Firefighting Helicopter Down west of Edmonton
Heath Coleman was widely regarded amongst those who new him as an excellent person, pilot, and colleague. I have many happy memories of working with and for him and his training was superb. May he Rest In Peace, he will be well remembered by many.
FP
FP
Join Date: Dec 2018
Location: Canada
Posts: 170
Likes: 0
Received 0 Likes
on
0 Posts
Join Date: Mar 2014
Location: Canada
Posts: 59
Likes: 0
Received 0 Likes
on
0 Posts
https://tsb.gc.ca/eng/enquetes-investigations/aviation/2021/A21W0045/A21W0045.html
Air transportation safety investigation A21W0045
TSB has completed this investigation. The report was published on 7 September 2022.
https://tsb.gc.ca/eng/rapports-repor.../a21w0045.html
Final Report
Yellowhead Helicopters Ltd.
Bell Textron Inc. 212 (helicopter), C-GYHQ
Evansburg, Alberta, 4 NM WNW
28 June 2021
Exerpts:
Metallurgical analysis of the 4 pins (part number 204-012-104-005) revealed that the failed pin (serial number FNFS90, bottom of Figure 7) was manufactured from 316 stainless steel, whereas the other 3 pins (serial numbers FNFS49, FNFS54, and FNFS75) were manufactured from H11 tool steel.
The TSB Rockwell hardness test of the failed pin averaged 7.6 on the C scale
The Bell engineering drawing used to manufacture the part number 204-012-104-003 pin specified a hardness of 50.0 to 53.5 on the Rockwell C scale as a critical characteristic of that pin. This characteristic is obtained through the double-tempering process on H11 tool steel.
The investigation determined that, when the occurrence pins were manufactured in the fall of 2018, FMC stored the raw material in its stores area by material diameter, not by type or composition. This meant, for example, that all rods that were 1 inch in diameter were stored together, regardless of the material they were made of (aluminum, carbon steel, stainless steel, brass, etc.). As a result, the onus was on the individual selecting the material for the job at hand to ensure that it was of the correct composition and specification.
On 02 October 2018, the stores department at FMC released the 8 rods of H11 tool steel to the production floor to begin the manufacturing process.
The investigation determined that the 8 rods of H11 tool steel would have yielded only approximately 320 pins.
From 12 to 14 November 2018, the rods of raw material, which varied in length from 132 to 156 inches, were cut up into 36-inch lengths and then further cut into 3.3-inch lengths. The resulting 343 pieces ...
Air transportation safety investigation A21W0045
TSB has completed this investigation. The report was published on 7 September 2022.
https://tsb.gc.ca/eng/rapports-repor.../a21w0045.html
Final Report
Yellowhead Helicopters Ltd.
Bell Textron Inc. 212 (helicopter), C-GYHQ
Evansburg, Alberta, 4 NM WNW
28 June 2021
Exerpts:
Metallurgical analysis of the 4 pins (part number 204-012-104-005) revealed that the failed pin (serial number FNFS90, bottom of Figure 7) was manufactured from 316 stainless steel, whereas the other 3 pins (serial numbers FNFS49, FNFS54, and FNFS75) were manufactured from H11 tool steel.
The TSB Rockwell hardness test of the failed pin averaged 7.6 on the C scale
The Bell engineering drawing used to manufacture the part number 204-012-104-003 pin specified a hardness of 50.0 to 53.5 on the Rockwell C scale as a critical characteristic of that pin. This characteristic is obtained through the double-tempering process on H11 tool steel.
The investigation determined that, when the occurrence pins were manufactured in the fall of 2018, FMC stored the raw material in its stores area by material diameter, not by type or composition. This meant, for example, that all rods that were 1 inch in diameter were stored together, regardless of the material they were made of (aluminum, carbon steel, stainless steel, brass, etc.). As a result, the onus was on the individual selecting the material for the job at hand to ensure that it was of the correct composition and specification.
On 02 October 2018, the stores department at FMC released the 8 rods of H11 tool steel to the production floor to begin the manufacturing process.
The investigation determined that the 8 rods of H11 tool steel would have yielded only approximately 320 pins.
From 12 to 14 November 2018, the rods of raw material, which varied in length from 132 to 156 inches, were cut up into 36-inch lengths and then further cut into 3.3-inch lengths. The resulting 343 pieces ...
Quote: “The investigation determined that, when the occurrence pins were manufactured in the fall of 2018, FMC stored the raw material in its stores area by material diameter, not by type or composition. This meant, for example, that all rods that were 1 inch in diameter were stored together, regardless of the material they were made of (aluminum, carbon steel, stainless steel, brass, etc.). As a result, the onus was on the individual selecting the material for the job at hand to ensure that it was of the correct composition and specification.”
Words fail me!
Words fail me!
Someone is going to get sued for a lot of money for that cockup.
Albatross.....I shall offer some words about that......"Now what could possibly go wrong with a system like that?".
Who could possibly thought there was no risk of harm with such a concept?
How many QA inspections and reviews took place with that not be discovered and fixed that would have prevented that death of a good and decent innocent Man?
I would love to be sitting on the Jury for that Civil Suit....as there would be some bankruptcies as a result.
Were I Criminal Prosecutor I might be looking into a case that would result in criminal charges.
This kind of thing is not just another "Golly Gee Whiz...we sure messed up on that one!" event and that be it over and done with.
Who could possibly thought there was no risk of harm with such a concept?
How many QA inspections and reviews took place with that not be discovered and fixed that would have prevented that death of a good and decent innocent Man?
I would love to be sitting on the Jury for that Civil Suit....as there would be some bankruptcies as a result.
Were I Criminal Prosecutor I might be looking into a case that would result in criminal charges.
This kind of thing is not just another "Golly Gee Whiz...we sure messed up on that one!" event and that be it over and done with.
The initial error was shocking enough. But the the defective pins were identified at the heat treater and came back in a separate box with a red tag, individually marked with yellow lines, and bearing distinctly different oxide colors. They were somehow mixed back in, and later recorded as passing(!) hardness tests. (I'd also be surprised if the huge difference in hardness wasn't obvious when the parts were stamped with serial numbers, though the report doesn't say exactly how that was done.) Maybe they got confused over whether they were manufacturing helicopter parts or paperweights?
I'd also be surprised if the huge difference in hardness wasn't obvious when the parts were stamped with serial numbers
Join Date: Mar 2014
Location: Canada
Posts: 59
Likes: 0
Received 0 Likes
on
0 Posts
Links from the public domain w/ excerpts:
.
.
- https://www.bloomberg.com/profile/company/0001963D:US
Fore Machine Company, Inc. was founded in 1978. The company's line of business includes manufacturing industrial machinery.
5912 Eden Dr Fort Worth, TX 76117 United States
. - https://www.bloomberg.com/profile/co...D:US#xj4y7vzkg
Fore Machine, LLC manufactures aircraft engines and engine parts. The Company offers CNC machining, structural bonding, mechanical assembly, metal finishing, and sheet metal fabrication services. Fore Machine serves defense and aerospace industries in the State of Texas.
INCORPORATED: 01/23/2017
5933 Eden Drive Haltom City, TX 76117 United States
. - https://www.prnewswire.com/news-rele...300469825.html
FORT WORTH, Texas, June 6, 2017 /PRNewswire/ --
P4G Capital Partners ("P4G Capital") announced today [2017] that it has acquired the assets of Fore Machine Company, Inc. ("Fore Machine", www.foremachine.com) and Aero Components, Inc. ("Aero Components", www.aero-components.com).
The management teams of both companies will be staying on and rolling a significant portion of their proceeds into the new entity as the companies expand their operations to provide even better response times, quality, and service to their customers with enhanced capabilities and even more control over chemical processes.
"Fore Machine and Aero Components represent the perfect first investment for our new platform," said Rachel Lehman, Managing Director of P4G Capital. "We're excited to be working side-by-side with these amazing companies and the fantastic people that make these companies great."
. - .https://www.indeed.com/cmp/Fore-Machine/reviews
Working at Fore Machine: 15 Reviews
. - https://reorg.com/aero-components-restructuring/
CASE SUMMARY: Aero Components to Reorganize With Remaining Debtors Liquidating Through RSA That Would Provide Sponsor With 100% of New Equity
See: "Events Leading to the Bankruptcy / Prepetition Restructuring Efforts"
See also: "Background"
"the debtors’ overall financial health has suffered as a result of complications with debtor Fore Machine that led to the loss of its primary customer, liquidity constraints and the ultimate decision by the debtors board to cease Machine’s operations in November 2021."
"“Despite Machine’s corrective actions,” in November Bell canceled all outstanding purchase orders with Machine"
Complications.
"“Despite Machine’s corrective actions,” in November Bell canceled all outstanding purchase orders with Machine"
Complications.
Join Date: Mar 2014
Location: Canada
Posts: 59
Likes: 0
Received 0 Likes
on
0 Posts
Yes.
Following that passage, appearing under Background
.
I do not know the circumstances of this case, but one scenario that springs to mind is of a long established, family-owned company that has been passed down to a second generation which then, out of necessity or ambition, invites outside money and influence into the board room to secure survival or spur growth - with predictable consequences. And in this instance, what I am sure were unintended outcomes.
The restructuring document features comments about demand-vs-capacity issues in 2020. The crash investigation report features remarks about issues in 2017. Reviewers on Indeed.com claiming to be employees post remarks mentioning demand-vs-cap issues going back some time from 2021.
.
Following that passage, appearing under Background
.
"Machine’s primary customer, Bell Helicopter, ended its relationship with the debtors in November 2021, threatening Machine’s near-term going concern capacity and leading to the debtors’ board’s ultimate decision to cease all operations to preserve cash. The board and its advisors concluded that, given the proprietary nature of the Machine’s equipment, assemblies and processes, a sale to Bell would maximize the value of Machine’s assets for its stakeholders. With the exception of a relatively small amount of inventory and work-in -progress inventory, Machine’s offer to sell substantially all of its assets was rejected by Bell."
.I do not know the circumstances of this case, but one scenario that springs to mind is of a long established, family-owned company that has been passed down to a second generation which then, out of necessity or ambition, invites outside money and influence into the board room to secure survival or spur growth - with predictable consequences. And in this instance, what I am sure were unintended outcomes.
The restructuring document features comments about demand-vs-capacity issues in 2020. The crash investigation report features remarks about issues in 2017. Reviewers on Indeed.com claiming to be employees post remarks mentioning demand-vs-cap issues going back some time from 2021.
.
Last edited by EddyCurr; 10th Sep 2022 at 08:04.
What boggles my mind is that the company must have been extremely aware of the stringent requirements for the manufacture of these critical parts. After all, even from reading the report we can tell that a significant emphasis was placed on quality control and certification - on paper. But with all these hoops they had to jump through, in the end they still didn't seem to take quality control seriously. In any decent aviation company I've ever worked at, obvious problems, like storing different materials together that are easily confused, would've been noted by someone and reported in a safety management system to be investigated and rectified.
It sounds like this company and its employees didn't understand why all the certification was being required to begin with, as if they were making door latches for garbage cans or something.
It sounds like this company and its employees didn't understand why all the certification was being required to begin with, as if they were making door latches for garbage cans or something.
EddyCurr, in passing on link to the TSB report, included a few excerpts. But I think these are also noteworthy:
1.17.4.1 Oversight of Fore Machine Company: ...Without parts manufacturing authority, FMC could not certify the parts it was manufacturing as airworthy; therefore, Bell would inspect and certify the products FMC produced, and issue the appropriate airworthiness documentation when it later sold those parts to customers.
but earlier in the report:1.17.2.3 Process for first article inspection: Bell has a first article inspection validation process in place to assess the manufacturing production process and to assess the final product the first time a vendor produces a new part for Bell. ...In this case, the first article inspection validation was carried out at the vendor’s facility (FMC). The third party service provider inspector logs in to Bell’s IT systems to complete and document the inspection process just as an inspector who worked directly for Bell would do.
What boggles my mind is that the company must have been extremely aware of the stringent requirements for the manufacture of these critical parts
A partial seizure of the right engine-driven fuel pump’s (EDFP) spindle shaft and sleeve bearing, resulted in high torsional loads. As a result of those high loads, the drive coupling to the EDFP sheared. Consequently, the EDFP was unable to provide sufficient fuel flow to sustain engine operation at take-off power.
Metallurgical examination of the sleeve bearing and spindle shaft from the EDFP revealed localised galling damage - an abnormal wear mechanism that can lead to high friction and seizure. The sleeve bearing had been remanufactured under the specifications of an engineering order during the last component overhaul. Although the manufacture of the replacement component correctly complied with the requirements of the engineering order, the specified material did not possess the galling resistance properties required for use with a high-speed fuel pump.
Metallurgical examination of the sleeve bearing and spindle shaft from the EDFP revealed localised galling damage - an abnormal wear mechanism that can lead to high friction and seizure. The sleeve bearing had been remanufactured under the specifications of an engineering order during the last component overhaul. Although the manufacture of the replacement component correctly complied with the requirements of the engineering order, the specified material did not possess the galling resistance properties required for use with a high-speed fuel pump.
Poor compensation for a Life and all of the harm it caused to the family in its loss of a family member.
Sometimes I do like Lawyers when I see a fair and legitimate demand for compensation is obtained.
I wonder if Punitive Damages were bargained away during the settlement process.
Sometimes I do like Lawyers when I see a fair and legitimate demand for compensation is obtained.
I wonder if Punitive Damages were bargained away during the settlement process.
The following users liked this post:
