Agusta A109
Avoid imitations
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Questions posed by one of the Seagull twins (my answers aren't type specific):
2. Do you have a ladder available for your pre-flight inspection?
Not often. Try finding and using one in a dark, wet, muddy and windy field. We climb up on the airframe like most other helicopter pilots have to do.
3. Is there a culture that prevents a pilot taking the time to carry out a thorough pre-flight inspection?
A 14 hour day beginning and ending in a dark, wet, muddy and windy field doesn't help.
So these were pilot failures because neither didn't spot his aircraft had been put back together incorrectly and hadn't been properly checked by a supervisor?
Presumably the engineer's work WAS throughly checked and oversigned by a supervisor in view of the nature of the work carried out?
Pilots do their best ferchristssake, out of self preservation (they are always in the crash and engineers usually aren't). Realistically, a pilot isn't likely to spot something like this that two engineers, with access to the manufacturer's information and diagrams with proper access and lighting, sadly missed. The AAIB, with all their facilities, also seem to have missed it in a retrospective investigation!
P.S. With regard to the other questions - in most cases, pilots are there to fly the aircraft, not to organise the engineering department.
As usual some of the dirt gets dished downwards and onwards.
2. Do you have a ladder available for your pre-flight inspection?
Not often. Try finding and using one in a dark, wet, muddy and windy field. We climb up on the airframe like most other helicopter pilots have to do.
3. Is there a culture that prevents a pilot taking the time to carry out a thorough pre-flight inspection?
A 14 hour day beginning and ending in a dark, wet, muddy and windy field doesn't help.
So these were pilot failures because neither didn't spot his aircraft had been put back together incorrectly and hadn't been properly checked by a supervisor?
Presumably the engineer's work WAS throughly checked and oversigned by a supervisor in view of the nature of the work carried out?
Pilots do their best ferchristssake, out of self preservation (they are always in the crash and engineers usually aren't). Realistically, a pilot isn't likely to spot something like this that two engineers, with access to the manufacturer's information and diagrams with proper access and lighting, sadly missed. The AAIB, with all their facilities, also seem to have missed it in a retrospective investigation!
P.S. With regard to the other questions - in most cases, pilots are there to fly the aircraft, not to organise the engineering department.
As usual some of the dirt gets dished downwards and onwards.
Last edited by ShyTorque; 20th Nov 2004 at 09:29.
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Seagull
So where do you draw the line on exactly what you're going to check on a preflight then?
Presumably at least every possible item visible externally. Are you going to check serial numbers of components and cross reference them to make sure no-one has fitted duff (eg ex-mil) parts? Are you going to check the exact type of nuts and bolts used? Rivet type? How about getting your magnifying glass out to check for cracks along all critical stressed components?
And how long is all this taking you on a 109 - or any other type? How often are you going to check all this? First flight of the day, or after flight over one hour?
What are you going to trust your engineers to have done correctly? Presumably everything that you cannot see without dismantling the acft. Internals on engines, gearboxes, servos etc etc. Still leaves a lot of trust.
No question thorough pre-flight checks are important, but one has to be realistic about what can reasonably be expected to be picked up.
It's easy to be wise after the event and I'm sure now every 109 pilot checks the scissor link, especially after maintenance to this area. But in my view it was entirely reasonably for the pilots not to have spotted this in their pre-flights, assuming this risk was unknown to them.
So where do you draw the line on exactly what you're going to check on a preflight then?
Presumably at least every possible item visible externally. Are you going to check serial numbers of components and cross reference them to make sure no-one has fitted duff (eg ex-mil) parts? Are you going to check the exact type of nuts and bolts used? Rivet type? How about getting your magnifying glass out to check for cracks along all critical stressed components?
And how long is all this taking you on a 109 - or any other type? How often are you going to check all this? First flight of the day, or after flight over one hour?
What are you going to trust your engineers to have done correctly? Presumably everything that you cannot see without dismantling the acft. Internals on engines, gearboxes, servos etc etc. Still leaves a lot of trust.
No question thorough pre-flight checks are important, but one has to be realistic about what can reasonably be expected to be picked up.
It's easy to be wise after the event and I'm sure now every 109 pilot checks the scissor link, especially after maintenance to this area. But in my view it was entirely reasonably for the pilots not to have spotted this in their pre-flights, assuming this risk was unknown to them.
Seagull:
Not A109 type rated, and unlikely to be, but I do have a keen interest on reading the accident reports, and in seeing reasoned discussion before slagging people off.
Not A109 type rated, and unlikely to be, but I do have a keen interest on reading the accident reports, and in seeing reasoned discussion before slagging people off.
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Rotorspeed,
So where do you draw the line on exactly what you're going to check on a pre-flight then?
The minimum requirement is explained in your flight manual.
Engineers make mistakes. Usually these mistakes are detected by the engineer and corrected. If the engineer fails to detect his own error, there are systems in place that should find that mistake. The pilot pre-flight inspection is the last part of those systems. Don’t underestimate the value of a through pre-flight inspection.
However to be able to carry out worthwhile pre-flight inspection you require specific training. Make sure you get it.
I am not being wise after the event. This problem is well known and documented. We need to look at why the system failed.
Nr Fairy,
I agree with you. Making villains and scape goats out of the people who are working at the coal face is taking a very narrow view of the problem.
I am hopping that I can convince you and many others that there is an underlying systematic problem. The system failed.
1. The person carrying out the hands on work could have prevented this incident.
2. The engineer certifying for this work should have supervised and checked that it had been carried out correctly.
3. The supervisor that certified the dual inspection should have eyeballed the job.
4. The engineer that carried out the daily inspection had an opportunity to pick this problem up.
5. And finally the pilot had an opportunity to pick this problem up during his pre-flight inspection.
Why did all these people fail to detect a known problem?
I do not have all day to sit here and explain to you the many possible reasons why all of these people failed. I would however like to take the time and talk about #1, the person that got the ball rolling.
The rotating scissor link that was fitted incorrectly is shaped in a way that looks like it should go on the wrong way. It is shaped so that it functions with sufficient clearances. The part in subject is not easer to fit reversed, nor is it quicker to fit incorrectly. There is no motivation for the person fitting this item to fit it incorrectly. It is not a short cut so we can all go to lunch! The only reason this part gets fitted incorrectly is lack of education. Training !! Training !! Training !! Training !!
Pilots need to take an interest in the amount and quality of training that their engineers receive. And that the right people get that training.
If it were possible to put right all other factors that contributed to this incident. Fatigue, stress. weather, racism, engineering work load, internal company conflicts, communication between pilots and engineers and so on. You are doomed to repeat this type of error if your staff is not trained properly.
No body likes accidents!!
Everybody likes training!! (Except the bean counters of course that would be happier to pay the insurance premiums rather than pay for training)
So where do you draw the line on exactly what you're going to check on a pre-flight then?
The minimum requirement is explained in your flight manual.
Engineers make mistakes. Usually these mistakes are detected by the engineer and corrected. If the engineer fails to detect his own error, there are systems in place that should find that mistake. The pilot pre-flight inspection is the last part of those systems. Don’t underestimate the value of a through pre-flight inspection.
However to be able to carry out worthwhile pre-flight inspection you require specific training. Make sure you get it.
I am not being wise after the event. This problem is well known and documented. We need to look at why the system failed.
Nr Fairy,
I agree with you. Making villains and scape goats out of the people who are working at the coal face is taking a very narrow view of the problem.
I am hopping that I can convince you and many others that there is an underlying systematic problem. The system failed.
1. The person carrying out the hands on work could have prevented this incident.
2. The engineer certifying for this work should have supervised and checked that it had been carried out correctly.
3. The supervisor that certified the dual inspection should have eyeballed the job.
4. The engineer that carried out the daily inspection had an opportunity to pick this problem up.
5. And finally the pilot had an opportunity to pick this problem up during his pre-flight inspection.
Why did all these people fail to detect a known problem?
I do not have all day to sit here and explain to you the many possible reasons why all of these people failed. I would however like to take the time and talk about #1, the person that got the ball rolling.
The rotating scissor link that was fitted incorrectly is shaped in a way that looks like it should go on the wrong way. It is shaped so that it functions with sufficient clearances. The part in subject is not easer to fit reversed, nor is it quicker to fit incorrectly. There is no motivation for the person fitting this item to fit it incorrectly. It is not a short cut so we can all go to lunch! The only reason this part gets fitted incorrectly is lack of education. Training !! Training !! Training !! Training !!
Pilots need to take an interest in the amount and quality of training that their engineers receive. And that the right people get that training.
If it were possible to put right all other factors that contributed to this incident. Fatigue, stress. weather, racism, engineering work load, internal company conflicts, communication between pilots and engineers and so on. You are doomed to repeat this type of error if your staff is not trained properly.
No body likes accidents!!
Everybody likes training!! (Except the bean counters of course that would be happier to pay the insurance premiums rather than pay for training)
Seagull:
You've made my point. The swiss cheese started here - designing a safety critical part so it CAN (and therefore, at some stage, WILL) be fitted in reverse, is something else which slipped through the net, as well as the engineer fitting it in reverse and the pilot not noticing it was fitted in reverse. But if the part looks like it fits, DOES fit, and does the job for a bit before failing AND Agusta knew about it BEFORE these two accidents, you may have a point.
It's happened before - an RAF Jaguar was lost/almost lost (I can't remember which since I read the report ages ago in a waiting room at Alan Mann and haven't been back since) because a hydraulic pipe could be fitted in such a way as to cross-connect TWO separate hyd systems, and a leak in one system led to loss of both. There will be numerous such examples in aviation history.
If you have had time to check the MM pages shown in the accident reports, can you compare them with yours and see if they've changed ? I think your point is a bit weakened if the changes occurred after these two accidents, and before your training.
The rotating scissor link that was fitted incorrectly is shaped in a way that looks like it should go on the wrong way. It is shaped so that it functions with sufficient clearances. The part in subject is not easer to fit reversed, nor is it quicker to fit incorrectly
It's happened before - an RAF Jaguar was lost/almost lost (I can't remember which since I read the report ages ago in a waiting room at Alan Mann and haven't been back since) because a hydraulic pipe could be fitted in such a way as to cross-connect TWO separate hyd systems, and a leak in one system led to loss of both. There will be numerous such examples in aviation history.
If you have had time to check the MM pages shown in the accident reports, can you compare them with yours and see if they've changed ? I think your point is a bit weakened if the changes occurred after these two accidents, and before your training.
Last edited by The Nr Fairy; 21st Nov 2004 at 04:16.
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Seagull
You say: "I am not being wise after the event. This problem is well known and documented. We need to look at why the system failed."
Maybe I've missed something in previous posts, but exactly where was this problem "well known and documented" prior to the first UK accident in Jan 2000? Were there previous incidents/accidents elsewhere due to incorrect scissor link installation, the cause of which was published before Jan 2000? What form of information dissemination about this risk are you referring to that the pilots of the two UK accidents should have seen?
Or was this just something that someone happening to do a 109E course at Agusta before Jan 2000 would have been told?
Apart from being curious, very important information, and presumably you know the answers.
You say: "I am not being wise after the event. This problem is well known and documented. We need to look at why the system failed."
Maybe I've missed something in previous posts, but exactly where was this problem "well known and documented" prior to the first UK accident in Jan 2000? Were there previous incidents/accidents elsewhere due to incorrect scissor link installation, the cause of which was published before Jan 2000? What form of information dissemination about this risk are you referring to that the pilots of the two UK accidents should have seen?
Or was this just something that someone happening to do a 109E course at Agusta before Jan 2000 would have been told?
Apart from being curious, very important information, and presumably you know the answers.
Seagull:
You really haven't twigged, have you ?
You need to tell us WHEN Agusta changed the MMs. Before or after 2000 ?
I think you're getting off on being smug about all this. When one of your aircraft has a ding, let's hope the maintainers are vindicated.
You really haven't twigged, have you ?
You need to tell us WHEN Agusta changed the MMs. Before or after 2000 ?
I think you're getting off on being smug about all this. When one of your aircraft has a ding, let's hope the maintainers are vindicated.
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This thread has exposed a very important concept, important for us all.
I have collected a pile of tools from engineers who unwillingly donated them to me when I inspected a hundred helicopters incompletely maintained, and hardly ready for flight. I have also done enough shoddy flying to help learn a hundred lessons and a gather a few aches and pains, I can assure you there is no easy answer here, no fool-proof system, and no person blameless enough to cast the first stone.
I recall Howard Cosell, the rather loadmouthed television commentator (and never a player) of American Football, getting rather carried away criticizing one player for making a mistaken play. Cosell's partner in the broadcast booth was a former pro player who waited for a slow-down in the tirade, and then he said, "You know, Howard, it 's a lot harder down on the field than it looks from up here."
Any accident is a chain of errors, and the rarer the errors the more time between accidents. It is the more experienced aviator who actually thanks himself when he finds the mistake early enough to break the chain, and also who knows when one of his peers makes a mistake, there but for the grace of God go I.
Our profession as pilot or as engineer is unlike most others, because we are right out there, no where to hide.
I have collected a pile of tools from engineers who unwillingly donated them to me when I inspected a hundred helicopters incompletely maintained, and hardly ready for flight. I have also done enough shoddy flying to help learn a hundred lessons and a gather a few aches and pains, I can assure you there is no easy answer here, no fool-proof system, and no person blameless enough to cast the first stone.
I recall Howard Cosell, the rather loadmouthed television commentator (and never a player) of American Football, getting rather carried away criticizing one player for making a mistaken play. Cosell's partner in the broadcast booth was a former pro player who waited for a slow-down in the tirade, and then he said, "You know, Howard, it 's a lot harder down on the field than it looks from up here."
Any accident is a chain of errors, and the rarer the errors the more time between accidents. It is the more experienced aviator who actually thanks himself when he finds the mistake early enough to break the chain, and also who knows when one of his peers makes a mistake, there but for the grace of God go I.
Our profession as pilot or as engineer is unlike most others, because we are right out there, no where to hide.
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I'm not an A109E pilot, but I have heard about these crashes and as I understand it, the maintenance manual extant at the time of the first two crashes did not indicate in any way which was the correct way to fit the scissor link.
I think Seagull Hunter is being overbearingly smug in his own knowledge and I hope none of us here on a forum will one day be offering comments on something resulting from what he did because of incomplete knowledge - even if he did do a factory course.
If the manufacturer made it possible in its design process to make a part which could be fitted either of two ways and made no reference to it in its documentation or factory courses at the time I do not think you can possible blame a factory-trained engineer if it was not spotted.
I think Seagull Hunter is being overbearingly smug in his own knowledge and I hope none of us here on a forum will one day be offering comments on something resulting from what he did because of incomplete knowledge - even if he did do a factory course.
If the manufacturer made it possible in its design process to make a part which could be fitted either of two ways and made no reference to it in its documentation or factory courses at the time I do not think you can possible blame a factory-trained engineer if it was not spotted.
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You are all barking up the right tree about fitment of the scissor link - however you should note it can STILL be fit backwards today - sure everyone now knows about this problem so for a while it should not happen again - BUT a couple of years down the road, who knows when the dust has setled and new people have come into the chain - Augusta have change the manuals, but not the part itself - still exactly the same as day one!!!
As for the pilots checking it on a walkround - sure they do now, as any sensible aviator would; but before the incident, it was just another part of the head - secure and looks correct! interesting to read how many experts we have after the event!!! May you never cock up - cause we will all be waiting to pounce!!
HOW GUILTY DOES AUGUSTA FEEL ABOUT THIS - ANSWER - They don't give a Toss!
As for the pilots checking it on a walkround - sure they do now, as any sensible aviator would; but before the incident, it was just another part of the head - secure and looks correct! interesting to read how many experts we have after the event!!! May you never cock up - cause we will all be waiting to pounce!!
HOW GUILTY DOES AUGUSTA FEEL ABOUT THIS - ANSWER - They don't give a Toss!
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Seagull
You make some good points. Shame your points are lost to most of us because of you aggressive nature.
You said that this part looks like it should go on back to front. I disagree, for you to be able to do this, either the bushes and or bolts would have to be fitted contrary to the convention of having the bolt head facing the direction of rotation.
I don’t know if any of the contributors to this string are close to this event but I would like to hear from the people involved so I can better understand what and how it happened. There must be someone out there that really knows.
You make some good points. Shame your points are lost to most of us because of you aggressive nature.
You said that this part looks like it should go on back to front. I disagree, for you to be able to do this, either the bushes and or bolts would have to be fitted contrary to the convention of having the bolt head facing the direction of rotation.
I don’t know if any of the contributors to this string are close to this event but I would like to hear from the people involved so I can better understand what and how it happened. There must be someone out there that really knows.
picture of this scissor link
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The wirelocking is correct, not having a 109 ticket I can't answer about the swashplate, but what I can say is some of you appear to have very low opinions of those of us to whom you entrust your lives. Some of you also appear to be very good at talking out of your rear ends.
Facts gentlemen, not flying club waffle, you are talking about a very serious set of incidences.
Facts gentlemen, not flying club waffle, you are talking about a very serious set of incidences.
Last edited by quichemech; 1st Feb 2005 at 12:24.
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Why can't the part come from the factory with a stamp on it in permanent ink that has an arrow and says "This End Up". What would be difficult about this? Visual inspection would then be a no-brainer.