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AAIB June2018

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Old 26th Jun 2018, 09:49
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AAIB June2018

AW109 SP Grand New G-IWFC

Unlatched hatch contacts main rotors during test flight.
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Old 26th Jun 2018, 10:49
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You've gotta attach most of the blame (not all of it) to the pilot - haven't you?
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Old 26th Jun 2018, 13:30
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Originally Posted by Thomas coupling
You've gotta attach most of the blame (not all of it) to the pilot - haven't you?
Good job we are not under CAA control, or we would be fitting mandatory cowling latch mods to every 109 Helicopter.......
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Old 26th Jun 2018, 16:27
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Originally Posted by Thomas coupling
You've gotta attach most of the blame (not all of it) to the pilot - haven't you?
I read it as that the cowling was opened and closed rotors running (by the second engineer), which photos of the type show to be feasible, rather than that the pilot missed it in his pre-flight. Could be wrong of course.
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Old 26th Jun 2018, 20:56
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A BT was issued a while back, explaining how the catches themselves, if incorrectly operated, could sit flush with the cowling, as per normal, but in fact the "hook" of the catch missed the "hoop" on the airframe.

A "gotcha" that was pointed out to me many years ago, during my initial walk round lesson.
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Old 26th Jun 2018, 21:10
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Yep - I’m afraid this is an old ‘gotcha’ of this latch type - such a shame that it is still catching people out - shows either a failure of type rating teaching or regulatory oversight.
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Old 27th Jun 2018, 06:03
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Sounds more like a poor design!
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Old 27th Jun 2018, 09:58
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This kind of nonsense is typical of manufacturers of all kinds.

A proven problem / weakness is identified - in this case a latch that can be put in a position where it appears to be closed and is not. Their solution is not to redesign the latch so that it is unambiguous, their "solution" is to tell people about their crap design so they can say "we warned you it was crap so if you make a mistake it's your fault".

How's that for a Safety Culture we can all be proud of eh?
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Old 27th Jun 2018, 14:29
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Is this really a proven problem? Anyone know of other incidents? It is very obvious from the feel of these catches whether the finger has caught the latch. And the slightest tug on closing the cowling will show whether it has latched. This is clearly a basic engineer error - no doubt aggravated by the fact the cowling closing was done in a hurry in a noisy, turbulent rotors running environment. And I bet it won't happen again at Sywell!

Does it need a redesign - that would no doubt cost all owners circa £5k - £10k? No!
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Old 30th Jun 2018, 07:46
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So safety is fine as long as doesn't cost the owner more money? Nice!
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Old 30th Jun 2018, 08:36
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If every catch or control was redesigned so that it would be impossible to make a mistake the aircraft would be impossible to service or operate.
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Old 30th Jun 2018, 09:19
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Originally Posted by Fareastdriver
If every catch or control was redesigned so that it would be impossible to make a mistake the aircraft would be impossible to service or operate.
That's true - However, on at least one type I've flown it was possible for the catches to appear to be secure when they were not. They insist (sensibly) that we paint the inside of a footwell step in a contrasting colour in case it is left open for flight (consequences absolutely none) but on the other hand they take no action for a demonstrated human factors trap such as this that could quite easily take out the helicopter and it's occupants.

I'm not suggesting that they should be designed to preclude any kind of mistake, however, surely it is not beyond the wit of man to design and construct a fastener that can't appear to be closed when it's not!

And I remain deeply cynical of the continued attitude of OEMs in cases like this. "We've warned you about our crap design so it's you problem if you make a mistake". And then they bombard you with spam SBs written by their legal department rather than their engineers listing all the ways it's not their fault if you screw up. "Look at SB blah blah blah Your Honour - We clearly told him it was dangerous to make this mistake with our equipment so how can it be our fault?"
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Old 30th Jun 2018, 09:37
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The AW 109 has been in service for over forty years. The catch involved has been installed in hundreds of thousands of aircraft from the 1930s. It's a but late to throw ones hands up in horror because somebody did it wrong.
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Old 30th Jun 2018, 09:46
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Shades of the BK117 engine bay doors, which started with two catches each and now have five!
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Old 30th Jun 2018, 10:21
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On the S76 we had a problem with similar catch. They attached a short plate over the loose end which was locked down with a dzus fastener. They issued us with a small piece of metal with blade ends so that you could unlock and lock them when offshore.

I never saw them on any other company's aircraft.
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