of a current regulation or even propose a new regulation. The procedure is clearly spelled out and the FAA must consider those proposals. The official website www.usfaa.gov can be accessed and the pertinent rules and forms, etc....can be located for one's use in such an effort.

Does the CAA in the UK have such a vehicle for outsiders to make such proposals?

If the CAA Annual Certificate of Airworthiness (CofA) inspection does not certify the aircraft to be "airworthy" then just what does all that time, effort, paperwork, and cost of that exercise provide?

Sounds like Flying Lawyer might want to start looking at catalogues of Warbirds for sale.......in this country...there would be some very interesting law suits being filed!

I wonder what records the US Army might be able to produce for the now retired fleet of TH-55A's that were off the shelf purchases of the 269 helicopter. They operated several hundreds of the things from the 1960's to sometime in the early 80's as a Primary trainer. What if someone was to get permission to do an inspection on the mothballed fleet out at Davis Monthan AFB in Arizona and determine how many had bad clusters?

THIS DATA CURRENT AS OF THE FEDERAL REGISTER DATED FEBRUARY 27, 2003



14 CFR - CHAPTER I - PART 11


§ 11.39 How may I participate in FAA's rulemaking process?

You may participate in FAA's rulemaking process by doing any of the following:

(a) File written comments on any rulemaking document that asks for comments, including an ANPRM, NPRM, SNPRM, a final rule with request for comments, or a direct final rule. Follow the directions for commenting found in each rulemaking document.

(b) Ask that we hold a public meeting on any rulemaking, and participate in any public meeting that we hold.

(c) File a petition for rulemaking that asks us to adopt, amend, or repeal a regulation.


This is taken from the US FAA Regulations, United States Code (USC) Chapter 14, Part 11.

Maybe the UK should have something similar?

NTSB Identification: FTW03FA028
14 CFR Part 91: General Aviation
Accident occurred Friday, November 01, 2002 in Fort Gibson, OK
Aircraft: Hughes 269A, registration: N8885F
Injuries: 1 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed.

On November 01, 2002, approximately 1150 central standard time, a Hughes 269A helicopter, N8885F, impacted the terrain following a loss of control during cruise flight near Fort Gibson, Oklahoma. The helicopter was owned and operated by Tundra Resources Corporation of Tulsa, Oklahoma. The private pilot, sole occupant, received fatal injuries, and the helicopter was destroyed during the impact sequence and post-crash fire. Visual meteorological conditions prevailed for the planned cross-country flight, and a flight plan was not filed. The 14 Code of Federal Regulations Part 91 flight originated from Cookson, Oklahoma, at an unknown time, with a planned destination of Tulsa, Oklahoma.

One witness, who observed the helicopter flying to the west for about 8 seconds, reported a piece of the tail rotor separated. Subsequently, the helicopter pitched to the right, the main rotor separated, the helicopter started spinning, and descending toward the ground.

A second witness reported that he heard a "pop." Subsequently, he observed the main rotor slowing, wobbling, stop turning, break away from the helicopter and travel forward of the helicopter. The helicopter pitched "nose forward and then fell almost vertical." This witness found one tail rotor blade, the left tailboom strut (GPS latitude 35 degrees 46.50 minutes North; 095 degrees 08.19 West), the right stabilator, and the main rotor (GPS latitude 35 degrees 47.00 minutes North; longitude 095 degrees 08.20 minutes West).

Local authorities and the NTSB investigation team, who responded to the accident site, found the helicopter (GPS latitude 35 degrees 46.59 minutes North; longitude 095 degrees 08.19 minutes West) in an inverted attitude at the base of a tree in the wooded wildlife management

NTSB Identification: FTW90FA183 . The docket is stored on NTSB microfiche number 45513.
14 CFR Part 91: General Aviation
Accident occurred Monday, September 17, 1990 in KINGSVILLE, TX
Aircraft: HUGHES 269A, registration: N403SD
Injuries: 1 Fatal.
THE PILOT WAS ON A CATTLE HERDING FLIGHT AND WAS FLYING AT AN ALTITUDE OF ABOUT 100 FT AGL, WHEN THE HELICOPTER'S TAIL BOOM ASSEMBLY SEPARATED. THE HELICOPTER BEGAN TO SPIN TO THE RIGHT, THEN IT NOSED OVER AND COLLIDED WITH THE TERRAIN. AN EXAMINATION REVEALED THAT THE LEFT FLANGE ON THE TAIL BOOM SADDLE FITTING (PN: 269A2324) HAD FAILED FROM FATIGUE, WHICH RESULTED IN SEPARATION OF THE TAIL BOOM.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

THE FATIGUE FAILURE OF THE LEFT FLANGE ON THE TAIL BOOM SADDLE FITTING.

[SASless]

Sounds like the FAA is on top of the matter.....how does this compare with the CAA AD?



Airworthiness Directives


Header Information
DEPARTMENT OF TRANSPORTATION

Federal Aviation Administration

14 CFR Part 39
[Docket No. 2001-SW-58-AD; Amendment 39-12726; AD 2001-25-52]

RIN 2120-AA64
Airworthiness Directives; Schweizer Aircraft Corporation Model 269A, 269A-1, 269B, 269C, and TH-55A Helicopters
PDF Copy (If Available):



Preamble Information

Regulatory Information

2001-25-52 Schweizer Aircraft Corporation: Amendment 39-12726. Docket No. 2001-SW-58-AD. Supersedes AD 76-18-01, Amendment No. 39-2707, Docket No. 72-WE-23-AD.

Applicability: Model 269A, 269A-1, 269B, 269C, and TH-55A helicopters, with tailboom support strut (strut) assemblies, part number (P/N) 269A2015 or P/N 269A2015-5; tailboom center attach fitting, P/N 269A2324; or with a center frame aft cluster fitting, P/N 269A2234 or 269A2235, installed, certificated in any category.

Note 1: This AD applies to each helicopter identified in the preceding applicability provision, regardless of whether it has been otherwise modified, altered, or repaired in the area subject to the requirements of this AD. For helicopters that have been modified, altered, or repaired so that the performance of the requirements of this AD is affected, the owner/operator must request approval for an alternative method of compliance in accordance with paragraph (d) of this AD. The request should include an assessment of the effect of the modification, alteration, or repair on the unsafe condition addressed by this AD; and if the unsafe condition has not been eliminated, the request should include specific proposed actions to address it.

Compliance: Required as indicated, unless accomplished previously.

To prevent failure of a strut clevis lug (lug) on a center frame aft cluster fitting (cluster fitting), rotation of a tailboom into the main rotor blades, and subsequent loss of control of the helicopter, accomplish the following:

(a) Within 10 hours time-in-service (TIS), and thereafter at intervals not to exceed 50 hours TIS, for helicopters with cluster fittings, P/N 269A2234 or 269A2235:

(1) Using paint remover, remove paint from the lugs on each aft cluster fitting. Wash with water and dry.

(2) Dye-penetrant inspect the lugs on each aft cluster fitting. See Figure 1.

(3) If a crack is found, before further flight, replace the cracked cluster fitting with an airworthy cluster fitting. Cluster fittings, P/N 269A2234 and 269A2235, are not eligible to replace a cracked cluster fitting.




FIGURE 1



(b) For helicopters with strut assemblies P/N 269A2015 or 269A2015-5, accomplish the following:

(1) At intervals not to exceed 50 hours TIS:

(i) Remove the strut assemblies, P/N 269A2015 or P/N 269A2015-5.

(ii) Visually inspect the strut aluminum end fittings for deformation or damage and dye-penetrant inspect the strut aluminum end fittings for a crack in with accordance Step II of Schweizer Service Information Notice No. N-109.2, dated September 1, 1976 (SIN N-109.2).

(iii) If deformation, damage, or a crack is found, before further flight, modify the strut assemblies by replacing the aluminum end fittings with stainless steel end fittings, P/N 269A2017-3 and -5, and attach bolts in accordance with Step III of SIN N-109.2; or replace each strut assembly P/N 269A2015 with P/N 269A2015-9, and replace each strut assembly P/N 269A2015-5 with P/N 269A2015-11.

(2) Within 500 hours TIS or one year, whichever occurs first, modify or replace the strut assemblies in accordance with paragraph (b)(1)(iii) of this AD.

(c) For Schweizer Aircraft Corporation Model 269C helicopters, within 100 hours TIS, serialize each strut assembly, P/N 269A2015-5 and 269A2015-11, in accordance with Schweizer Service Information Notice No. N-108, dated May 21, 1973.

(d) An alternative method of compliance or adjustment of the compliance time that provides an acceptable level of safety may be used if approved by the Manager, New York Aircraft Certification Office (NYACO), FAA. Operators shall submit their requests through an FAA Principal Maintenance Inspector, who may concur or comment and then send it to the Manager, NYACO.

Note 2: Information concerning the existence of approved alternative methods of compliance with this AD, if any, may be obtained from the NYACO.

(e) Special flight permits may be issued in accordance with 14 CFR 21.197 and 21.199 to operate the helicopter to a location where the requirements of this AD can be accomplished.

(f) The inspections and modifications shall be done in accordance with Steps II and III of Schweizer Service Information Notice No. N-109.2, dated September 1, 1976 and Schweizer Service Information Notice No. N-108, dated May 21, 1973, as applicable. This incorporation by reference was approved by the Director of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. Copies may be obtained from Schweizer Aircraft Corporation, P.O. Box 147, Elmira, New York 14902. Copies may be inspected at the FAA, Office of the Regional Counsel, Southwest Region, 2601 Meacham Blvd., Room 663, Fort Worth, Texas; or at the Office of the Federal Register, 800 North Capitol Street, NW., suite 700, Washington, DC.

(g) This amendment becomes effective on May 8, 2002, to all persons except those persons to whom it was made immediately effective by Emergency AD 2001-25-52, issued December 14, 2001, which contained the requirements of this amendment.



Footer Information

Federal Register Information





Comments

[Dennis Kenyon]

From Dennis Kenyon.

Having just contributed a note to pprune for further discussion, I plan to keep reading the industry's forum notes on my son's G-ZAPS accident. I am disturbed to note an earlier Hughes 269 accident that has not been included in the AAIB report. (not the November 2002 Oklahoma fatal) N403SD crashed fatally in USA on 17th Sept 1990 bringing the listed number of airborne failures now to eight ! Nine including the Australian failure to a 2234-3 airframe. So presumably there are other accidents around the world not yet included in the AAIB report.
So just to confirm I am planning to raise the profile of my son's accident via TV (Meridian have broadcast a five minute report) MP's, then aviation journals and next, perhaps a Channel 4 piece.

I have to say that from time to time, I go home and tell myself ... sod it and everyone. Just forget it all. Nothing will bring young Dennis back. Let someone else suffer my son's fate. What rotten luck. Next morning, I wake and come to my senses and realise I have a greater responsibilty to the industry. As I have said previously .. there must never be a ninth, (now tenth) accident.

Just to say again .. if anywhere out there wishes to discuss any aspect of this tragic event, just call me at my Shoreham Office.

And please .. please keep your views coming.

Dennis Kenyon.

[Dennis Kenyon]

Reply for Lu,

Thanks for the interest re G-ZAPS.
Yes, Rex Parkinson (whom I've known for many years) and Jeremy barnett, did invite me to provide some details for the report, but not the actual investigation process. But now that the AAIB report is publised - I am making it my job now to getting very involved.
As we all know the formal AAIB report, is a 1000% comprehensive coverage and apart from the accident causes themselves, it highlights some risky anomolies in other procedures, ie LAMS against HMI and Flight Manual checks A and pre-flight.

It calls on a tightening of welding procedures and authorities. As we stand today, any approved welder can set about any airframe, (presumably a B747) and effect welding repair work on a type he knows absolutely nothing about.
There is no requirement to check the legality of the work, nor any requirement to record details of serial number, type etc, worked on. Had some kind of Certificate of Maker's compliance been in the system for G-ZAPS, the welder would not have completed the requested work and once again, lives would not have been lost.

I believe every helicopter pilot and engineer should read it in detail.

In the next few days and weeks, it is my intention to bring my son's accident under the spotlight. But even here I am fearful. We all know that at my last count there were seventeen accidents to R22 following initial 'mast bumping' and M/R head separation. But it went on for years before the industry addressed the problem adequately.
I'd have to say, Frank Robinson never shied away from his responsibilty to the industry and ensured the run of R22 accidents was made general knowedge while he set about curing the problem. (I have the NTSB list of 17 by serial and registration number)
If only someone at Hughes and latterly Schweizer (or the FAA/CAA) had done the same for the early 269's. Possibly seven or eight accidents prevented and my son still with me.

Thanks to all who are helping with their contributions.

Dennis Kenyon.





we 0\ areveals

[ali250]

Dennis,

As a long time friend of both you and young Den I feel totally powerless to help you. Of course I will support you in writting letters voicing opinions and in any other method you feel that is necessary, but will it really help?

It's only a small token gesture, but looking at the responses to a thread that is concerning the misfortune that has happened to me and my company, currently running along side this thread, there are some good people in pprune that have voiced some very strong views, for this I must thank them all. I am sure they will do their bit to support your case.

Getting back to my gesture, you have convinced me that the 269a/b and early 269c's with the thin clusters are unsafe to fly (an accident waiting to happen AGAIN!). As one of a few TRE's on this type of aircraft who can carry out LPC's and CAA flight tests I've decided not to to fly this aircraft until the new thicker cluster has been fitted. I would also like to point out that my pilots have also agreed not to fly these helicopters. At least I feel like I / we are doing something to support your case.


Good hunting

Bill

[Dantruck]

Reference your last post, re Lu
A good point, well made, says I
Dantruck

[Genghis the Engineer]

One gets a clue as to why Lu tends to get ignored by various authorities.

G

[Fair Flair]

Reply to Ali250

Any support will help Dennis and its good to see so many people
determined to add their voices to this issue.

Your decision not to fly the unmodifyed Hughes 300 will actually not only help support Dennis, but could also benefit you by keeping you alive a bit longer than might otherwise be the case if you carried on flying the early type of this machine!


The CAA stance is baffling - if the continued failure of a component had been to a B747 and not a Hughes 300, there is no question that they would have taken effective action at an early stage. I can only conclude its a numbers game, an acceptable body count if you like.

And if the CAA continue to think that issuing yet more bits of paper is effective, then yet more people are doomed to die. Don't let it be you!

[Dennis Kenyon]

For my dear pilot friend Bill at BHH and all 269 pilots - yes I think it is a sensible decision to ban your flying of the 'thin wall' cluster models. The fact is that as I write, I have located no less than nine failures, ten with the later dash 3 Australia accident.

I have to say, I don't think we are likely to see another UK accident. I believe the awareness level is now so high. But what about in five years time, or ten. Remember these accidents are occuring around once per three years.

But what about some of the third world countries, where I guarantee pilots are flying the type knowing nothing at all of the problem.

Can you imagine how I have agonised over whether I should have spotted the cracked cluster one flight prior to my son's fatal. I just have to convince myself it was not there to be seen, but this is against the evidence of the metallurgist. But once all models are modified, we can start to fly a safe helicopter again. I love flying the type, a fine training machine - a view increasingly shared by many instructors in our industry.

And finally - just another call to the CAA. Please .. please do it now. How do you feel knowing that yet another pilot lost his life just four months ago. Don't wait for the FAA Forget your legal exposure. Mandate the fitting now. Cluster failure accidents now total NINE. !!! If you don't it is just a question of time before we are reading about the tenth.

Dennis Kenyon.

[Helinut]

I wanted to ask what a pilot who is very concerned at the way the CAA have acted in this case, but does not happen to fly the Hughes, should do?

I guess my question is directed probably to Dennis. I want to help, but I am not sure what is the best thing to do. Is there anything useful that I and other pilots can do to help??

[Dennis Kenyon]

From Dennis Kenyon,

First a reply to Hovernut, (aren't we all) I'm not sure that as a non Hughes driver there is much you can do practically. But if my words and the letters above are taken on board AND you help publicise my son's accident - that will perhaps allow the CAA to appreciate the strength of feeling ot here, and bring the matter to the public's attention and perhaps put pressure on the CAA.

BHH pilot's are not flying the affected type. (early Hughes models, 1970's serial nos 0-570.) If all pilots in the country act similarly - we will have effectlively grounded the type and bring this dangerous situation under control.

I am having e mail correspondence on the matter from many countries in the world and requests for more detail. On Friday 7th March, the south counties paper, Evening Argus are running a longsh piece. Being only interested in the dispute aspects of the story, the article is not that objective, but at least gets to the bones of the problem of the CAA's refusal to accept AAIB's recommendations.

But once again a CAA press office spokesman trotted out the familiar, "the accident to G-ZAPS was due to the illegal actions of an engineer." When asked what they had to say about the other eight accidents where there had been no welding to the critical clevis cluster, the reply was "we have no 'significant' knowledge of the other accidents. Presumably they don't believe the AAIB report which list them all, by serial number, registration, date, location and description of failure.

It just goes on and on. So just to confirm, a writ was served on the CAA today.

I can think of no logical reason why the AAIB recommendations are not accepted, except perhaps the legal liability aspect - I'm sure our flying lawyer will know more of that and may have something to say perhaps. At the time of the G-ZAPS failure, the cost of modification by cluster modification/replacement to the Dash 3 item was in the £10,000 - £15,000 area, (the change required engine pylon removal, with attendant M/R hub/blades off, tail boom and gear box split. However, I am advised by a well respected Hughes engineer (ML at Sywell) that the work can now be done for well under £5,000. Not much to ensure a safe helicopter I would have thought.

Please keep your words coming.

Dennis Kenyon

[Heliport]

Lu

I see you've deleted the post which I edited, and to which I added comments.
That is your right.
However, the warning I added to your post still stands:

I've given you more leeway on this forum than any other contributor. I have done so out of respect for your advanced years.
However, I will not allow you to use this high profile thread to gain a wider audience for your pet theories which have nothing whatsoever to do with the very specific issues under discussion.

I have previously had to ban you from this forum.
If you post once more on this thread, I will ban you from PPRuNe entirely - not just from this forum.

If you think I'm bluffing - try me.

Heliport

[ali250]

Dennis,

About 18 months ago we replaced a suspect rear cluster on a later Schweizer 300 (G-GINZ). As you can imagine there were very few welders willing to do this job. However, once we overcome that hurdle I couldn't believe how easy the job was to do. The part was $1200 the rest was made up of one days labour, including the hire of the jig. The total bill was around £2,000. If we double this for replacing both clusters then I can confirm your estimate was spot on.

By you bringing the cost of this mod to the attention of the owners (and I know of 2 within our area). Maybe they might think their lives are worth at least this amount? I'm sure by the end of your campaign every potential Hughes 269/300 purchaser will know about these "thin wall clusters" and refuse to buy the aircraft unless this work has been carried out!

Bill

[Happy Landing !]

Dennis,

I know not an awful lot about the 300's. That said, I have followed your most frustrating situation from day one, with great interest and admiration of your persistance against the red tape and bureaucracy you/we seem to be up against.

It beggars belief that such an important safety issue can be cast aside, or swept under the carpet with a blatant disregard to the voice (s) of those who are fundamentally at the sharp end.

My belief is in this case "the tail SHOULD be wagging the dog" and not the other way round.

No other industry in this day and age, with Health & Safety, Public Accountability and Best working practices, would ever dare stoop so low for fear of serious reprisal.

Count me in.

Happy

[ShyTorque]

I am not qualified to fly this type of helicopter but speaking as an experienced helicopter (and to a lesser extent, fixed wing) pilot I cannot understand the stance of the CAA. They surely have a mandate to take whatever action is possible in order to prevent a recurrence of this catastrophic structural failure.

Having one man made a scapegoat is not the way to go, they are shirking their responsibility IMHO.

This thread is beginning to sound like the Mull of Kintyre Chinook crash in some respects. Blame an individual rather than address the wider problem.

Dennis, we haven't met but please accept my sincere condolences.

[Dennis Kenyon]

Thursday 13th.

I thought Rotorhead readers might like an update on the G-ZAPS accident, since I am not letting go of this safety issue until our CAA come to their senses.

I have always been a great CAA supporter believing that overall they get it right most of the time (in a difficult environment) But now I find myself in conflict with their decision. I attended the Belgrano this afternoon for an 'over sixty' stress ECG - and there framed at the entrance stood the logo we know so well. SAFETY IS NO ACCIDENT.
I had to stop and think as I parked the car. Do the anonymous guys/engineers who made the decision to not accept the AAIB recommendations also stop to read it !!

As a former AOC holder, I know full well the lengths my CAA OPS Inspector would go to in ensuring I ran a safe operation, and boy would he pick up as much as a thirty minute overun on my FTLS (flight time limitation scheme) or a lift off at 20 lbs fuel load below my approved minimum. I considered this as 'nit picking' but always decided that if my operation was made more safe, then such inspections were welcome.

But now we have a glaring safety issue. One where the FAA/CAA decision not to accept an AAIB recommendation HAS ALREADY RESULTED in a further accident. Absolutely and totally and without argument an unacceptable situation. I believe the CAA may well have cause to regret their inaction, certainly in the USA/FAA case where the lawyers are already sharpening knives following the Tulsa November 2002 accident.

As earlier advised, I have instituted the first prod towards legal proceedings. The Sussex paper - 'Evening Argus' has run a prominent news story on the case which I am hoping will be taken up elsewhere on a national basis.
Mr Gerald Howarth M.P. is behind me and may decide to take political action. So gentlemen, I have set the ball rolling and rather like Saddam Hussein, the CAA only have to make one small decision to avert a war. Please issue the mandate for cluster component change the AAIB are recommending.

Thanks to my friends and colleagues in the industry for their words of support. At times I feel like going to bed and forgetting the whole sodding thing. Then my lost son tells me I have to do something for him. And I am doing just that.

Dennis Kenyon.

[Dennis Kenyon]

From Dennis Kenyon.

Just a small update on the G-ZAPS position.

Earlier, doubt was expressed that the MP route might not achieve anything. So to tell you all, that Gerald Howarth M.P. (shadow defence minister) is in correspondence with me. He advised the matter is being taken up with the CAA. I will keep pprune advised of any significant developments.

Pat Malone of the AOPA mag is running the piece in next month's issue.

I have submitted an article to Flight and will ask Ian Seager (Flyer)and Dave Calderwood (Pilot) to do something. For whatever reason, the CAA are (rather like Tony Blair) entrenched in their
position - and as I have said before, the only remedy I (and the industry) have is through the media, which for all their faults and assets, will bring the issue to the public's attention.

I will keep writing.

Just a smallie for Genghis - is it lawful for me to leave the cluster on my Schweizer 269, G-DRKJ unpainted - just varnished. I know that I couldn't detect the crack on G-ZAPS through the paint and a little dirt. So that is MY FIX. I hope not wrong.

A big thanks to all my pilot and other friends who are with me on this issue.
DRK





[

[Genghis the Engineer]

Answering the question directed at me:-

Just a smallie for Genghis - is it lawful for me to leave the cluster on my Schweizer 269, G-DRKJ unpainted - just varnished. I know that I couldn't detect the crack on G-ZAPS through the paint and a little dirt. So that is MY FIX. I hope not wrong.

Since you've asked the question publically, I have to publically say I've no rotary wing maintenance qualifications - any RW engineering training I have is on the design and certification side, so no idea about the specific legalities I'm afraid.

Having said that, I have regularly in my certification work refused engineering designs specifically because surface treatments were used in fatigue critical areas that I considered had significant potential to hide cracking or (equally seriously) corrosion.

There are specific aircraft surface treatments available that will crack with the substrate (underlying material) and I'd certainly recommend you check what's (a) available, and (b) approved for your aircraft.

Incidentally, dry dirt is a wonderful crack detection tool. It is amazing how often fatigue cracks show up in the surface muck as lines of different colour, long before the crack is visible to the naked eye. I'm a great believer in a qualified person inspecting an airframe immediately before it's washed.



In a wider context

Mr Kenyon. Like many people I've lost friends and colleagues in aviation accidents; however, despite that I can only guess at the personal impact that the loss of your son has had. Could I take an opportunity to express my respect for your approach and attitude, when a lesser man might have simply walked away and tried to forget, or simply descended into vitriol.

If I can be of any assistance in what you're trying to do, not as a rotary wing expert - which I'm not particularly, but as somebody who is a CAA whole-aircraft design signatory and thus familiar with the processes, competencies and personalities that surround this whole thing, as well as a degree of professional credibility as an aeronautical engineer then please drop me an Email.

We all have to detail with the CAA, and this underlying attitude, competence (or lack thereof) and approach needs knocking on the head before it further impacts other areas, as much as for the safety of Hughes 300 crews.

G

[B47]

Nothing, but nothing, is more important than this issue.

The hypocrisy and inconsistency of the CAA's position can be well illustrated by the AD issued last year to all Bell 47 operators. One or two cracks were found in main rotor grips (to the best of my knowledge the first in over thirty years on several thousand B47s) and the life of the component was halved, effectively grounding all B47s that had grips over TSN 1200 hours. It necessitated the replacement of such grips at a cost of £8k a set and caused a world-wide shortage in the process. Leaving aside the arguable justification for this AD, my point is that the practical evidence of this problem i.e. one or two ships, was substantially less in number than those 269s known to have had the clevis lug cracks.

Why not the same reaction from the CAA to the 269 problem that if ignored will result in deaths on average every four years?

I have no useful knowledge of the 269 but perhaps the B47 illustration may be of use to illuminate the CAA's ridiculous stance on this. It's shameful and their desperation to avoid direct criticism over what we all understand to be the purpose of a CofA is transparent.

[Dennis Kenyon]

For Genghis - from Dennis Kenyon.

Thanks indeed for your notes and advice. Without an engineering background, I just figured that I'm more likely to eyeball a crack if the metal is there to be seen. But I appreciate that's simple pilot talk. I'll check elsewhere for the proper position. (not the CAA I'd now have to say)

But to ask a view. Sir - how do you personally see the CAA's position.

Am I missing something when I suggest they have been 'grossly negligent' How else can it be when a decision 'not to act - is followed by a further fatal. Paul Kenward failed to consult the proper documentation and was placed on a manslaughter charge. So why don't I have a similar charge levelled at the CAA.

I have said previously that I am trying to keep emotion out of this thread, but the bald truth of this situation remains.

Had the CAA acted in the early days my son would not have lost his life in a totally avoidable accident. In March 2000 I made this statement: "G-ZAPS was the eighth left hand clevis fatigue failure accident and if the CAA or FAA do not act there will be a ninth." I feel nothing but anger that my words turned to reality in November 2002.

I can only repeat, this is a totally unacceptable situation. Please can we hear from others who feel the same or please justify the reverse position.

Sincerely to all.

Dennis Kenyon.

[Head Turner]

I am a newcommer to this forum and having read through all of this file I can only hold my head in my hands in dispair.

Here is an obvious problem that shows yet again the awfulness of the British aviation regulating authority, CAA.

The CAA I understand are amongst many things, mandated to upholding the rules and regulations (the police of flying) and authorising aircraft and associated systems for safe operations(certification).

They are lightening quick to do the police business because I guess it must be easy money. There is a rule which has been broken, go to court, judge gives ruling, end of story. Here the CAA plays the proscecuter.
Now in this case they are the accused or at least it appears so, and they don't like to go to court and be judged.
It takes a brave man to stand up and say 'I'm sorry, I was wrong, and I will make amends'

Or have I got it wrong?

[John Bicker]

As someone from well outside the UK it is apparent that several things stand out.
I am surprised that the CAA allows you to maintain a helicopter to LAMS. I thought that this was intended for older fixed wing types which had no manufacturers maintenance schedule.

The SIN on these clusters has been around since about 1975 and an FAA AD was first issued about the same time.

I would doubt that any of this scenario would have occurred had the aircraft been maintained in accordance with the Instructions for Continuing Airworthiness as required by a Type Certificate which would have included compliance with SIN's. This may have also precluded the attempt at a weld repair as the procedure is not documented.

It is tragic that this "problem" which is well known in the 300 "community" was not controlled accordingly.

Just because something is legal does not necccessarily mean it is safe. As to a CAA surveyor determining airworthiness of an aircraft I am afraid that is not and will never be the case. The LAME determines airworthiness, a surveyor can only establish compliance by the LAME with current regulations. You will never see an Airworthiness authority actually release an aircraft to service.

I have always been amazed at the attitude that a "fresh" 100 or annual is thought by some to be a guarantee of safety or continuing airworthiness until the next scheduled inspection. Nothing could be further from the truth.

[Genghis the Engineer]

Whilst a LAME does indeed release an individual aircraft as fit for service, a CAA surveyor (by which I mean DLS) releases the aircraft TYPE as fit for service. An aircraft can be superbly maintained, but if the basic design is deficient it is still not safe. (And of-course, the converse is also true).

In other words, both must be got right.

G

[t'aint natural]

John: You say: 'It is tragic that this "problem" which is well known in the 300 "community"...
I'm not sure it was well-known in the 300 community. I've spoken to a number of high-time 300 pilots, and none of them knew of it until the manslaughter charge. As to engineers, Paul Kenward certainly had an imperfect grasp of it.
On the FAA AD back around 1975, I haven't been able to trace that. Do you have more information?

[Cyclic Hotline]

FAA AD 2001-25-52 (reproduced in the AAIB report) supercedes FAA AD 76-18-01, which I presume is the original AD that John refers to.

Dennis, in reference to your question about leaving the affected welded area visible, this is a common practice on other types that require frequent reccurring inspection. We generally reprotect the area with aerosol spray clear lacquer. It is not uncommon to see highly stressed areas of airframe devoid of any painted finish, to facilitate easy and thorough inspection.

Although you should confer with your maintenance provider and approved maintenance instructions, it is unusual for any manufacturer to specify a paint or other finish for a part (there are exceptions; blades, etc.), other than a specifically prohibited type of finish. What you are proposing is a very good solution to ensuring the continued Airworthiness of the affected part.

I am very sorry about what happened to your son. I am still digesting the remainder of the report and its proposals.

[John Bicker]

The current AD is here: http://www.airweb.faa.gov/Regulatory_and_Guidance_Library/rgAD.nsf/WebCurrentADFRMakeModel/EC92FEAC0A05FB6886256BA40057C3E6?OpenDocument

2001-25-52 SCHWEIZER AIRCRAFT CORPORATION: Docket No. 2001-SW-58-AD. Supersedes 76-18-01, Amendment No. 39-2707, Docket No. 72-WE-23-AD.

Applicability: Model 269A, 269A-1, 269B, 269C, and TH-55A helicopters, with tailboom support strut (strut) assemblies, part number (P/N) 269A2015 or P/N 269A2015-5; tailboom center attach fitting, P/N 269A2324; or with a center frame aft cluster fitting, P/N 269A2234 or 269A2235, installed, certificated in any category.

Note 1: This AD applies to each helicopter identified in the preceding applicability provision, regardless of whether it has been otherwise modified, altered, or repaired in the area subject to the requirements of this AD. For helicopters that have been modified, altered, or repaired so that the performance of the requirements of this AD is affected, the owner/operator must request approval for an alternative method of compliance in accordance with paragraph (d) of this AD. The request should include an assessment of the effect of the modification, alteration, or repair on the unsafe condition addressed by this AD; and if the unsafe condition has not been eliminated, the request should include specific proposed actions to address it.

Compliance: Required as indicated, unless accomplished previously.

To prevent failure of a strut clevis lug (lug) on a center frame aft cluster fitting (cluster fitting), rotation of a tailboom into the main rotor blades, and subsequent loss of control of the helicopter.....

Open the pre-amble to see the reason's for the AD.

Here is the current AD pre-amble:Preamble Information
AGENCY: Federal Aviation Administration, DOT.

ACTION: Final rule; request for comments.
SUMMARY: This document publishes in the Federal Register an amendment adopting Airworthiness Directive (AD) 2001-25-52, which was sent previously to all known U.S. owners and operators of Schweizer Aircraft Corporation (Schweizer) Model 269A, 269A-1, 269B, 269C, and TH-55A helicopters by individual letters. This AD supersedes an existing AD that requires inspecting and modifying or replacing, if necessary, the aluminum end fittings of each tailboom support strut (strut). That AD also requires inspecting the tailboom center attach fittings and center frame aft cluster fittings for damage, and if damaged parts are found, replacing the damaged parts. This AD requires inspecting and replacing, if necessary, each strut clevis lug (lug) on each tailboom center frame aft cluster fitting (cluster fitting), certain strut assemblies, certain tailboom attachments, and certain frame aft cluster fittings. Modifying or replacing each strut assembly within a certain time period and serializing certain strut assemblies are also required. This AD is prompted by an accident in the United Kingdom involving the in-flight structural failure of a Schweizer Model 269C helicopter. The actions specified by this AD are intended to prevent failure of a lug on a cluster fitting, rotation of a tailboom into the main rotor blades, and subsequent loss of control of the helicopter....

If you read the preamble you will see that the AD is the same as the one issued in 76-18-01 except for the requirement to inspect the fittings within 10 hours TIS and precludes certain other requirements. This was done at the behest of the UK CAA. This cluster problem has been known since 1975 at the minimum.

DATES: Effective May 8, 2002, to all persons except those persons to whom it was made immediately effective by Emergency AD 2001-25-52, issued on December 14, 2001, which contained the requirements of this amendment.

This AD also covers this problem: 88-17-04 SCHWEIZER AIRCRAFT CORPORATION (MCDONNELL DOUGLAS HELICOPTER COMPANY, HUGHES HELICOPTERS, INC).: Amendment 39-5975. Applies to helicopter Models 269A, TH-55A (all S/N's operated in civil use), 269A-1, 269B, and 269C, certificated in any category. (Docket No. 88-ASW-26)

Compliance is required as indicated, unless already accomplished.

To prevent possible loss of the tail boom support strut and tail boom which could result in loss of the helicopter.........

I have read the report and don't see where the regulators are at fault. Clearly from the report the AD simply was not complied with and an illegal unsatisfactory repair was performed and the net result was as described in both AD's. I would suggest that certain people read the aviation definition of "Acceptable" and "Approved". Acceptable information or data is able to be "accepted" and possibly approved and so is therefor not "Approved" data.

It was also clear in the report that several other aircraft were found to be affected by this AD but were not in compliance by the statement that "paint and other grime precluded any visual inspection being able to be carried out".

What's wrong with this picture? Or is it something geographical or cultural?

No I do not work for any manufacturer, authority or other similar entity. I am an LAME of 20 odd years and this is my profession that others are possibly not taking much care with.

Apologies for the long winded post but some may have trouble locating the pertinent info.

[Genghis the Engineer]

Sorry to sounds dense, but...

(1) Is it not part of the problem that this FAA AD hasn't been mandated by UK CAA? Or am I missing something?

(2) I think we all accept that the LAE in this case was still negligent. How negligent, and whether his punishment was appropriate is a separate question. Given that, would the changes to procedure, proposed by AAIB, and rejected by CAA, not have given a much better chance of his failure of procedure being picked up and prevented from causing this tragedy?

G

[John Bicker]

Genghis,

1/ I am not that familiar with the UK CAA requirements.
Do they have a web site like other authorities, i.e. FAA, CASA (AUS), NZCAA etc. where the AD Schedule is listed?
If so I can't find it.
Surely the maintenance schedule in the UK mandates the use of the manufacturers maintenance data or Instructions for Continuing Airworthiness. This would include the SIN's which are MANDATORY and cover everything in the AD's most of the time.

The level of maintenance as required by the authorities will always be the "minimum" standard.

2/ Maybe the term LAE should re-include the term "maintenance" to become LAME. This might preclude the perception that we are engineers which in most cases we are not. What made the LAE in question think he had any idea that he could just dream up a repair scheme?

Of note, was this LAE responsible for the lack of maintenance on the other aircraft found not to comply? If not those responsible for these other aircraft should be held to account and possibly prosecuted the same way. There is a clear case.

Most of the items in the AAIB report and CAA response are possibly relevant and you are right you can be pedantic and address each issue but the facts simply remain.

For whatever reason an AD and Mandatory Service Instruction Notice were not complied with.
An "unapproved" repair was carried out for whatever reason.
The component failed as it was known to be capable of. It was obviously not known by all concerned. The net result was as is known.

How long has this persisted? Relying on the regulatory authority standards is no guarantee and is, I will say it again, a minimum standard. Is there a culture of minimum standard = minimum cost? More than 3 people appear to have paid the ultimate cost.

[Genghis the Engineer]

UK CAA's website is at www.srg.caa.co.uk

Up to a point, it's not a bad website. However, one of their more bizarre balls-ups of recent years was when CAA privatised it's publications department (now known as Documedia). When they did this, stacks of airworthiness data was surreally transferred to Documedia's copyright. So, being now a commercial company, they make you pay for this data, and will only provide printed copies at a price.

So, BCARs, STCs, AANs, ADs, MPDs, TCs, and various other documents are not readily available to the casual investigator. This is despite many of these still being CAA copyright, the excuse that some of these aren't seems to be used for not giving us any of this data online. Of course, it helps them keep using this dreadful phrase "the authority must be consulted", giving them the right to keep changing goalposts, rather than making policy clear, public and universal.

Regarding implementation of overseas ADs, the requirement for compliance isn't automatic. What normally happens is that CAA is notified of an overseas AD, reviews it, and then decides whether or not to issue it's own. This case, if I read it correctly, is rather odd. AAIB issued the same recommendation 2001-45 to CAA and FAA. FAA have implemented it, CAA haven't.


Regarding LAE/ LAME issues. The UK has a particular problem over the term Engineer which just about everybody feels is theirs exclusively. But you are quite right, somebody qualified to do maintenance, hasn't necessarily been equipped to make those sort of decisions (and of-course, vice-versa). Separately to that, much of UK aviation tries to work in a "no blame culture". In that, most Brits would consider the appropriate treatment for the negligent LAME would have been suspension and retraining / requalification, not emprisonment. AAIB does not allocate blame, it recommends ways to make things safer, an approach we're quite happy with - but at odds with many other countries (and in this case at odds with UK CAA). Whilst you are right that there probably are grounds for similar prosecution of other LAME where other faults have been found, to most of us here the treatment of the chap who serviced G-ZAPS was the anomaly.

And as to minimum standard = minimum cost, I think this occurs everywhere. I've seen it far worse in the US than anywhere in the UK, but let's face it, accountants rule the roost and also few customers will go for the safer operator, they'll go for the cheaper. Which is exactly why safety measures must be mandatory - when nobody is allowed not to comply, it ceases to be a commercial issue.

G

[t'aint natural]

John: I'm getting my part numbers mixed up here.
The original version of the AD required periodic inspection, and replacement if cracks were found.
Mr Kenyon's case is that it should have specified replacement with the redesigned "thick-wall" cluster, rather than allowing another thin-wall cluster to be installed.
Schweizer specified replacement with a thick-wall cluster, but the FAA (and the CAA) did not.
It's clear that the inspection regime didn't cure the problem, as people kept on being killed regularly for decades thereafter, and are still dying.

[Cyclic Hotline]

The FAA AD is automatically mandated, as the basis of all certification of this product is based upon the original (and current/revised) FAA Type Certificate Data Sheet (http://www.airweb.faa.gov/Regulatory_and_Guidance_Library/rgMakeModel.nsf/CurrentModelsbyTCHolder/9875D09D5E203F1286256C6800666987?OpenDocument) (TCDS) and any changes mandated to that product via Airworthiness Directive. This does not preclude any other Airworthiness Authority from issuing their own AD (in the case of the CAA) or through other mandatory medium, to address an airworthiness issue that they believe compromises the safety or airworthiness of the product whilst operated under their jurisdiction and oversight; which could include mandating SIN's, SB's, etc should they determine this would be beneficial.

The AAIB report does address the matter of origination, determination and implementation of changes to the basic Airworthiness basis of the product in paragraph 2.3 of their report.

Note: Although the above SINs and SB B-263 were stated to be 'mandatory' by Hughes and Schweizer in the text of these documents, only the relevant regulatory agency has the authority to make such documents legally 'mandatory' and thus binding upon the owners/operators of aircraft. In the case of SINs N-217, N-220 and N-221, these therefore only became legally mandatory when the FAA issued AD 88-17-04. The current system thus relies heavily upon the regulators recognising the importance, from a flight safety standpoint, of certain inspections and modifications recommended by manufacturers in order that associated Airworthiness Directives can be issued to ensure compliance, as far as legally possible.

Schweizer stated the following in this context:

'Schweizer Aircraft Corporation strongly emphasises that Red Border Service Notices and Service Bulletins are mandated by SAC and must be complied with as specified within the directives. Compliance with FAA AD Notices is required by law. It is the operator's responsibility to ensure that all applicable Red Border Service Notices, Service Bulletins and FAA AD Notes have been complied with prior to the first flight of the day (FAR 91.403). Any pilot who operates a 269 Series Helicopter against which mandatory Service Notices, Service Bulletins or FAA AD Notes are outstanding, does so at his own risk.'

As the report correctly states, the determination and classification of any publication to be mandatory, is only deemed so by the mandate of the certifying authority. A manufacturer does not have the ability to determine mandatory action to a certificated product, without regulatory oversight and approval by either an AD, change to the TCDS, or directly referenced data contained within the TCDS. An AD is mandatory, but a SIN, SB or whatever else is not unless specifically countenanced by the authority it is operated under.

The FAA Airworthiness Directive Manual (http://www1.faa.gov/certification/aircraft/ad_manual.rtf) provides a complete reference to the process and system for the issuance of AD's.

As regards the availability of CAA documentation and reference materials, I think this is an absolutely disgraceful state of affairs. Quite how aviation safety can be promoted and served by a total lack of transparency to source documentation (and the myriad of means of conveying this information) defies my simple logic. In contrast, refer to the basic FAA website (http://www1.faa.gov) where every single piece of documentation we have discussed is freely available, along with every pre-requisite regulatory and interpretive source required to comprehend the system and the contents contained therein.

[Dennis Kenyon]

From Dennis Kenyon.

Sirs,

I'm happy to see some very qualified engineers taking part in this discussion. But can I reduce the matter to simple terms. The constant quoting of various AD's SB's etc, is all very well, but the bones of my taking issue with the CAA is simple.

One accident is happenstance, a second may be a coincidence, but when a third occurs something is going wrong.

My contention is that following the third accident a more responsible and aware authority, (be it FAA or CAA or uncle tom cobley) should have accepted the fact that the flow of AD's, SB's being released etc, while being a proper course of action - WERE SIMPLY NOT WORKING.
In such circumstances the obvious fix was to mandate the fitting of the re-designed (dash 3) clevis cluster. Had the FAA/CAA done this, my son and others would not have lost their lives.

Then when the AAIB formally recommended the mandating of the
later component, it is totally and absolutely unacceptable for the FAA/CAA to refuse. So an eighth accident occurs and another pilot loses his life.
Do I now have to formally advise the CAA that if another fatal occurs, I WILL RAISE a manslaughter charge against the individual responsible for the CAA's decision. Perhaps that might concentrates someone's mind.

Paul Kenward made a mistake relying on memory and the weld work in front of him. Negligent yes, but had the regulatory authorities acted properly when the problem became apparent, he would not have found himself in that invideous position. It is significant that the AAIB found six 'causal factors' for the accident, one directed to the engineer, and two to the CAA.

Also note that of the nine accidents I have tracked down, only one, (G-ZAPS) was the subject of a weld repair. One might even argue, (although not backed up by the metallurgist) that Kenward's weld repair actually prolonged the cluster life which was on its way to a failure anyway.

Please continue the contributions which I am following avidly.

Dennis Kenyon.

[John Bicker]

Cyclic Hotline,

I beg to differ on your opinion that SIN's etc. are not mandatory.

Given that the aircraft maintenance statement declares the schedules to be used in maintaining an aircraft normally involve use of the Instructions for Continuing Airworthiness (read Maintenance Manual) as required by the Type Certificate, the SIN or SB's are part of that data. Where the SB or SIN or whatever terminology is used states that it is mandatory this is the case, it is not optional. The aircraft is declared to be maintained IAW data that is in the statement and that shall be the case. Where the authority comes in to play is that certain items outside this criteria having an effect and which may not be an SB or SIN is their perogative.
I don't know where the "optional" SB issue came from. On the 269 it starts with the Basic HMI and then the model appendixes and incudes all other pertinent data of which SB's form a part. Granted an AD is the definitive statement, but just because there is no AD does not mean a mandatory bulletin may not be complied with. It is part of ICA of the TC.

It appears that this accident is possibly attributed to a broad systemic misunderstanding of what is required.

That's the way I've interpreted things from day one - I'll accept that I may be wrong and will stand corrected if it is the case.

[John Bicker]

To add:

Transport Canada agree's with me.

AIRWORTHINESS NOTICE - B055 EDITION 1 - 4 JULY 2000



SERVICE BULLETIN COMPLIANCE



The purpose of this notice is to clarify to Aircraft Maintenance Engineers and operators the need to comply with manufacturers’ service bulletins, service letters, etc.Ê



Leaving aside publications made mandatory by airworthiness directives or equivalent mandatory notices issued by the airworthiness authority responsible for the initial type design of the product, manufacturers’ publications may be considered under three general headings:



(i)ÊÊÊÊÊÊ Recommended methods and practices for the performance of work;



(ii)ÊÊÊÊ Recommended modifications, inspections, and times between overhaul;





and



(iii)ÊÊÊ Mandatory actions established as part of the type certification process.





Although a single publication may in practice deal with more than one topic, in this notice each group will be dealt with separately:



1.ÊPublications specifying methods and practices for the performance of work



Publications under this heading may be considered as amendments to the instructions for continued airworthiness (ICA).Ê As such, pursuant to Canadian Aviation Regulation (CAR)Ê571.02, they constitute one of three acceptable sources for such data (the other two are equivalent methods and standard industry practice).



2.ÊPublications recommending the incorporation of modifications, the performance of inspections, or times between overhaul



Except where otherwise specified in Std 625, Appendix C, compliance with publications dealing with these topics is optional.Ê However, aircraft owners have a duty to be aware of the contents of these publications, and to evaluate the need for compliance in light of their own circumstances.Ê Commercial operators should have a formalized process for conducting this evaluation, as part of the evaluation program required by CARÊ706.



3.ÊPublications providing information regarding airworthiness limitations established as part of the type certification process



On occasion the communication of airworthiness limitations, such as component life limits or maintenance requirements is accomplished by referring to service bulletins or equivalent notices.Ê When used in this manner the content of the bulletin is a condition of the type certificate; and, except where Transport Canada has granted approval to deviate, compliance is mandatory.



The above explanation should assist AMEs and operators in deciding on the need for compliance with service bulletins, service letters, etc.Ê Further guidance in individual cases may be obtained from Transport Canada Centres.

[t'aint natural]

Most of this is irrelevant.
There is only one question to be answered.
Why is the CAA refusing the AAIB's urgent request to mandate the fitting of the safe cluster?
Is it just loss of face?
Or are they worried about legal action?

[Dennis Kenyon]

From Dennis Kenyon.

Gentlemen,

Just another small pint to place in the pot.

Today I attended the CAA Display Pilots seminar at Cranfield. A good day of course and its always interesting to exchange views with other professionals dispaly pilots.

But when the topic of display safety came up, I was intrigued to hear the CAA point out that one of their targets was to spot, 'trends' Yes of course and we all agreed.

But where was any effort made to spot a 'trend' during the previous and continueing occurrence of clevis cluster component fatigue failures to the Hughes 269's ?? Other than to issue more 'pieces of paper'

Trailing the history of previous failures - these extend over a thirty years period, but as follows.

1972 G-AWVL, Ser No 0234 England.
1974 JA-7552 Ser No 0438 Japan.
1974 ZK-HEV Ser No 0351 New Zealand

Then a 16 year gap to ...

1990 N403SD Ser No 071 USA
1991 N8955F Ser No 0172 USA
1993 N7032U Ser No 0327 USA
1994 N64732 Ser No 0341 USA
2000 G-ZAPS Ser No 041 England
2002 N8885F Ser No TBA USA

Is there anyone out there who has any doubt that a tenth will happen ? (unless the FAA/CAA act now. There is also the possibility of other unrecorded failures.

Again many thanks for the fund of professional advice coming in.

Dennis Kenyon.

[Heliport]

There's a very good article by Dennis Kenyon in this month's General Aviation the UK AOPA journal.

(The journal has recently changed publisher and is much improved.)

[Fair Flair]

I see this subject is waning which is a little sad since the subject and the accidents are still happening.

The CAA are entrenched in their outmoded and ancient thinking and never seem to have heard of risk management or the general principle that it is always preferable to 'engineer out' accident risks.

We are now up to nine clevis cluster failure accidents, and gentlemen, believe it or not, just a few days ago - a further mid air break up has occurred in Australia. It seems highly likely from witness statements that the circumstances replicate the known failures, which will bring us to a total of ten accidents. How many corpses do the FAA and CAA need to see before mandating the remedy that is staring them in the face.

I despair .......

[Thomas coupling]

Dennis,

Am I missing something, here...
Why are operators / owners waiting for the authorities to do something?

Why don't they simply carry out their own policing of this fault and circumvent the whole issue?
If I owned / operated one of these, it would have been repaired /grounded /scrapped, ages ago:confused: :confused: :confused:

[Qualityman]

Dennis,

Though we don't stay in touch as often as we should, our thoughts are always with you. I share the same anger frustration and absolute disbelief in "the System" (what B****y system!) as all the postees above.

Is there anything that we as operators can do to help? I'm sure just from reading the posts above that the support you would get from other schools and AOC companies would be phenomenal. Surely there must be some way that we can unite to make our voices and opinions louder.

I'll help in any way possible, just as Bill has already offered, and I'm sure that others you mentioned in your earlier post must be willing to help.

Please let me know if there is anything we can do.

with my greatest respect as always,

Paul Curtis.

[Heliport]

A f/w engineer friend makes the following comments:

Recommendation 2001-80- Rejected by CAA
AAIB recommend that general guidance is issued about weld repairs to aircraft. The obvious place for this would be CAP 455 (airworthiness notices). Taking my copy from the shelf I see similar guidance on painting, fabric covering, installation of fireproof fabrics, use of MOGAS and various other issues. The omission of welding from there seems like an anomaly, so no, I don't accept CAA's position.

Recommendation 2001-81- Rejected by CAA
AAIB recommend that welders should be required to check that a repair is legal before issuing any paperwork on it. Seems like commonsense to me, but if commonsense has failed, regulating it seems sensible - so I don't accept CAA's position.

Recommendation 2001-82- Partially accepted by CAA
I don't know how partial CAA's acceptance of this is, but the proposal is to introduce a mandatory welding certificate of conformity. Since the rest of the engineering industry brought this in through the EN728 welding fabrication standard several years ago, compliance in full should be a doddle - just latch onto the European standard and provide some paperwork that will interface with it. How CAA proposes to comply, I don't know.

Recommendation 2001-83- Partially accepted by CAA
CAA partially accepted a recommendation that they should remind LAE and maintenance organisations not to do any work on an aircraft without checking the paperwork first. Frankly, a trivial recommendation and compliance in any form is equally painless.

Recommendation 2001-84- Rejected by CAA
CAA should carry out a survey of operating experience overseas before approving a foreign type and ensure that any areas that have caused problems are looked at deeply. Whilst I know from personal experience that this evidence is very hard to obtain, CAA have done this before anyway - it was their grounds for refusing to allow any Bede-jets to fly. I struggle to understand why this, which is only good practice, can't be included in their working procedures - again I'm at odds with Gatwick.

Recommendation 2001-85- Rejected by CAA
CAA should clearly define who is allowed to carry out and sign for a DI. And CAA have a problem with this? Whilst the current situation is fairly clear (a type-rated pilot or a type-rated LAE) if that isn't enshrined in regulation is jolly well should be. Again, I think CAA is wrong.

Recommendation 2001-86- Wholly Accepted by CAA
CAA have accepted that only approved and current checklists should be used for flying training and testing. At first sight this seems reasonable. However, extended across the entire CofA aircraft fleet this means that (for example) anybody training on an R44 with a modified checklist based upon the POH but adding in functionality checks on the specific nav-gear needs to get formal approval for their FRCs, at considerable cost.
I actually would have preferred to see partial acceptance by CAA of this, along the lines of a regulation that all checklists must as a minimum include what's in the current and amended POH. Saves grief for CAA, saves money for the flight school, makes life safer for the student pilot.

Recommendation 2001-87
Directed at Schweizer, recommending a specific inspection of the hub for cracks in the POH. So, clearly not relevant directly to CAA.

Recommendation 2001-41- Rejected by CAA
AAIB identified that several unapproved weld repairs in a safety critical area had occurred, and therefore recommended an AD mandating immediate inspection of the fleet. This is standard practice on any aircraft class, and seems nothing but common sense to me. So, again, I don't agree with CAA's position.

Recommendation 2001-45- Rejected by CAA
AAIB recommend that a component identified as having significant potential for catastrophic failure should be compulsarily replaced. Without seeing the design engineering reports for this, I am reluctant to comment on how bad the old one was, and how good the new one. But, I would merely comment that CAA have before now grounded significant (30+) sized fleets on me for similar reasons, and on one occasion without CAA actually seeing the engineering reports first.
Perhaps AAIB should have directed this to Schweizer recommending a mandatory SB?

Recommendation 2001-88- Rejected by CAA
AAIB have recommended that CAA review JAR-145 to require the documentation retention practices to be in-line with UK ANO. Well, if I worked for CAA I'd reject this, but not because it's a bad idea. In the current environment, JAR-145 is going to be replaced with ECAR-M and it's companions in the next year or two. Really, this was a null recommendation because by the time CAA had complied, neither JAR-145 nor ANO will exist any more - or at-least not in their current form. I hope that CAA rejected it on these grounds, and has at-least undertaken to pass this specific concern to the EASA secretariat or ECAR-M drafting committee.

Recommendation 2001-89- Rejected by CAA
AAIB recommended withdrawl of LAMS for this series of helicopter, and CAA didn't like the fact. Well, in my opinion LAMS should NEVER have been used for anything but a reference source for constructing type specific schedules. No two aircraft types are identical, so in my mind having identical maintenance schedules for each type never made any sense. If CAA had accepted this it would clearly have made their lives much harder since it would be a nail in the coffin of LAMS, and many new schedules would need specifically approving. But, in my opinion, the safety benefit, across the GA fleet (fixed and rotary) would be well worth it.
You don't have a generic "light aeroplane" or "light helicopter" operators manual do you?

Recommendation 2001-90- Rejected by CAA
This is really only an extension of 2001-89, adding further detail to how to sort out the undesirable situation of generic maintenance schedules. In rejecting this, CAA are only being consistent.

Recommendation 2001-91- Rejected by CAA
Lets get this straight. AAIB have recommended that if an aircraft seat requires an upper torso restraint (according to the ANO), and there isn't one, the seat should be rendered unusable (which lets face it, only means removing the laptstrap and fitting a placard saying "baggage compartment only"). And CAA rejected this, despite about 2 years ago issuing an MPD (equivalent to an AD) mandating rear UTR for 2,500 flexwing microlights following a similar AAIB recommendation.
Not only does it surprise me that CAA aren't prepared to mandate what is only a bit of cheap safety common sense, but it is incredibly inconsistent with what they've done before.

So, in summary, I'm not 100% in disagreement with the CAA's viewpoint, some of their decisions I agree with. But, I'm of the opinion that about 85% of their position is ill-thought-out and unsustainable under rigorous scrutiny. Including, please note, that I don't agree with their full acceptance of 2001-86.


I think occasionally as Engineers we forget that much of our conversation is gobbledook even to other professionals in our own industry. Let me try a plain English summary and if any of my colleagues disagree, I'm sure they'll say:p

AAIB has investigated the G-ZAPS accident and recommended how to prevent a similar accident. The recommendations had two parts, technical (how to stop this happening to the same aircraft type) and procedural (how to trap failures to do things properly before they cause an accident in any type).

CAA has rejected the majority of all these recommendations. Their arguments rest on the fact of negligence on the part of Paul Kenward. The professionals here, who have reviewed the arguments do not agree. Our collective view is that although negligence is clearly serious and needs to be rectified, the airworthiness system must be robust enough to deal with the failure of any one part - be it mechanical or human - before a fatality occurs. In that, we all seem to disagree with most of CAA's position.


I'm somewhat out of my professional training now, but I'd like to make a comment about Mr Kenyon's manslaughter point. If I'm wildly out, perhaps a legal professional could set me right.

CAA's system divides the airworthiness decision making process between many people and departments. This makes it very hard to point the finger at a single responsible person - something that corporate manslaughter laws require. A proposed corporate killing offense would rectify this, but is not yet on the statute books.

I think you would be within your rights to demand that CAA name the manager responsible for the decision not to rectify this problem earlier, and not to implement AAIB's recommendations. I imagine that you will be met by a refusal, but this refusal in itself would be valid grounds then to take the issue to ministerial level or the HSE. The latter is very aggresive in such cases, witness a handful of rail accident related prosecutions, and although their policy is to be hands-off in aviation cases, they are not bound by law to do so.

Plenty of food for thought there.
Any comments?

Heliport

[t'aint natural]

Thomas Coupling:
You are missing something.
Until Dennis Kenyon started making a fuss, few operators knew this problem existed.
Depite all the self-righteous twaddle from the CAA about the promulgation of this, that and the other, it simply wasn't registering until Kenyon started shouting from the rooftops.
I've spoken to four UK type operators and all of them say they had no idea this sequence of accidents had occurred. The accidents happened over a period of 30 years in various parts of the world, so that's understandable.

[Shawn Coyle]

A comment about checklists...

Recommendation 2001-86- Wholly Accepted by CAA
CAA have accepted that only approved and current checklists should be used for flying training and testing. At first sight this seems reasonable. However, extended across the entire CofA aircraft fleet this means that (for example) anybody training on an R44 with a modified checklist based upon the POH but adding in functionality checks on the specific nav-gear needs to get formal approval for their FRCs, at considerable cost.
I actually would have preferred to see partial acceptance by CAA of this, along the lines of a regulation that all checklists must as a minimum include what's in the current and amended POH. Saves grief for CAA, saves money for the flight school, makes life safer for the student pilot.

There is no requirement to follow the checklists, (if indeed there is a published checklist. The only part of the Flight Manual that is required to be followed is the Limitations section (it says it must be followed, the other 'approved' sections don't say this). Every time you put in an STC, you probably modify the checklist anyway, so you would have a very difficult time ensuring that the checklist itself was 'approved'.
Every time an inspector went on a flight test, he would have to troll through the Flight Manual and supplements and make sure the checklist in the aircraft contained all the necessary things - a real time waster.
Some older (fixed wing mostly) aircraft don't even have checklists- it's all done by placards....
For what it's worth.

[Genghis the Engineer]

There was a programme of great relevance to the legal issues associated with this on BBC Radio 4 this morning, specifically "Unreliable Evidence" discussing the issues of corporate killing / corporate manslaughter / health and safety negligence prosecutions.

The webpage for the programme is at http://www.bbc.co.uk/cgi-perl/whatson/prog_parse.cgi?FILENAME=20030422/20030422_0900_49700_45809_30 and it's repeated at 2130 local (2030Zulu) today. Non UK Ppruners can listen to it on the BBC website at www.bbc.co.uk/radio4 when it's on.

G