Helicopter engineer cleared of manslaughter after crash
Joined: Mar 2002
Posts: 489
Likes: 2
From: UK
Helinut,
I agree with your sentiments and those of several of the other posts on this subject. Maybe we should try to be a little more constructive.
The real problem is that helicopters are extremely complicated machines in which hidden forces and destructive mechanisms exist in great numbers. Such mechanisms are not properly understood by specialist design engineers employed by the helicopter manufacturers, let alone maintenance technicians.
The tragedy here is that this individual's experience has almost certainly worked against him. What has happened is that he has tried to extrapolate a procedure to situation that is only subtly different to repairs he has carried out many, many times before. Tragically in this case, subtle differences in helicopters frequently have disproportionately significant effects that cannot be predicted without substantial prior knowledge and understanding of complex engineering science.
Knowledge that it is unreasonable to assume a maintenance technician could ever posses (in the necessary volume) - if they did they would be design engineers!
I think what we should learn from this tragedy is that while aircraft maintenance is covered by procedure, attention must be paid in the future to explaining during training why a maintenance engineer should never carry out a repair without an exact manufacturer approved procedure. i.e. They do not have the expertise to accurately predict the consequences of there actions. Then possibly go on to explain some of the processes at work in a helicopter to adequate detail.
What I have said here is of course a generalisation as to the capabilities of helicopter maintenance technicians. Obviously some helicopter technicians will be superior to others and to those individuals I mean no offence, however by regulating for the lowest common denominator we can achieve a safety net that nobody can legitimately slip through.
“As an Engineer, it is more important to know what you don't know than what you do. - Be aware of the limits of your capability.”
The technician in question should not be in jail, but he should certainly have lost he license and be prevented from being an aircraft technician in the future.
I wish to express my sincerest condolences to the families of those lost and to the technician and his family. This is a terrible tragedy and we should take a moment to consider that is could just as easily have been any of us. Though the technician has shouldered the blame in this case it is the system that has failed – there is no way he would have carried out the repair had he been equipped with the knowledge that I’ve suggested.
CRAN
I agree with your sentiments and those of several of the other posts on this subject. Maybe we should try to be a little more constructive.
The real problem is that helicopters are extremely complicated machines in which hidden forces and destructive mechanisms exist in great numbers. Such mechanisms are not properly understood by specialist design engineers employed by the helicopter manufacturers, let alone maintenance technicians.
The tragedy here is that this individual's experience has almost certainly worked against him. What has happened is that he has tried to extrapolate a procedure to situation that is only subtly different to repairs he has carried out many, many times before. Tragically in this case, subtle differences in helicopters frequently have disproportionately significant effects that cannot be predicted without substantial prior knowledge and understanding of complex engineering science.
Knowledge that it is unreasonable to assume a maintenance technician could ever posses (in the necessary volume) - if they did they would be design engineers!
I think what we should learn from this tragedy is that while aircraft maintenance is covered by procedure, attention must be paid in the future to explaining during training why a maintenance engineer should never carry out a repair without an exact manufacturer approved procedure. i.e. They do not have the expertise to accurately predict the consequences of there actions. Then possibly go on to explain some of the processes at work in a helicopter to adequate detail.
What I have said here is of course a generalisation as to the capabilities of helicopter maintenance technicians. Obviously some helicopter technicians will be superior to others and to those individuals I mean no offence, however by regulating for the lowest common denominator we can achieve a safety net that nobody can legitimately slip through.
“As an Engineer, it is more important to know what you don't know than what you do. - Be aware of the limits of your capability.”
The technician in question should not be in jail, but he should certainly have lost he license and be prevented from being an aircraft technician in the future.
I wish to express my sincerest condolences to the families of those lost and to the technician and his family. This is a terrible tragedy and we should take a moment to consider that is could just as easily have been any of us. Though the technician has shouldered the blame in this case it is the system that has failed – there is no way he would have carried out the repair had he been equipped with the knowledge that I’ve suggested.
CRAN
Joined: Apr 2002
Posts: 16
Likes: 0
From: Beyond Stonehenge
Agree completely that something should be done, just that I don't think a custodial sentence is always the right action. Believe that loss of license, precluding his right to practise (earn), is entirely appropriate as it has been for both engineers and pilots in the past. Whether more should be done is another question.
Joined: Nov 2000
Posts: 24
Likes: 0
From: Passed the invisable wall
After reading the above, we still do not know the whole story, was the engineer told the full story or was he just asked to recert a repaired component?. As I've aways said the jockeys are paid for something that might never happen and we are paid less than car mechanics to know an degreed engineers job, call me cynic but its true.
We are all in the same boat, keeping the flying public safe and the jockeys too, but the poor old engineer is treated like a second class citizen and payed as such.
I hope the engineer's rights and judgement isn'ts going to effect the public image of the industry as the media does...
We are all in the same boat, keeping the flying public safe and the jockeys too, but the poor old engineer is treated like a second class citizen and payed as such.
I hope the engineer's rights and judgement isn'ts going to effect the public image of the industry as the media does...
Joined: Mar 2000
Posts: 5,197
Likes: 1
From: UK
As I undertand it the engineer saw a small hairline crack, called in a specialist aviation welding firm who said it could be repaired by welding. They didn't ask if a weld repair was allowed. He thought it was, and without checking the books, gave the go-ahead.
Heliport
Heliport
Moderator
Joined: Feb 2000
Aviation Qualifications: CPL
Posts: 14,480
Likes: 178
From: UK
There but for the grace of god go many of us, who can truly say that they checked every possible thing available to be checked, every time they make an Engineering decision.
However, this is not a new instance. There was a case where the engineers who designed a walkway that collapsed killing about 20 people were charged with, and convicted of, manslaughter. This is not a dissimilar case.
I think it's inevitable than any Engineer or technician whose decision has led to a death can expect at the very least a very robust investigation. If somebody has failed to perform to the very highest standards, they can expect reprisals. It's the form and source of the investigation and reprisals that are key.
I'd argue that the legal system jumped, inevitably because the Engineering profession is so poor at policing itself. If this was a medical cock-up, the offender would be up before the BMA (or equivalent outside the UK) - in other words a jury of his peers. They have the power to regrade, or even disqalify somebody. In extremis, they'd of-course refer something to the public prosecuting authority (Harold Shipman is an extreme example of just this).
I think we'd all rather our own mistakes, if (god forbid) we make any that cause death or injury, are judged by our peers than a criminal court. One might conject that a jury of Engineers would have removed the chaps license, and required a strenuous plan of education and supervision. Painful and humiliating, and probably should be, but far more constructive than 8 months inside (and may I make a point, he'll probably still have his license when he comes out - is that wise? for anybody?).
G
However, this is not a new instance. There was a case where the engineers who designed a walkway that collapsed killing about 20 people were charged with, and convicted of, manslaughter. This is not a dissimilar case.
I think it's inevitable than any Engineer or technician whose decision has led to a death can expect at the very least a very robust investigation. If somebody has failed to perform to the very highest standards, they can expect reprisals. It's the form and source of the investigation and reprisals that are key.
I'd argue that the legal system jumped, inevitably because the Engineering profession is so poor at policing itself. If this was a medical cock-up, the offender would be up before the BMA (or equivalent outside the UK) - in other words a jury of his peers. They have the power to regrade, or even disqalify somebody. In extremis, they'd of-course refer something to the public prosecuting authority (Harold Shipman is an extreme example of just this).
I think we'd all rather our own mistakes, if (god forbid) we make any that cause death or injury, are judged by our peers than a criminal court. One might conject that a jury of Engineers would have removed the chaps license, and required a strenuous plan of education and supervision. Painful and humiliating, and probably should be, but far more constructive than 8 months inside (and may I make a point, he'll probably still have his license when he comes out - is that wise? for anybody?).
G
Pilots' Pal
Joined: Nov 1998
Posts: 1,158
Likes: 0
From: USA
Some guys & gals defer snags or carry out repairs without due reference to approved manuals/tech services/TC holder etc (something I'm sure we've all done to some degree in our careers). Any unapproved repair invalidates the C of A (as does an unapproved modification). If there are no published limits or repairs, that means there are probably none and your next step is to call Tech Services. Let them assume the problem. If the company has limited or no design authority, they go back to the TC holder/OEM and ask their advice. Hopefully, the TC holder/OEM will come back with an NTO, which, depending on your company procedures, should be covered by a concession. Don't forget, an NTO only implies that there is no technical reason why the situation could not exist - it does constitute an airworthiness approval. It is ultimately up to the certifying engineer (in consultation with the NAA if required) to determine acceptance.
In my experience, commercial pressure, or perceived notions of helping the company (an accident certainly doesn't help), are factors in occurences such as these. There have been cases where engineers have not even referred to the manual, thinking that the defect is trivial, only to find, after consulting the MEL or the TC holder/OEM, that the situation is a no-go. Such perceptions sometimes have, as demonstrated here, tragic or potentially tragic outcomes.
Don't forget that, as demonstrated by this topic, it is the certifying engineer who carries the can, despite the fact that corporate failings have probably generated the situation in which he finds himself. Commercial considerations are secondary, safety is the number one priority.
I have some sympathy with the engineer involved with the helicopter repair and doubt jail is the right punishment. It is likely he is absolutely mortified by the accident and may not be inclined to continue his career.
On a related point, all the human factors training in the world is not going to help. You could spend two days on the course, identifying and agreeing with the situations described, only to get back to work and find yourself in the situation. Systems create situations. A good system can create an atmosphere conducive to safety, a bad system could hurt someone.
In my experience, commercial pressure, or perceived notions of helping the company (an accident certainly doesn't help), are factors in occurences such as these. There have been cases where engineers have not even referred to the manual, thinking that the defect is trivial, only to find, after consulting the MEL or the TC holder/OEM, that the situation is a no-go. Such perceptions sometimes have, as demonstrated here, tragic or potentially tragic outcomes.
Don't forget that, as demonstrated by this topic, it is the certifying engineer who carries the can, despite the fact that corporate failings have probably generated the situation in which he finds himself. Commercial considerations are secondary, safety is the number one priority.
I have some sympathy with the engineer involved with the helicopter repair and doubt jail is the right punishment. It is likely he is absolutely mortified by the accident and may not be inclined to continue his career.
On a related point, all the human factors training in the world is not going to help. You could spend two days on the course, identifying and agreeing with the situations described, only to get back to work and find yourself in the situation. Systems create situations. A good system can create an atmosphere conducive to safety, a bad system could hurt someone.
Last edited by Bus429; 17th May 2002 at 07:15.
Joined: Nov 2001
Posts: 2,397
Likes: 0
From: Inside the M25
I have no comment on the wrongs and rights of this case. I'd like to point out that you don't send people to jail to make them feel bad, though. It's because they have offended society and are therefore being withdrawn from it. Or maybe it's to rehabilitate them. But what they feel is not really connected with it.
I'll shut up now, as that remark was not about this case.
I'll shut up now, as that remark was not about this case.
Joined: Feb 2001
Posts: 60
Likes: 0
From: London, Ontario, Canada
Just my 2 cents worth...
First cent: I agree that the sentence for the engineer involved probably won't make him feel any worse, and he will probably be the most cautious mechanic in the world now (assuming he gets to be a mechanic again), but can we be absolutely sure? Will we bet more lives on it? From what I know of this case (very little, I admit), I can't say 100% yes or no on either question, so I think we must err on the safe side.
Second cent: Like most jail sentences, the intent here is not only to punish and/or reform the jailed person, but to also dissuade others. From the volume of discussion here, that part seems to be working.
First cent: I agree that the sentence for the engineer involved probably won't make him feel any worse, and he will probably be the most cautious mechanic in the world now (assuming he gets to be a mechanic again), but can we be absolutely sure? Will we bet more lives on it? From what I know of this case (very little, I admit), I can't say 100% yes or no on either question, so I think we must err on the safe side.
Second cent: Like most jail sentences, the intent here is not only to punish and/or reform the jailed person, but to also dissuade others. From the volume of discussion here, that part seems to be working.
Avoid imitations
Joined: Nov 2000
Aviation Qualifications: ATPL
Posts: 15,110
Likes: 1,083
From: Wandering the FIR and cyberspace often at highly unsociable times
I have a great deal of sympathy for all involved, especially the families of the deceased, but including the engineer who appears to have made a terrible error of judgement. Jail sentence or not, he will live with the awful knowledge of his part in this fatal accident.
Personally, I would have thought that although justice must be seen to be done, a jail sentence was perhaps not really appropriate.
My condolences to all.
Personally, I would have thought that although justice must be seen to be done, a jail sentence was perhaps not really appropriate.
My condolences to all.
Fleet Manager
Joined: Apr 2001
Aviation Qualifications: ATPL
Posts: 7,442
Likes: 307
From: various places .....
Thanks to Heliport for noting this thread in another place ....
More than a few questions implicit in this thread.
The enthusiasm with which the police pursue a case in a specialist arena ? .. plenty of similar cases around (eg the Ansett Dash crash in NZ not all that long ago, and the various efforts to acquire CVR data for prosecutions in a variety of jurisdictions) where we all are left wondering why the police spend such effort in going down a "not very useful to safety" pathway... "eye for an eye" considerations aside ... I suppose much of the problem derives from the legal system's endeavours to view life in black and white, rather than real world shades of grey.
The question as to the technician's losing his ticket ? What would that achieve ? Presuming, as seems reasonable, that he is a very experienced and basically competent fellow .. he made a mistake (more specifically a wrong call), apparently due to pressure of work, and the mistake on this occasion proved to have disastrous consequences. He is most unlikely to act without due diligence in the future and, more importantly, one could envisage that he will become a great advocate to his junior colleagues in respect of the need for doing things in a disciplined manner. I, for one, would see little, if any, necessary benefit to be had in taking away his livelihood ... would it not be more useful for his professional competence to be reviewed and any appropriate retraining undertaken ? Had the events been associated with demonstrated and persistent wilful recklessness (ie entrenched cowboy behaviour) one might take a contrary view ...
There are several major engineering points, not at all limited to the rotary community, to be made.
(a) the manufacturer's team puts a lot of dollars into developing a safe-for-flight product. The Type Certification procedure attests that the system's best reckoning is that this has been achieved... not a guarantee ... only a best guess assessment.
Usually, as we see, operational experience points out various flaws in the product which were not detected or foreseen during the initial program and the continuing airworthiness programs are there precisely to address these sorts of problems. When it works well, it works very well ...
The way we get around in service problems involves for the manufacturer or, more correctly, the holder of the Type Certificate .. which may not necessarily be the OEM ..
(i) in some cases, revisiting the certification .. which, in the extreme, can result in the TC's being cancelled or subject to quite onerous restrictions .. at times this avenue results in great cost for the manufacturer only to demonstrate that the original design is fine and that some other gremlin was as work ... eg an operational technique which was inappropriate.
(ii) the manufacturer's internal review processes will review accident/incident/occurence details with a view to figuring out what went on and whether some change(s), either in the design (eg a new part, modification, operational technique, or fatigue limit), maintenance (eg a new procedure or inspection), operations(eg handling guidance to pilots) or whatever is required to maintain TC compliance. Sometimes the perceived significance is so great that the change will be mandated, by AFM/MM change, SB and/or AD. ADs can be initiated either by the manufacturer, in concert with the regulatory authority, or the regulatory authority sometimes will act unilaterally.
In the main, this is taken very seriously by the manufacturer's systems for all the usual commercial reasons .. to which I can attest, having chaired such a group in a previous life.
It is a matter for regret that, sometimes, a manufacturer will lose sight of the safety raison d'etre and try to avoid acknowledging that a problem does exist or delay taking hold of the problem and fixing it. For instance, blow out panels in the widebodies to get around deformation problems following a cargo hold explosive decompression took a little while to filter through.
The matter of fatigue assessment and damage prediction is, to some extent, still a black art and is based very heavily on presumptions as to the way in which the operator is going to operate the aircraft and, quite importantly, the operational environment within which the aircraft is to be operated. Problems which might arise in this arena could include consistent operations rather different to the typical flight profile presumed by the manufacturer's fatigue engineers .. eg extensive operations at low level when the fatigue assumptions were based on a typical flight cycle involving a significant period of cruise above low level mechanical turbulence. Some readers may recall a number of inflight failures when low level pipeline inspections first became popular ... For some aircraft, the manufacturer will endeavour to address this type of problem by specifying different fatigue retirement criteria for different typical flight profiles.
One very significant difficulty in the fatigue area is that of non-terminating damage assessment inspections for damage tolerant designs. The presumption is that the development of a crack (and, despite whatever you might think ... aircraft, being highly loaded structures .. especially in the rotary world ... are going to suffer cracks in all sorts of places) will be predictable over time and that, if we inspect with sufficient frequency, we will detect and be able to correct before the crack gets to a size where the basic airworthiness of the beast deteriorates significantly. Often these inspections are extremely difficult and critical. If either the operational scenario or maintenance procedures change in a way that is unconservative, then the basic assumptions in the inspection process are invalidated.
If a field repair is made which compromises these presumptions, then the whole fatigue design process might just as well be thrown into the circular filing cabinet.
I know nothing more about this specific accident other than what I have read in these threads, but it appears, in this case, that the technician, after seeking specialist advice (which may or may not have been entirely appropriate to the task), made an unfortunate (and consequently tragic) wrong call.
It is a basic requirement in procedures adopted by the signatory States that the technician operate in accordance with approved data .. if he/she doesn't do so for any reason, then there is a breakdown in the protections developed by the system with an increased potential for mishap. It appears that this may have been the root cause of this specific accident.
(b) the manufacturer's published data is the final output of the design/manufacturing process and, invariably, gives precious little detailed information as to what went into the process. The principal consequence of this is that the end user has to be fairly careful in ensuring that the published procedures are, in fact, followed sensibly and accurately. Several consequences of this system are ...
(i) the regulatory systems provide for the approval of in-service modifications (and a weld process different to what the manufacturer specifies .. such as appears to have been involved here.. would definitely be included) following appropriate assessment. The US DER style of system, which is echoed in other countries, establishes a network of specialist professional engineers to provide in-service certification design services either via or external to the manufacturer. In many cases the manufacturer has a lot of data which cannot be obtained by other means other than at great expense .. it follows that the DER type of chappie moves very cautiously ... which would have been the case for this sort of welded structure.
(ii) the usual requirement imposed on the technician is that he/she must work in accordance with approved data (manufacturer's data, DER style approved information, ADs, etc). The question, in this case, of whether the manufacturer specified that the weldment not be rewelded is not the point .. that sort of problem can often be got around by consideration either of how the weld is done or post weld treatment ... the main problem is that the defenses built into the system break down when people make wrong calls.
The question of wrong calls is not exclusive to the technician fraternity in any way .. it applies across the whole spectrum of activities ... what it comes down to is a simple test ... as an appropriately skilled and trained person, in respect of this particular decision/operation, do I know so much about it and is it so basic to my discipline that it is a fundamental skill ? If the answer is yes .. then do whatever is required with appropriate skill and care. If the answer is no .. then go look up some information to resolve whatever the potential problem may be ...
For the techician, we don't expect that he look up a book before spinning a nut onto a bolt .. but we do expect that he refers to approved data to check the torque load to which the nut is to be tightened ...
For the pilot, we don't expect that he look up a book to find out the mechanics of shooting an ILS .. but we do expect that he refers to the plate to check frequencies, courses, minima and the like ...
.. and one can generate similar examples in each and every discipline involved in the aviation game ...
This sort of event, and the consequences of it, should highlight to each and every one of us the need for disciplined and cautious conduct of our various aviation activities ..... as one who has made his fair share of mistakes and wrong calls over the years ... may I echo the sentiment that .. "there, but for the grace of God .. "
More than a few questions implicit in this thread.
The enthusiasm with which the police pursue a case in a specialist arena ? .. plenty of similar cases around (eg the Ansett Dash crash in NZ not all that long ago, and the various efforts to acquire CVR data for prosecutions in a variety of jurisdictions) where we all are left wondering why the police spend such effort in going down a "not very useful to safety" pathway... "eye for an eye" considerations aside ... I suppose much of the problem derives from the legal system's endeavours to view life in black and white, rather than real world shades of grey.
The question as to the technician's losing his ticket ? What would that achieve ? Presuming, as seems reasonable, that he is a very experienced and basically competent fellow .. he made a mistake (more specifically a wrong call), apparently due to pressure of work, and the mistake on this occasion proved to have disastrous consequences. He is most unlikely to act without due diligence in the future and, more importantly, one could envisage that he will become a great advocate to his junior colleagues in respect of the need for doing things in a disciplined manner. I, for one, would see little, if any, necessary benefit to be had in taking away his livelihood ... would it not be more useful for his professional competence to be reviewed and any appropriate retraining undertaken ? Had the events been associated with demonstrated and persistent wilful recklessness (ie entrenched cowboy behaviour) one might take a contrary view ...
There are several major engineering points, not at all limited to the rotary community, to be made.
(a) the manufacturer's team puts a lot of dollars into developing a safe-for-flight product. The Type Certification procedure attests that the system's best reckoning is that this has been achieved... not a guarantee ... only a best guess assessment.
Usually, as we see, operational experience points out various flaws in the product which were not detected or foreseen during the initial program and the continuing airworthiness programs are there precisely to address these sorts of problems. When it works well, it works very well ...
The way we get around in service problems involves for the manufacturer or, more correctly, the holder of the Type Certificate .. which may not necessarily be the OEM ..
(i) in some cases, revisiting the certification .. which, in the extreme, can result in the TC's being cancelled or subject to quite onerous restrictions .. at times this avenue results in great cost for the manufacturer only to demonstrate that the original design is fine and that some other gremlin was as work ... eg an operational technique which was inappropriate.
(ii) the manufacturer's internal review processes will review accident/incident/occurence details with a view to figuring out what went on and whether some change(s), either in the design (eg a new part, modification, operational technique, or fatigue limit), maintenance (eg a new procedure or inspection), operations(eg handling guidance to pilots) or whatever is required to maintain TC compliance. Sometimes the perceived significance is so great that the change will be mandated, by AFM/MM change, SB and/or AD. ADs can be initiated either by the manufacturer, in concert with the regulatory authority, or the regulatory authority sometimes will act unilaterally.
In the main, this is taken very seriously by the manufacturer's systems for all the usual commercial reasons .. to which I can attest, having chaired such a group in a previous life.
It is a matter for regret that, sometimes, a manufacturer will lose sight of the safety raison d'etre and try to avoid acknowledging that a problem does exist or delay taking hold of the problem and fixing it. For instance, blow out panels in the widebodies to get around deformation problems following a cargo hold explosive decompression took a little while to filter through.
The matter of fatigue assessment and damage prediction is, to some extent, still a black art and is based very heavily on presumptions as to the way in which the operator is going to operate the aircraft and, quite importantly, the operational environment within which the aircraft is to be operated. Problems which might arise in this arena could include consistent operations rather different to the typical flight profile presumed by the manufacturer's fatigue engineers .. eg extensive operations at low level when the fatigue assumptions were based on a typical flight cycle involving a significant period of cruise above low level mechanical turbulence. Some readers may recall a number of inflight failures when low level pipeline inspections first became popular ... For some aircraft, the manufacturer will endeavour to address this type of problem by specifying different fatigue retirement criteria for different typical flight profiles.
One very significant difficulty in the fatigue area is that of non-terminating damage assessment inspections for damage tolerant designs. The presumption is that the development of a crack (and, despite whatever you might think ... aircraft, being highly loaded structures .. especially in the rotary world ... are going to suffer cracks in all sorts of places) will be predictable over time and that, if we inspect with sufficient frequency, we will detect and be able to correct before the crack gets to a size where the basic airworthiness of the beast deteriorates significantly. Often these inspections are extremely difficult and critical. If either the operational scenario or maintenance procedures change in a way that is unconservative, then the basic assumptions in the inspection process are invalidated.
If a field repair is made which compromises these presumptions, then the whole fatigue design process might just as well be thrown into the circular filing cabinet.
I know nothing more about this specific accident other than what I have read in these threads, but it appears, in this case, that the technician, after seeking specialist advice (which may or may not have been entirely appropriate to the task), made an unfortunate (and consequently tragic) wrong call.
It is a basic requirement in procedures adopted by the signatory States that the technician operate in accordance with approved data .. if he/she doesn't do so for any reason, then there is a breakdown in the protections developed by the system with an increased potential for mishap. It appears that this may have been the root cause of this specific accident.
(b) the manufacturer's published data is the final output of the design/manufacturing process and, invariably, gives precious little detailed information as to what went into the process. The principal consequence of this is that the end user has to be fairly careful in ensuring that the published procedures are, in fact, followed sensibly and accurately. Several consequences of this system are ...
(i) the regulatory systems provide for the approval of in-service modifications (and a weld process different to what the manufacturer specifies .. such as appears to have been involved here.. would definitely be included) following appropriate assessment. The US DER style of system, which is echoed in other countries, establishes a network of specialist professional engineers to provide in-service certification design services either via or external to the manufacturer. In many cases the manufacturer has a lot of data which cannot be obtained by other means other than at great expense .. it follows that the DER type of chappie moves very cautiously ... which would have been the case for this sort of welded structure.
(ii) the usual requirement imposed on the technician is that he/she must work in accordance with approved data (manufacturer's data, DER style approved information, ADs, etc). The question, in this case, of whether the manufacturer specified that the weldment not be rewelded is not the point .. that sort of problem can often be got around by consideration either of how the weld is done or post weld treatment ... the main problem is that the defenses built into the system break down when people make wrong calls.
The question of wrong calls is not exclusive to the technician fraternity in any way .. it applies across the whole spectrum of activities ... what it comes down to is a simple test ... as an appropriately skilled and trained person, in respect of this particular decision/operation, do I know so much about it and is it so basic to my discipline that it is a fundamental skill ? If the answer is yes .. then do whatever is required with appropriate skill and care. If the answer is no .. then go look up some information to resolve whatever the potential problem may be ...
For the techician, we don't expect that he look up a book before spinning a nut onto a bolt .. but we do expect that he refers to approved data to check the torque load to which the nut is to be tightened ...
For the pilot, we don't expect that he look up a book to find out the mechanics of shooting an ILS .. but we do expect that he refers to the plate to check frequencies, courses, minima and the like ...
.. and one can generate similar examples in each and every discipline involved in the aviation game ...
This sort of event, and the consequences of it, should highlight to each and every one of us the need for disciplined and cautious conduct of our various aviation activities ..... as one who has made his fair share of mistakes and wrong calls over the years ... may I echo the sentiment that .. "there, but for the grace of God .. "
Last edited by john_tullamarine; 19th May 2002 at 01:48.
Joined: Mar 2000
Posts: 5,197
Likes: 1
From: UK
B. Sousa
My US Co-Moderator's decision to close the previous thread was a kind and sensitive gesture with which I agreed entirely.
I understand your concern but, since that time, it has been brought to my attention that Captain Kenyon feels there are many lessons which need to be learnt from this tragedy, including by the regulatory authorities.
Far from wanting people to hold a respectful silence, which inevitably means the crash soon becomes just another statistic, he does not wish this tragedy to be forgotten. He is determined that it should not be forgotten until changes are made ro prevent a similar tragedy happening again. If he succeeds, it will mean that some good will have come out of his son's death.
Captain Kenyon can rest assured that he may use Rotorheads to obtain publicity for his cause so long as we are the Moderators.
My US Co-Moderator's decision to close the previous thread was a kind and sensitive gesture with which I agreed entirely.
I understand your concern but, since that time, it has been brought to my attention that Captain Kenyon feels there are many lessons which need to be learnt from this tragedy, including by the regulatory authorities.
Far from wanting people to hold a respectful silence, which inevitably means the crash soon becomes just another statistic, he does not wish this tragedy to be forgotten. He is determined that it should not be forgotten until changes are made ro prevent a similar tragedy happening again. If he succeeds, it will mean that some good will have come out of his son's death.
Captain Kenyon can rest assured that he may use Rotorheads to obtain publicity for his cause so long as we are the Moderators.
Joined: Jan 2001
Posts: 739
Likes: 0
From: Dallas, TX USA
I find myself in complete agreement with John_tullamarine.
The "system" as it's set up in the aviation world, is in the main a very safe system. Deviation from the regs or procedures of that system, without very expert advice, and manufacturer and governing body approval, can have very tragic consequences.
I had very similar thoughts regarding this accident and intended to post them, but John did it 10 times better than I could have.
The "system" as it's set up in the aviation world, is in the main a very safe system. Deviation from the regs or procedures of that system, without very expert advice, and manufacturer and governing body approval, can have very tragic consequences.
I had very similar thoughts regarding this accident and intended to post them, but John did it 10 times better than I could have.
Joined: Nov 2000
Posts: 185
Likes: 3
MODERATOR
I think all I said was that in my opinion you were out of order. I must admit that I have no idea why you should ask people to give opinions on the legal process, when probably only flying lawyer has all the facts at his disposal or the necessary knowledge of the UK legal process. Inviting ill informed comment of this type has little value.
My thoughts rest with the ex BA captain who commited suicide not so long ago. The legal process is a very blunt instrument and the end results are often unforeseen. In this case inviting people to second guess the decision of a judge who has listened to the whole case seems rather odd.
To turn this tragedy into a quiz question seems to me to be inapropriate.
I think all I said was that in my opinion you were out of order. I must admit that I have no idea why you should ask people to give opinions on the legal process, when probably only flying lawyer has all the facts at his disposal or the necessary knowledge of the UK legal process. Inviting ill informed comment of this type has little value.
My thoughts rest with the ex BA captain who commited suicide not so long ago. The legal process is a very blunt instrument and the end results are often unforeseen. In this case inviting people to second guess the decision of a judge who has listened to the whole case seems rather odd.
To turn this tragedy into a quiz question seems to me to be inapropriate.
The Original Whirly
Joined: Feb 1999
Aviation Qualifications: CPL
Posts: 4,327
Likes: 2
From: Belper, Derbyshire, UK
Rob L,
I for one am finding this discussion useful and informative. Quiz question? No, discussion. The two are different. Exactly WHY do you object to other people discussing it? Nobody's forcing you to read this thread. The people involved, ie Dennis Kenyon, have no objection. So what's it to you?
You don't have to agree with any of us, but we have a right to our opinions. So lay off the moderators, and if you want to make your reasons clear, do so.
Because at the moment all you're doing is effectively yelling that you don't like it.
I for one am finding this discussion useful and informative. Quiz question? No, discussion. The two are different. Exactly WHY do you object to other people discussing it? Nobody's forcing you to read this thread. The people involved, ie Dennis Kenyon, have no objection. So what's it to you?
You don't have to agree with any of us, but we have a right to our opinions. So lay off the moderators, and if you want to make your reasons clear, do so.
Because at the moment all you're doing is effectively yelling that you don't like it.
Joined: May 2002
Posts: 1,704
Likes: 1
From: Who can say?
Perhaps a non-whirly pilot could be permitted to enter the discussion...
The engineer concerned did not fail to check whether a weld could be performed. He knew it could. The problem was, on which side it could be performed, and he got that wrong.
He made a mistake, and had not checked.
He was not jailed (in my understanding) for making the mistake. He was considered negligent in not checking the details of what welding could be performed, and he was jailed for that negligence.
You will not stop people making mistakes by threatening to lock them up. But you may persuade them to be as thoroughly diligent as anyone might wish in the performance of their duties.
This is, as has been expressed many times, a thoroughly tragic case. The engineer concerned has expressed his total and genuine remorse for what happened, and the consequences.
I am not in favour of punishing him further by taking away his licence. What he did was an error of judgement that he (and anyone he trains) will never, ever repeat.
I would prefer to have him working on my aircraft than someone who has yet to learn the same lesson.
The engineer concerned did not fail to check whether a weld could be performed. He knew it could. The problem was, on which side it could be performed, and he got that wrong.
He made a mistake, and had not checked.
He was not jailed (in my understanding) for making the mistake. He was considered negligent in not checking the details of what welding could be performed, and he was jailed for that negligence.
You will not stop people making mistakes by threatening to lock them up. But you may persuade them to be as thoroughly diligent as anyone might wish in the performance of their duties.
This is, as has been expressed many times, a thoroughly tragic case. The engineer concerned has expressed his total and genuine remorse for what happened, and the consequences.
I am not in favour of punishing him further by taking away his licence. What he did was an error of judgement that he (and anyone he trains) will never, ever repeat.
I would prefer to have him working on my aircraft than someone who has yet to learn the same lesson.
Joined: Feb 2001
Posts: 603
Likes: 0
From: US
Genghis:
I was a Civil Engineering student at the time of the walkway collapse at the Hyatt Regency Hotel in Kansas City, MO. There are many places on the web that you can find information about it. Here's one:
http://www.uoguelph.ca/~ajenney/webpage.htm
That collapse was quickly used as a case study in our classes. The web site shown above has sketches of the joint in question, with the original design and the as-built. There were two walkways, one above the other. The original design had both walkways supported by one 30' long (IIRC) rod. Quite rightly, the contractor did not like this design, because it would require threading the support beam for the upper walkway (and its nut) 20' feet up the rod. It was essentially unbuildable.
The as-built redesign had two rods: 1) one rod from the ceiling to the beam supporting the upper walkway, and 2) one rod from the beam supporting the upper walkway to the beam supporting the lower walkway. The box beams in the as-built design were basically unchanged from the original design.
Any structural engineer type (whether civil or mechanical) worth his or her salt will immediately recognize that the as-built places approximately double the load on the box beams supporting the upper walkway. In the original design, the upper beams support only the weight of the upper walkway itself (plus anyone standing on it) -- the load of the lower walkway is supported by tension in the rod. In the as built, the lower walkway is supported by the lower rods. The lower rods are supported by the upper box beams. Thus, in the as-built, the upper beams are now supporting both the upper walkway and the lower walkway.
And then there's the details of the joint itself...
Yes, a number of engineers lost their licenses. There was plenty of blame to go around, however. The original design wasn't great. The redesign was done by the structural fabricators, who should have caught the problem. The designers should have caught the problem when reviewing the redesign. The constructors should have recognized the problem with the redesign as well.
My point ("yes, get to the point!" I hear you say...) is that this was an incredibly obvious error, immediately obvious to most junior year undegraduates.
OFBSLF
(who is no longer a civil engineer and now drives keyboards for a living)
I was a Civil Engineering student at the time of the walkway collapse at the Hyatt Regency Hotel in Kansas City, MO. There are many places on the web that you can find information about it. Here's one:
http://www.uoguelph.ca/~ajenney/webpage.htm
That collapse was quickly used as a case study in our classes. The web site shown above has sketches of the joint in question, with the original design and the as-built. There were two walkways, one above the other. The original design had both walkways supported by one 30' long (IIRC) rod. Quite rightly, the contractor did not like this design, because it would require threading the support beam for the upper walkway (and its nut) 20' feet up the rod. It was essentially unbuildable.
The as-built redesign had two rods: 1) one rod from the ceiling to the beam supporting the upper walkway, and 2) one rod from the beam supporting the upper walkway to the beam supporting the lower walkway. The box beams in the as-built design were basically unchanged from the original design.
Any structural engineer type (whether civil or mechanical) worth his or her salt will immediately recognize that the as-built places approximately double the load on the box beams supporting the upper walkway. In the original design, the upper beams support only the weight of the upper walkway itself (plus anyone standing on it) -- the load of the lower walkway is supported by tension in the rod. In the as built, the lower walkway is supported by the lower rods. The lower rods are supported by the upper box beams. Thus, in the as-built, the upper beams are now supporting both the upper walkway and the lower walkway.
And then there's the details of the joint itself...
Yes, a number of engineers lost their licenses. There was plenty of blame to go around, however. The original design wasn't great. The redesign was done by the structural fabricators, who should have caught the problem. The designers should have caught the problem when reviewing the redesign. The constructors should have recognized the problem with the redesign as well.
My point ("yes, get to the point!" I hear you say...) is that this was an incredibly obvious error, immediately obvious to most junior year undegraduates.
OFBSLF
(who is no longer a civil engineer and now drives keyboards for a living)
Moderator
Joined: Feb 2000
Aviation Qualifications: CPL
Posts: 14,480
Likes: 178
From: UK
Oh dear, I was actually talking about a completely different walkway collapse, the one at http://www.hse.gov.uk/press/e00013.htm two years ago.
Somebody once said to me that there were two differences between a Doctor and an Engineer. One was that a Doctor could bury his mistakes and an Engineer had to live with his. The other was that Doctors can only kill one person at a time.
Yet more evidence, as if it were needed, as to the need for rigour and crosschecking in our profession!
G
Somebody once said to me that there were two differences between a Doctor and an Engineer. One was that a Doctor could bury his mistakes and an Engineer had to live with his. The other was that Doctors can only kill one person at a time.
Yet more evidence, as if it were needed, as to the need for rigour and crosschecking in our profession!
G
Just Dropped In
Joined: May 2001
Posts: 131
Likes: 1
From: um....er.....
I have been following this thread with interest. I share Whirlys sentiments, in that it is very informative.
On the 21st of April 2000 an engineering error caused the tail rotor on the twin squirrel I was flying to fail. The result was a well publicised Police helicopter in the roof of a house in Cardiff.
Thankfully there was no physical injuries to the house occupants or crew.
Mentally it is a different matter. The occupants of the house, the two police officers onboard & the engineers involved have all suffered, as did I, to some degree or other. The occupants of the house & the engineers particularly.
The engineers were suspended, debriefed, retrained & returned to work.
Lessons were learnt by all.
The engineer jailed in this tragic accident made a mistake, a mistake with tragic consequences. But he stood up & admitted his mistake.
The family of all concerned must have suffered terribly & my heart goes out to them.
But make no mistake, the engineer will have suffered too.
How does a prison sentance serve any purpose at all. Obviously steps must be taken to minimise & hopefully eradicate mistakes within the aviation world....but jailing a man? It serves no purpose to further punish a man, who will already have punished himself far more severly than anyone else can & he will continue to do so.
& what of the regulatory body that failed to regulate? Are we jailing CAA inspectors too for signing the C of A? Please don't forget that these regulatory bodies were involved aswell.
Are we to further compound this tragedy by learning nothing?
Capt. Stable you said it well, I would rather have the gentleman concerned servicing my aircraft than someone yet to learn by mistakes.
For the record.
I feel that all of us who are involved in aviation take upon ourselves a vast responsibility... be we pilots, engineers, ATCOs or otherwise. We pride ourselves on our professionalism, and are right to do so.
I have accepted the responsibilty of flying the machine, but I would not wish to bear the burden placed upon our engineers.
I feel for all concerned.
Mr Kenyon.... I salute you.
My heart, thoughts & prayers are with you & your familly.
On the 21st of April 2000 an engineering error caused the tail rotor on the twin squirrel I was flying to fail. The result was a well publicised Police helicopter in the roof of a house in Cardiff.
Thankfully there was no physical injuries to the house occupants or crew.
Mentally it is a different matter. The occupants of the house, the two police officers onboard & the engineers involved have all suffered, as did I, to some degree or other. The occupants of the house & the engineers particularly.
The engineers were suspended, debriefed, retrained & returned to work.
Lessons were learnt by all.
The engineer jailed in this tragic accident made a mistake, a mistake with tragic consequences. But he stood up & admitted his mistake.
The family of all concerned must have suffered terribly & my heart goes out to them.
But make no mistake, the engineer will have suffered too.
How does a prison sentance serve any purpose at all. Obviously steps must be taken to minimise & hopefully eradicate mistakes within the aviation world....but jailing a man? It serves no purpose to further punish a man, who will already have punished himself far more severly than anyone else can & he will continue to do so.
& what of the regulatory body that failed to regulate? Are we jailing CAA inspectors too for signing the C of A? Please don't forget that these regulatory bodies were involved aswell.
Are we to further compound this tragedy by learning nothing?
Capt. Stable you said it well, I would rather have the gentleman concerned servicing my aircraft than someone yet to learn by mistakes.
For the record.
I feel that all of us who are involved in aviation take upon ourselves a vast responsibility... be we pilots, engineers, ATCOs or otherwise. We pride ourselves on our professionalism, and are right to do so.
I have accepted the responsibilty of flying the machine, but I would not wish to bear the burden placed upon our engineers.
I feel for all concerned.
Mr Kenyon.... I salute you.
My heart, thoughts & prayers are with you & your familly.
Last edited by Roofus; 25th May 2002 at 23:43.
Guest
Posts: n/a
Unfortunately, OFBSLF and Ghengis are quite off base in the walkway analogy, and roofus perpetuates it in his post.
The Engineer in the helicopter case is not an engineer, he is a mechanic, authorized to follow repair guidelines and fix aircraft. He can change the oil. He can use nuts and bolts to change a part. He can conduct authorized repairs using maintenance procedures and common aerospace techniques.
He is not educated or trained as a true professional Engineer, and is not capable of originating or approving a design in any sense. He is not paid to originate a new design or repair technique, he cannot change the maintenance manual that a professional engineer wrote.
It is unfortunate that British usage of "engineer" blurs this important destinction. Most of the world uses a different title for mechanic than for engineer, to avoid this error. British usage stems from the fact that the terms were in use before the profession of engineer was differentiated, and before engineering schools were created.
The Engineer in the helicopter case is not an engineer, he is a mechanic, authorized to follow repair guidelines and fix aircraft. He can change the oil. He can use nuts and bolts to change a part. He can conduct authorized repairs using maintenance procedures and common aerospace techniques.
He is not educated or trained as a true professional Engineer, and is not capable of originating or approving a design in any sense. He is not paid to originate a new design or repair technique, he cannot change the maintenance manual that a professional engineer wrote.
It is unfortunate that British usage of "engineer" blurs this important destinction. Most of the world uses a different title for mechanic than for engineer, to avoid this error. British usage stems from the fact that the terms were in use before the profession of engineer was differentiated, and before engineering schools were created.