Maintenance Release destroyed in Benalla accident -ATSB Report

[Tee Emm]

The revised edition of the ATSB report on the Benalla GPS approach accident to the Cheyenne is now published. Very comprehensive indeed and lessons to be learned by those GA pilots who rely blindly on GPS. In discussing the serviceability of the accident aircraft the report had this to say:

"A duplicate of the current maintenance release was held by the aircraft’s approved maintenance organisation. Although the duplicate listed scheduled maintenance requirements, it did not include certifications for daily inspections and in-service defects that may have occurred subsequent to the issue of the maintenance release. Those items would only have been entered on the document that was destroyed in the accident".

Over the past forty years or more, where an aircraft has gone in and caught fire or is totally destroyed, the current maintenance release is destroyed and with it all evidence of recorded defects since the last 100 hourly inspection. The fact that a duplicate copy of the new maintenance release is kept by the certifying authority means nothing unless old defects were not fixed and carried over. Very rarely does that happen in GA aircraft.

While it is a fact that many pilots are reluctant to record defects in the maintenance release, nevertheless it is possible that certain defects may have had a bearing on the cause of some fatal accidents. This evidence is lost forever when the maintenance release is destroyed in the wreckage.

You would think that after all these years ATSB and CASA would have collaborated to ensure a copy of the current maintenance release is left at the point of each departure in order to preserve evidence in case of an accident. Isn't that why CVR's are mandated on larger aircraft - for the same flight safety reasons?

[OZBUSDRIVER]

YBLA FINAL REPORT

Time for another read.

JUST TO ADD- additional information about the possibility of dead reckoning navigation by the GPS receiver was provided. The ATSB investigation was reopened to examine that possibility and an amended report issued. That investigation found that dead reckoning navigation could not be positively established as there were inconsistencies between dead reckoning principles and the recorded radar data. Neither could it reconcile how a pilot would continue navigation by GPS with the alerts and warnings provided by the GPS receiver and the instrument indications. As a result of the reopened investigation, the ATSB issued a safety advisory notice alerting users of GPS navigation receivers to take appropriate action to ensure familiarity with dead-reckoning operation and any associated receiver-generated warning messages.

About says it all.

[the wizard of auz]

I always thought the MR was fire proof for exactly that reason.
I know the waxy ones are ink proof..... ya can't write on em.

[OZBUSDRIVER]

Interesting addition of a BASI report from 1997 right at the end of this report. Not in the original final report

The Bureau of Air Safety Investigation recommends that Airservices Australia review the provision of air traffic services to maximise the use of the currently available radar coverage particularly on routes used by regular public transport aircraft.

Hmmmmm, who would have got that put in this time around-

There is radar coverage available, inside and outside controlled airspace, which is not being utilised for the management of the national airspace. An increase in the use of this radar coverage by ATS would improve the level of safety for airspace users and fare paying passengers.

Now where have I heard this before?

Why was this report added this time around and not in the previous final report?

[OZBUSDRIVER]

Agree Wiz, certainly pen proof. Only way around this is the MR left in the office. How does that go if you get ramped?

Anyway, one of the directors testified there was nothing on the MR related to any defects when he last flew TNP the previous day.

[Wally Mk2]

I've never understood why an MR needs to follow a plane round day in day out. Can't see why an original carbon copy stays with the A/C for legal reasons & any maintenance issues be entered into the original MR upon returning to base. If the A/C suffers a defect whilst away from home base then the a tech recording log which stays with the A/C could be raised to satisfy the rule makers & the original MR has an entered defect recorded on it when next accessable.
This way a record of all previous & current defects allowable would be available for inspection for such events as the BLA case.
Planes don't crash on their own, they are put there by humans, one way or another.

RIP Kerry, I still think of those chats every time I fly into BLA that we had all those years ago down at the BLA bakery whilst we awaited the pax.
No GPS's then, well none that I had anyway.


Wmk2

[Charlie Foxtrot India]

I've never seen why it should be carried around for the very reason it would be destroyed when needed most as evidence; where I learned to fly you had a tech log that stayed at base, any defects were entered at the end of the flight, signed off when repaired or carried forward as "nil further" each flight. Made sense to me. Also had the advantage of being accessible to everyone even if the aircraft was away so you could schedule maintenance etc.

[the wizard of auz]

Yeah, but that was in Pomgolia. we do thing different here........maybe not better, but certainly different.

[peuce]

Scenario:

• MR stays at base ... nothing significant noted in it
• Aircraft departs for multi leg flight
• Aircraft gets defect on 2nd leg
• At next landing point, PIC notes defect in log, checks defect and elects to continue flight
• Aircraft crashes and burns during next leg
• ATSB scratches head ... were their any defects with aircraft ... checks MR at base ... nothing significant ...all OK

My point ... there is no real way to ensure up to date defect data is available.
There are pros and cons for both keeping MR or leaving MR. Only sure way is to equip each aircraft with an "Orange Tin Box" ... to put MR in.

[tnuc]

why do we even have a maintenance release ?
about time we caught up with the FAA

[Lodown]

tnuc, now don't go putting ideas into peoples' heads. We've always had a MR and we're not about to change now just because some whipper snipper thinks it's a good idea.

[john_tullamarine]

My point ... there is no real way to ensure up to date defect data is available.

Not so. While the standard GA MR doesn't address the concern, the airline and (many) corporate folk use multi-page tech log documents which incorporate the MR - as noted by CFI. Normal deal is a sign-off and tear out (which doesn't go with the aeroplane) at each aerodrome or something functionally similar.

Probably, for typical lightie ops, it would be a bit of an overkill and the present MR system is not a bad sort of compromise. Mind you, it wouldn't be terribly difficult for a periodic scan/photostat of the MR to be made for log book records.

Tee Emm's observation, however, is pertinent - if folk don't put entries in the MR, its value, as a log book addendum, is minimal.

Note that my comments are generalised and do not pertain in any way to any accident/incident.

[Dick Smith]

Following is an interesting statement by the ATSB:

Neither could it reconcile how a pilot would continue navigation by GPS with the alerts and warnings provided by the GPS receiver and the instrument indications

It is almost as if there are people at the ATSB who do not really understand human factors and human fallibility. My suggestion is that they interview a number of ATOs, and also talk to the people at Flight Safety in the USA. I believe they will find that just about any mistake a human being can make will be made at some time.

I understand there is lots of evidence of even the most experienced professional pilot missing important warning alerts.

I look forward to comments on this.

[Freewheel]

Dick,

There has been (I'm not sure if it's still the case) moves by ATSB to hire staff with specific qualifications in the area of Aviation Psychology to expand their knowledge base of just this point.

While I'm sure we imagine that each warning can be viewed as easily as your own "No" sign (thanks 60 minutes for that trip down memory lane), we all manage to have our bad days.

The point that is made though that reliance on a single aid without any form of cross check is what allowed what I speculate to have been a bad day turn into a tragedy.

[Tee Emm]

Anyway, one of the directors testified there was nothing on the MR related to any defects when he last flew TNP the previous day

Naturally. Except it would have been up to the ATSB investigator to decide if any recorded defect in the destroyed maintenance release could have been a factor or not.

[Lookleft]

A passenger on the accident flight was a Qantas S/O. I would assume he was sitting up front and it would also be a reasonable assumption that he would query any persistent warnings that the GPS system was displaying. Dick if you really knew anything about the ATSB you would know that they have world class HF people on staff. If you want their names download any research paper from their website as the HF investigators have their name published on the report.

[Dick Smith]

Lookleft, you state:

I would assume he was sitting up front and it would also be a reasonable assumption that he would query any persistent warnings that the GPS system was displaying.

I don’t agree. I don’t think this would be a reasonable assumption. A KLM 747 Captain once took off without a clearance at Tenerife and caused the highest number of fatalities ever in a non-terrorist airline accident in the world. What this shows is that you, or I, or even a Qantas second officer, can make human errors – none of us are infallible.

The explanation of what happened by John Chew (see here) is very, very feasible. Even the most experienced professionals can make errors. That is why there is such a concentration on human factor training to reduce this.

[Lookleft]

Dick The Tenerife accident was the result of a lot of HF considerations especially the concept of cockpit gradient which would not have been present in Benalla. I am not saying that there are no HF considerations but you originally asserted that the ATSB do not understand HF and that they have no expertise in this area. As an airline pilot I am resonably familiar with the two crew environment and its limitations. I also know that if I go up in a light aircraft then I take a professional interest in what is going on around me. If something like a GPS receiver was giving warning messages I would ask the pilot what it meant. You can't make the assumption that a pilot would deliberately ignore a warning in the absence of any other evidence such as a CVR.

Why aren't you still pushing for the installation of TAWS equipment for turbine aircraft of 6 seats or more? That equipment would have gone a long way to preventing this accident.

[peuce]

In defence of Dick Smith ... (what am I saying ???) .... I think he is saying that the Pilot's "mind" may have ignored the alleged GPS warning signals... not that the PIC made a conscious decision to ignore them.

I have no doubt that, in the midst of a busy/bumpy/tricky approach, such a thing could happen. I know I've been subjected to sensory overload on occassions.

Having said that, is there really any way to totally remove the possibility of such things happening ... short of a robotic arm sliding out of the panel and slapping you across the face?

Human Factors are Human Factors ...

[bushy]

Single pilot

A long time ago, in Adelaide a friend of mine (a PPL holder) was in the RHS of a chieftain which was flown by an instrument rated CPL holder, on a charter flight. They went into IMC soon after takeoff, and the aeroplane crashed into the Adelaide hills, killing everyone on board.

The ATSB (or whatever it was called that week) investigation found nothing wrong with the aeroplane, and tests showed that a Chieftain with autopilot disconnected and no-one flying it would follow the same track and altitudes that the accident aircraft did.

There was no evidence of pilot incapictation.

But there were two pilots up the front, and no proper two pilot system operating. Distraction may have been a factor. And this situation has been present in a number of serious accidents, including, I believe, Lockhart River and Benalla. In some cases the other pilot was a passenger, and in others he was crew. In fact, the Benalla accident aircraft carried a number of pilots.
If you go back to the HS 125 incident long ago you find that an aircraft crewed by infallible skygods from DCA and Qantas managed to land with the gear up.
And there are others.

It looks as if things can easily go very wrong when there is more than one pilot up front and no firm two pilot system in place.
In fact a single pilot may be safer than a two pilot crew in many cases.

There does seem to be a pattern here.