Same Old Story. Maintenance release not found in fatal accident.
Thread Starter
Join Date: Apr 2005
Location: Australia
Posts: 1,414
Likes: 0
Received 0 Likes
on
0 Posts
Same Old Story. Maintenance release not found in fatal accident.
ATSB have just released its report on a Dromadeer fatal accident in Queensland. Part of the report says this:
The most recent documented maintenance task carried out on the aircraft was a scheduled annual inspection and maintenance release issue that was completed on 29 June 2011. The maintenance release was valid until 29 June 2012 or 5,996.7 hours TTIS, whichever occurred first.
The investigation examined the aircraft’s maintenance documentation and no deficiencies were identified that would affect normal flight. Since the maintenance release was not recovered, the investigation was unable to determine if there were any recorded outstanding defects.
In the past years there have been dozens of ATSB/BASIS reports which stated either the maintenance release was destroyed in the crash fire or could not be found in the wreckage. Since the maintenance release and its entries of current and rectified defects is clearly a vital high priority part of the investigation process, it seems an illogical legal requirement to carry the original document in the aircraft on every single flight. The chances of the evidence in the maintenance release being destroyed in the accident is high - witness the comment by ATSB in their reports.
So why on earth does CASA persist with the ridiculous requirement to carry the original document in the aircraft? As far as I recall, in high capacity types, a copy of the current page of the maintenance document and signed by the captain, is left at each stage; along with a passenger and freight manifest. If the aircraft is destroyed in an accident it is easy to retrieve the last copy from the last port of call.
The subject has been discussed in Pprune over the years and in fact this writer wrote to CASA 15 years ago suggesting a review of the requirement. Whoever in CASA at the time wrote the reply, was not only not in the slightest bit interested, but said that it didn't matter if the maintenance release was destroyed since the original was kept by the maintenance organisation. He was obviously confused with the fact that the last maintenance release is filed away at the maintenance organisation - not the current one.
I am surprised (or maybe not) that ATSB or CASA are not particularly concerned if the current maintenance release carried in an aircraft is unavailable to these organisations because of its destruction in post accident fire.
Are they implying that any defects endorsed in the destroyed maintenance release willl probably have no bearing on the cause of the accident? Ostriches hiding their heads in the sand come to mind...
The most recent documented maintenance task carried out on the aircraft was a scheduled annual inspection and maintenance release issue that was completed on 29 June 2011. The maintenance release was valid until 29 June 2012 or 5,996.7 hours TTIS, whichever occurred first.
The investigation examined the aircraft’s maintenance documentation and no deficiencies were identified that would affect normal flight. Since the maintenance release was not recovered, the investigation was unable to determine if there were any recorded outstanding defects.
In the past years there have been dozens of ATSB/BASIS reports which stated either the maintenance release was destroyed in the crash fire or could not be found in the wreckage. Since the maintenance release and its entries of current and rectified defects is clearly a vital high priority part of the investigation process, it seems an illogical legal requirement to carry the original document in the aircraft on every single flight. The chances of the evidence in the maintenance release being destroyed in the accident is high - witness the comment by ATSB in their reports.
So why on earth does CASA persist with the ridiculous requirement to carry the original document in the aircraft? As far as I recall, in high capacity types, a copy of the current page of the maintenance document and signed by the captain, is left at each stage; along with a passenger and freight manifest. If the aircraft is destroyed in an accident it is easy to retrieve the last copy from the last port of call.
The subject has been discussed in Pprune over the years and in fact this writer wrote to CASA 15 years ago suggesting a review of the requirement. Whoever in CASA at the time wrote the reply, was not only not in the slightest bit interested, but said that it didn't matter if the maintenance release was destroyed since the original was kept by the maintenance organisation. He was obviously confused with the fact that the last maintenance release is filed away at the maintenance organisation - not the current one.
I am surprised (or maybe not) that ATSB or CASA are not particularly concerned if the current maintenance release carried in an aircraft is unavailable to these organisations because of its destruction in post accident fire.
Are they implying that any defects endorsed in the destroyed maintenance release willl probably have no bearing on the cause of the accident? Ostriches hiding their heads in the sand come to mind...
Last edited by A37575; 8th Jun 2012 at 12:06.
Join Date: Feb 2006
Location: The Zoo
Posts: 335
Likes: 0
Received 0 Likes
on
0 Posts
Plenty of companies where the original MR is in the aircraft and a carbon copy is left behind (Sector/Trip record per page)
Of course CASA would have to replace their wax paper with a similar system for it to expand to Class B aircraft.
Of course CASA would have to replace their wax paper with a similar system for it to expand to Class B aircraft.
Thread Starter
Join Date: Apr 2005
Location: Australia
Posts: 1,414
Likes: 0
Received 0 Likes
on
0 Posts
So where would you suggest the MR be left?
Join Date: Nov 2007
Location: Mars
Posts: 373
Likes: 0
Received 0 Likes
on
0 Posts
A37575 makes a good point. The MR is a way of letting the next pilot know what went wrong or any other issues but does anywhere else in the world carry the ONLY record of recent defects and/or corrective maintenance needed that could affect the safety of further flight and potentially the only sign-off, actually in the plane? (That's if it gets filled out with this information at all of course...)
Yes, so up to up to date maintenance info should be considered 'commercial in confidence'? Some pax, investigators and others (and/or their lawyers 
)might actually be quite interested in that. Much better it gets destroyed in the crash then eh?
Let's face it, with stuff like Flightaware, everyone knows in real time exactly what we are doing, where and how we're going. So what's the problem in letting those who have a legitimate nterest know we're doing the right thing with maintenance? Or in GA.culture, might there be some things we'd rather some folks did not know?
Yup just what every GA company needs, everyone else knowing who their clients are, how many hours are left on their MR, what defects they are flying with, how long they have to go till the next 100hrly.
)might actually be quite interested in that. Much better it gets destroyed in the crash then eh?Let's face it, with stuff like Flightaware, everyone knows in real time exactly what we are doing, where and how we're going. So what's the problem in letting those who have a legitimate nterest know we're doing the right thing with maintenance? Or in GA.culture, might there be some things we'd rather some folks did not know?
But of course this begs the question: How many defects, recorded by a pilot on a mantenance release, have led to a fatal accident. In GA I would guess not many.
Please don't tell me you want GA pilots to ensure that a copies of the mantenance release are to be left scattered across the countryside and this will be part of my next audit. I can see it now, "please wait here ladies and gentleman, the refuellers photocopier is not working".
By the way your example is a single seat ag aircraft.
Please don't tell me you want GA pilots to ensure that a copies of the mantenance release are to be left scattered across the countryside and this will be part of my next audit. I can see it now, "please wait here ladies and gentleman, the refuellers photocopier is not working".
By the way your example is a single seat ag aircraft.
… at each point of departure leave a copy of the relevant defects and times flown pages with an appropriate agent - refueller, local flying school, or like a flight note with anyone in the vicinity.
But let’s assume we find Fred in the Flying Club at the aerodrome we refueled at. We give Fred a copy of our MR. Is Fred obliged to keep it and, if so, for how long? We’re on a round Australia tour, by the way.
Hang on a sec: Fred’s going flying! He gives us a copy of his MR. Now what do we do?
A week and 6 stopovers after passing the copy to Fred, I crash 1,000nm away. Is Fred’s copy important and, if yes, how does the ATSB know about and find Fred?
Join Date: Oct 2010
Location: Styx Houseboat Park.
Posts: 2,055
Likes: 0
Received 0 Likes
on
0 Posts
Nannies rules 101.
CP - Hang on a sec: Fred’s going flying! He gives us a copy of his MR. Now what do we do?
Reg 362436.
1) The pilot of crashing aircraft must accurately complete the defect section of the Maintenance Release at least 1.76 Kms from the intended crash site.
2) The MR must be inserted into an approved empty boot polish tin and ejected no less than 500 meters from the intended point of impact.
a) Failure to do so constitutes a breach of the Act and is punishable by 2 years in prison after such hospital treatment as deemed by the DAME is complete.
b) Failure to properly fold the MR is a strict liability offence. 25,000 penalty points.
HAGW
Last edited by Kharon; 8th Jun 2012 at 23:25.
Just a thought, and feel free to shoot me down.
But as pointed out leaving a copy everywhere isn't very practical...so why wouldn't (This is taking a commercial organisation) you leave the original back at Base where its secure and people can't find out what it says but is accessible by CASA or the ATSB in the event its required?
Lets say something becomes defective en-route and you needed that noted on the MR, well call back to the office and let them know, chances are you're going to have to call them anyway to get it fixed.
Leaving the original back at base once its been signed off in the morning and then amending it if required seems to make a lot more sense!!
But as pointed out leaving a copy everywhere isn't very practical...so why wouldn't (This is taking a commercial organisation) you leave the original back at Base where its secure and people can't find out what it says but is accessible by CASA or the ATSB in the event its required?
Lets say something becomes defective en-route and you needed that noted on the MR, well call back to the office and let them know, chances are you're going to have to call them anyway to get it fixed.
Leaving the original back at base once its been signed off in the morning and then amending it if required seems to make a lot more sense!!
Why not go digital and input entries into an iPad where the information is stored in the cloud? It might even help people get their maths correct. The iPad could double as an EFB, manuals, charts etc.
Why not just keep going the way we are going.
A scenic flight mob I worked for recently always kept the MR's in the office. They even applied for a dispensation to do same but the request was never answered. Funny enough, come ramp check and audit times the CASA inspectors were always happy with the arrangement.
A scenic flight mob I worked for recently always kept the MR's in the office. They even applied for a dispensation to do same but the request was never answered. Funny enough, come ramp check and audit times the CASA inspectors were always happy with the arrangement.
Join Date: May 2008
Location: Australia
Posts: 429
Likes: 0
Received 0 Likes
on
0 Posts
All of these suggestions are increasing in expense and complexity. The most cost effective, practical and reliable method is a simple fax or photocopy or digital image of the MR once daily or when ever amended, where practical.
The reality is aircraft will end up away from base or be shuffled around the country side from base to base for different missions, making it impossible to leave the MR anywhere but in the aircraft (for the sake of the next pilot to be able to review the most current copy). There are exceptions to this where they could be left with a 24 hour operations department that collects and compares all maintenance information. Even in this instance keeping the MR in the aircraft is still more practical because the operations department still has (relatively) up to date information.
The idea of copying it per sector is just poorly thought out. Some crews will do as many as 10 sectors a day with aircraft doing up to 15 in a 24 hour period, spread that across 10-15 aircraft and you're talking up to 220 copies of MR's a day!
Even if you were to pursue a more accurate and up to date approach, by mandating a CC of the MR at every intermediate destination, would you really resolve the issue? Most minor defects are not detected until postflight or in the next preflight inspection and major defects that are detected are usually reported immediately, negating the need to leave a CC behind. In the cases where the known defects aren't reported immediately you will more than likely find they wouldn't have been entered in the MR at that point regardless (if at all), which is of course a cultural issue and arguably the real problem with regards to maintenance and defect reporting and recording.
If the operators who are abiding by the regulations (not speaking in terms of the above or other private or very small operators who may not have considered the consequences) are making the effort to record current defect items alternatively to the MR, then mandating more than what others have already implemented, at little or no cost, just adds to the bureaucratic jumble. A CAAP on possible internal monitorial means would be more than sufficient for those that have not considered the options and those that don't take it's advice wouldn't have appropriate records to make a mandate justifiable anyway.
The reality is aircraft will end up away from base or be shuffled around the country side from base to base for different missions, making it impossible to leave the MR anywhere but in the aircraft (for the sake of the next pilot to be able to review the most current copy). There are exceptions to this where they could be left with a 24 hour operations department that collects and compares all maintenance information. Even in this instance keeping the MR in the aircraft is still more practical because the operations department still has (relatively) up to date information.
The idea of copying it per sector is just poorly thought out. Some crews will do as many as 10 sectors a day with aircraft doing up to 15 in a 24 hour period, spread that across 10-15 aircraft and you're talking up to 220 copies of MR's a day!
Even if you were to pursue a more accurate and up to date approach, by mandating a CC of the MR at every intermediate destination, would you really resolve the issue? Most minor defects are not detected until postflight or in the next preflight inspection and major defects that are detected are usually reported immediately, negating the need to leave a CC behind. In the cases where the known defects aren't reported immediately you will more than likely find they wouldn't have been entered in the MR at that point regardless (if at all), which is of course a cultural issue and arguably the real problem with regards to maintenance and defect reporting and recording.
If the operators who are abiding by the regulations (not speaking in terms of the above or other private or very small operators who may not have considered the consequences) are making the effort to record current defect items alternatively to the MR, then mandating more than what others have already implemented, at little or no cost, just adds to the bureaucratic jumble. A CAAP on possible internal monitorial means would be more than sufficient for those that have not considered the options and those that don't take it's advice wouldn't have appropriate records to make a mandate justifiable anyway.
The ops manual provision (137.120(5)) does not appear to permit the non-carriage of entire documents, but rather only ‘a specified part of’ e.g. the ‘aeroplane’s flight and maintenance records’.
