Scandal or not? CAA rejects AAIB criticism and safety recommendations!
Answering the question directed at me:-
Just a smallie for Genghis - is it lawful for me to leave the cluster on my Schweizer 269, G-DRKJ unpainted - just varnished. I know that I couldn't detect the crack on G-ZAPS through the paint and a little dirt. So that is MY FIX. I hope not wrong.
Since you've asked the question publically, I have to publically say I've no rotary wing maintenance qualifications - any RW engineering training I have is on the design and certification side, so no idea about the specific legalities I'm afraid.
Having said that, I have regularly in my certification work refused engineering designs specifically because surface treatments were used in fatigue critical areas that I considered had significant potential to hide cracking or (equally seriously) corrosion.
There are specific aircraft surface treatments available that will crack with the substrate (underlying material) and I'd certainly recommend you check what's (a) available, and (b) approved for your aircraft.
Incidentally, dry dirt is a wonderful crack detection tool. It is amazing how often fatigue cracks show up in the surface muck as lines of different colour, long before the crack is visible to the naked eye. I'm a great believer in a qualified person inspecting an airframe immediately before it's washed.
In a wider context
Mr Kenyon. Like many people I've lost friends and colleagues in aviation accidents; however, despite that I can only guess at the personal impact that the loss of your son has had. Could I take an opportunity to express my respect for your approach and attitude, when a lesser man might have simply walked away and tried to forget, or simply descended into vitriol.
If I can be of any assistance in what you're trying to do, not as a rotary wing expert - which I'm not particularly, but as somebody who is a CAA whole-aircraft design signatory and thus familiar with the processes, competencies and personalities that surround this whole thing, as well as a degree of professional credibility as an aeronautical engineer then please drop me an Email.
We all have to detail with the CAA, and this underlying attitude, competence (or lack thereof) and approach needs knocking on the head before it further impacts other areas, as much as for the safety of Hughes 300 crews.
G
Just a smallie for Genghis - is it lawful for me to leave the cluster on my Schweizer 269, G-DRKJ unpainted - just varnished. I know that I couldn't detect the crack on G-ZAPS through the paint and a little dirt. So that is MY FIX. I hope not wrong.
Since you've asked the question publically, I have to publically say I've no rotary wing maintenance qualifications - any RW engineering training I have is on the design and certification side, so no idea about the specific legalities I'm afraid.
Having said that, I have regularly in my certification work refused engineering designs specifically because surface treatments were used in fatigue critical areas that I considered had significant potential to hide cracking or (equally seriously) corrosion.
There are specific aircraft surface treatments available that will crack with the substrate (underlying material) and I'd certainly recommend you check what's (a) available, and (b) approved for your aircraft.
Incidentally, dry dirt is a wonderful crack detection tool. It is amazing how often fatigue cracks show up in the surface muck as lines of different colour, long before the crack is visible to the naked eye. I'm a great believer in a qualified person inspecting an airframe immediately before it's washed.
In a wider context
Mr Kenyon. Like many people I've lost friends and colleagues in aviation accidents; however, despite that I can only guess at the personal impact that the loss of your son has had. Could I take an opportunity to express my respect for your approach and attitude, when a lesser man might have simply walked away and tried to forget, or simply descended into vitriol.
If I can be of any assistance in what you're trying to do, not as a rotary wing expert - which I'm not particularly, but as somebody who is a CAA whole-aircraft design signatory and thus familiar with the processes, competencies and personalities that surround this whole thing, as well as a degree of professional credibility as an aeronautical engineer then please drop me an Email.
We all have to detail with the CAA, and this underlying attitude, competence (or lack thereof) and approach needs knocking on the head before it further impacts other areas, as much as for the safety of Hughes 300 crews.
G
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Nothing, but nothing, is more important than this issue.
The hypocrisy and inconsistency of the CAA's position can be well illustrated by the AD issued last year to all Bell 47 operators. One or two cracks were found in main rotor grips (to the best of my knowledge the first in over thirty years on several thousand B47s) and the life of the component was halved, effectively grounding all B47s that had grips over TSN 1200 hours. It necessitated the replacement of such grips at a cost of £8k a set and caused a world-wide shortage in the process. Leaving aside the arguable justification for this AD, my point is that the practical evidence of this problem i.e. one or two ships, was substantially less in number than those 269s known to have had the clevis lug cracks.
Why not the same reaction from the CAA to the 269 problem that if ignored will result in deaths on average every four years?
I have no useful knowledge of the 269 but perhaps the B47 illustration may be of use to illuminate the CAA's ridiculous stance on this. It's shameful and their desperation to avoid direct criticism over what we all understand to be the purpose of a CofA is transparent.
The hypocrisy and inconsistency of the CAA's position can be well illustrated by the AD issued last year to all Bell 47 operators. One or two cracks were found in main rotor grips (to the best of my knowledge the first in over thirty years on several thousand B47s) and the life of the component was halved, effectively grounding all B47s that had grips over TSN 1200 hours. It necessitated the replacement of such grips at a cost of £8k a set and caused a world-wide shortage in the process. Leaving aside the arguable justification for this AD, my point is that the practical evidence of this problem i.e. one or two ships, was substantially less in number than those 269s known to have had the clevis lug cracks.
Why not the same reaction from the CAA to the 269 problem that if ignored will result in deaths on average every four years?
I have no useful knowledge of the 269 but perhaps the B47 illustration may be of use to illuminate the CAA's ridiculous stance on this. It's shameful and their desperation to avoid direct criticism over what we all understand to be the purpose of a CofA is transparent.
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For Genghis - from Dennis Kenyon.
Thanks indeed for your notes and advice. Without an engineering background, I just figured that I'm more likely to eyeball a crack if the metal is there to be seen. But I appreciate that's simple pilot talk. I'll check elsewhere for the proper position. (not the CAA I'd now have to say)
But to ask a view. Sir - how do you personally see the CAA's position.
Am I missing something when I suggest they have been 'grossly negligent' How else can it be when a decision 'not to act - is followed by a further fatal. Paul Kenward failed to consult the proper documentation and was placed on a manslaughter charge. So why don't I have a similar charge levelled at the CAA.
I have said previously that I am trying to keep emotion out of this thread, but the bald truth of this situation remains.
Had the CAA acted in the early days my son would not have lost his life in a totally avoidable accident. In March 2000 I made this statement: "G-ZAPS was the eighth left hand clevis fatigue failure accident and if the CAA or FAA do not act there will be a ninth." I feel nothing but anger that my words turned to reality in November 2002.
I can only repeat, this is a totally unacceptable situation. Please can we hear from others who feel the same or please justify the reverse position.
Sincerely to all.
Dennis Kenyon.
Thanks indeed for your notes and advice. Without an engineering background, I just figured that I'm more likely to eyeball a crack if the metal is there to be seen. But I appreciate that's simple pilot talk. I'll check elsewhere for the proper position. (not the CAA I'd now have to say)
But to ask a view. Sir - how do you personally see the CAA's position.
Am I missing something when I suggest they have been 'grossly negligent' How else can it be when a decision 'not to act - is followed by a further fatal. Paul Kenward failed to consult the proper documentation and was placed on a manslaughter charge. So why don't I have a similar charge levelled at the CAA.
I have said previously that I am trying to keep emotion out of this thread, but the bald truth of this situation remains.
Had the CAA acted in the early days my son would not have lost his life in a totally avoidable accident. In March 2000 I made this statement: "G-ZAPS was the eighth left hand clevis fatigue failure accident and if the CAA or FAA do not act there will be a ninth." I feel nothing but anger that my words turned to reality in November 2002.
I can only repeat, this is a totally unacceptable situation. Please can we hear from others who feel the same or please justify the reverse position.
Sincerely to all.
Dennis Kenyon.
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I am a newcommer to this forum and having read through all of this file I can only hold my head in my hands in dispair.
Here is an obvious problem that shows yet again the awfulness of the British aviation regulating authority, CAA.
The CAA I understand are amongst many things, mandated to upholding the rules and regulations (the police of flying) and authorising aircraft and associated systems for safe operations(certification).
They are lightening quick to do the police business because I guess it must be easy money. There is a rule which has been broken, go to court, judge gives ruling, end of story. Here the CAA plays the proscecuter.
Now in this case they are the accused or at least it appears so, and they don't like to go to court and be judged.
It takes a brave man to stand up and say 'I'm sorry, I was wrong, and I will make amends'
Or have I got it wrong?
Here is an obvious problem that shows yet again the awfulness of the British aviation regulating authority, CAA.
The CAA I understand are amongst many things, mandated to upholding the rules and regulations (the police of flying) and authorising aircraft and associated systems for safe operations(certification).
They are lightening quick to do the police business because I guess it must be easy money. There is a rule which has been broken, go to court, judge gives ruling, end of story. Here the CAA plays the proscecuter.
Now in this case they are the accused or at least it appears so, and they don't like to go to court and be judged.
It takes a brave man to stand up and say 'I'm sorry, I was wrong, and I will make amends'
Or have I got it wrong?
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As someone from well outside the UK it is apparent that several things stand out.
I am surprised that the CAA allows you to maintain a helicopter to LAMS. I thought that this was intended for older fixed wing types which had no manufacturers maintenance schedule.
The SIN on these clusters has been around since about 1975 and an FAA AD was first issued about the same time.
I would doubt that any of this scenario would have occurred had the aircraft been maintained in accordance with the Instructions for Continuing Airworthiness as required by a Type Certificate which would have included compliance with SIN's. This may have also precluded the attempt at a weld repair as the procedure is not documented.
It is tragic that this "problem" which is well known in the 300 "community" was not controlled accordingly.
Just because something is legal does not necccessarily mean it is safe. As to a CAA surveyor determining airworthiness of an aircraft I am afraid that is not and will never be the case. The LAME determines airworthiness, a surveyor can only establish compliance by the LAME with current regulations. You will never see an Airworthiness authority actually release an aircraft to service.
I have always been amazed at the attitude that a "fresh" 100 or annual is thought by some to be a guarantee of safety or continuing airworthiness until the next scheduled inspection. Nothing could be further from the truth.
I am surprised that the CAA allows you to maintain a helicopter to LAMS. I thought that this was intended for older fixed wing types which had no manufacturers maintenance schedule.
The SIN on these clusters has been around since about 1975 and an FAA AD was first issued about the same time.
I would doubt that any of this scenario would have occurred had the aircraft been maintained in accordance with the Instructions for Continuing Airworthiness as required by a Type Certificate which would have included compliance with SIN's. This may have also precluded the attempt at a weld repair as the procedure is not documented.
It is tragic that this "problem" which is well known in the 300 "community" was not controlled accordingly.
Just because something is legal does not necccessarily mean it is safe. As to a CAA surveyor determining airworthiness of an aircraft I am afraid that is not and will never be the case. The LAME determines airworthiness, a surveyor can only establish compliance by the LAME with current regulations. You will never see an Airworthiness authority actually release an aircraft to service.
I have always been amazed at the attitude that a "fresh" 100 or annual is thought by some to be a guarantee of safety or continuing airworthiness until the next scheduled inspection. Nothing could be further from the truth.
Whilst a LAME does indeed release an individual aircraft as fit for service, a CAA surveyor (by which I mean DLS) releases the aircraft TYPE as fit for service. An aircraft can be superbly maintained, but if the basic design is deficient it is still not safe. (And of-course, the converse is also true).
In other words, both must be got right.
G
In other words, both must be got right.
G
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John: You say: 'It is tragic that this "problem" which is well known in the 300 "community"...
I'm not sure it was well-known in the 300 community. I've spoken to a number of high-time 300 pilots, and none of them knew of it until the manslaughter charge. As to engineers, Paul Kenward certainly had an imperfect grasp of it.
On the FAA AD back around 1975, I haven't been able to trace that. Do you have more information?
I'm not sure it was well-known in the 300 community. I've spoken to a number of high-time 300 pilots, and none of them knew of it until the manslaughter charge. As to engineers, Paul Kenward certainly had an imperfect grasp of it.
On the FAA AD back around 1975, I haven't been able to trace that. Do you have more information?
FAA AD 2001-25-52 (reproduced in the AAIB report) supercedes FAA AD 76-18-01, which I presume is the original AD that John refers to.
Dennis, in reference to your question about leaving the affected welded area visible, this is a common practice on other types that require frequent reccurring inspection. We generally reprotect the area with aerosol spray clear lacquer. It is not uncommon to see highly stressed areas of airframe devoid of any painted finish, to facilitate easy and thorough inspection.
Although you should confer with your maintenance provider and approved maintenance instructions, it is unusual for any manufacturer to specify a paint or other finish for a part (there are exceptions; blades, etc.), other than a specifically prohibited type of finish. What you are proposing is a very good solution to ensuring the continued Airworthiness of the affected part.
I am very sorry about what happened to your son. I am still digesting the remainder of the report and its proposals.
Dennis, in reference to your question about leaving the affected welded area visible, this is a common practice on other types that require frequent reccurring inspection. We generally reprotect the area with aerosol spray clear lacquer. It is not uncommon to see highly stressed areas of airframe devoid of any painted finish, to facilitate easy and thorough inspection.
Although you should confer with your maintenance provider and approved maintenance instructions, it is unusual for any manufacturer to specify a paint or other finish for a part (there are exceptions; blades, etc.), other than a specifically prohibited type of finish. What you are proposing is a very good solution to ensuring the continued Airworthiness of the affected part.
I am very sorry about what happened to your son. I am still digesting the remainder of the report and its proposals.
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The current AD is here: http://www.airweb.faa.gov/Regulatory...6?OpenDocument
2001-25-52 SCHWEIZER AIRCRAFT CORPORATION: Docket No. 2001-SW-58-AD. Supersedes 76-18-01, Amendment No. 39-2707, Docket No. 72-WE-23-AD.
Applicability: Model 269A, 269A-1, 269B, 269C, and TH-55A helicopters, with tailboom support strut (strut) assemblies, part number (P/N) 269A2015 or P/N 269A2015-5; tailboom center attach fitting, P/N 269A2324; or with a center frame aft cluster fitting, P/N 269A2234 or 269A2235, installed, certificated in any category.
Note 1: This AD applies to each helicopter identified in the preceding applicability provision, regardless of whether it has been otherwise modified, altered, or repaired in the area subject to the requirements of this AD. For helicopters that have been modified, altered, or repaired so that the performance of the requirements of this AD is affected, the owner/operator must request approval for an alternative method of compliance in accordance with paragraph (d) of this AD. The request should include an assessment of the effect of the modification, alteration, or repair on the unsafe condition addressed by this AD; and if the unsafe condition has not been eliminated, the request should include specific proposed actions to address it.
Compliance: Required as indicated, unless accomplished previously.
To prevent failure of a strut clevis lug (lug) on a center frame aft cluster fitting (cluster fitting), rotation of a tailboom into the main rotor blades, and subsequent loss of control of the helicopter.....
Open the pre-amble to see the reason's for the AD.
Here is the current AD pre-amble:Preamble Information
AGENCY: Federal Aviation Administration, DOT.
ACTION: Final rule; request for comments.
SUMMARY: This document publishes in the Federal Register an amendment adopting Airworthiness Directive (AD) 2001-25-52, which was sent previously to all known U.S. owners and operators of Schweizer Aircraft Corporation (Schweizer) Model 269A, 269A-1, 269B, 269C, and TH-55A helicopters by individual letters. This AD supersedes an existing AD that requires inspecting and modifying or replacing, if necessary, the aluminum end fittings of each tailboom support strut (strut). That AD also requires inspecting the tailboom center attach fittings and center frame aft cluster fittings for damage, and if damaged parts are found, replacing the damaged parts. This AD requires inspecting and replacing, if necessary, each strut clevis lug (lug) on each tailboom center frame aft cluster fitting (cluster fitting), certain strut assemblies, certain tailboom attachments, and certain frame aft cluster fittings. Modifying or replacing each strut assembly within a certain time period and serializing certain strut assemblies are also required. This AD is prompted by an accident in the United Kingdom involving the in-flight structural failure of a Schweizer Model 269C helicopter. The actions specified by this AD are intended to prevent failure of a lug on a cluster fitting, rotation of a tailboom into the main rotor blades, and subsequent loss of control of the helicopter....
If you read the preamble you will see that the AD is the same as the one issued in 76-18-01 except for the requirement to inspect the fittings within 10 hours TIS and precludes certain other requirements. This was done at the behest of the UK CAA. This cluster problem has been known since 1975 at the minimum.
DATES: Effective May 8, 2002, to all persons except those persons to whom it was made immediately effective by Emergency AD 2001-25-52, issued on December 14, 2001, which contained the requirements of this amendment.
This AD also covers this problem: 88-17-04 SCHWEIZER AIRCRAFT CORPORATION (MCDONNELL DOUGLAS HELICOPTER COMPANY, HUGHES HELICOPTERS, INC).: Amendment 39-5975. Applies to helicopter Models 269A, TH-55A (all S/N's operated in civil use), 269A-1, 269B, and 269C, certificated in any category. (Docket No. 88-ASW-26)
Compliance is required as indicated, unless already accomplished.
To prevent possible loss of the tail boom support strut and tail boom which could result in loss of the helicopter.........
I have read the report and don't see where the regulators are at fault. Clearly from the report the AD simply was not complied with and an illegal unsatisfactory repair was performed and the net result was as described in both AD's. I would suggest that certain people read the aviation definition of "Acceptable" and "Approved". Acceptable information or data is able to be "accepted" and possibly approved and so is therefor not "Approved" data.
It was also clear in the report that several other aircraft were found to be affected by this AD but were not in compliance by the statement that "paint and other grime precluded any visual inspection being able to be carried out".
What's wrong with this picture? Or is it something geographical or cultural?
No I do not work for any manufacturer, authority or other similar entity. I am an LAME of 20 odd years and this is my profession that others are possibly not taking much care with.
Apologies for the long winded post but some may have trouble locating the pertinent info.
2001-25-52 SCHWEIZER AIRCRAFT CORPORATION: Docket No. 2001-SW-58-AD. Supersedes 76-18-01, Amendment No. 39-2707, Docket No. 72-WE-23-AD.
Applicability: Model 269A, 269A-1, 269B, 269C, and TH-55A helicopters, with tailboom support strut (strut) assemblies, part number (P/N) 269A2015 or P/N 269A2015-5; tailboom center attach fitting, P/N 269A2324; or with a center frame aft cluster fitting, P/N 269A2234 or 269A2235, installed, certificated in any category.
Note 1: This AD applies to each helicopter identified in the preceding applicability provision, regardless of whether it has been otherwise modified, altered, or repaired in the area subject to the requirements of this AD. For helicopters that have been modified, altered, or repaired so that the performance of the requirements of this AD is affected, the owner/operator must request approval for an alternative method of compliance in accordance with paragraph (d) of this AD. The request should include an assessment of the effect of the modification, alteration, or repair on the unsafe condition addressed by this AD; and if the unsafe condition has not been eliminated, the request should include specific proposed actions to address it.
Compliance: Required as indicated, unless accomplished previously.
To prevent failure of a strut clevis lug (lug) on a center frame aft cluster fitting (cluster fitting), rotation of a tailboom into the main rotor blades, and subsequent loss of control of the helicopter.....
Open the pre-amble to see the reason's for the AD.
Here is the current AD pre-amble:Preamble Information
AGENCY: Federal Aviation Administration, DOT.
ACTION: Final rule; request for comments.
SUMMARY: This document publishes in the Federal Register an amendment adopting Airworthiness Directive (AD) 2001-25-52, which was sent previously to all known U.S. owners and operators of Schweizer Aircraft Corporation (Schweizer) Model 269A, 269A-1, 269B, 269C, and TH-55A helicopters by individual letters. This AD supersedes an existing AD that requires inspecting and modifying or replacing, if necessary, the aluminum end fittings of each tailboom support strut (strut). That AD also requires inspecting the tailboom center attach fittings and center frame aft cluster fittings for damage, and if damaged parts are found, replacing the damaged parts. This AD requires inspecting and replacing, if necessary, each strut clevis lug (lug) on each tailboom center frame aft cluster fitting (cluster fitting), certain strut assemblies, certain tailboom attachments, and certain frame aft cluster fittings. Modifying or replacing each strut assembly within a certain time period and serializing certain strut assemblies are also required. This AD is prompted by an accident in the United Kingdom involving the in-flight structural failure of a Schweizer Model 269C helicopter. The actions specified by this AD are intended to prevent failure of a lug on a cluster fitting, rotation of a tailboom into the main rotor blades, and subsequent loss of control of the helicopter....
If you read the preamble you will see that the AD is the same as the one issued in 76-18-01 except for the requirement to inspect the fittings within 10 hours TIS and precludes certain other requirements. This was done at the behest of the UK CAA. This cluster problem has been known since 1975 at the minimum.
DATES: Effective May 8, 2002, to all persons except those persons to whom it was made immediately effective by Emergency AD 2001-25-52, issued on December 14, 2001, which contained the requirements of this amendment.
This AD also covers this problem: 88-17-04 SCHWEIZER AIRCRAFT CORPORATION (MCDONNELL DOUGLAS HELICOPTER COMPANY, HUGHES HELICOPTERS, INC).: Amendment 39-5975. Applies to helicopter Models 269A, TH-55A (all S/N's operated in civil use), 269A-1, 269B, and 269C, certificated in any category. (Docket No. 88-ASW-26)
Compliance is required as indicated, unless already accomplished.
To prevent possible loss of the tail boom support strut and tail boom which could result in loss of the helicopter.........
I have read the report and don't see where the regulators are at fault. Clearly from the report the AD simply was not complied with and an illegal unsatisfactory repair was performed and the net result was as described in both AD's. I would suggest that certain people read the aviation definition of "Acceptable" and "Approved". Acceptable information or data is able to be "accepted" and possibly approved and so is therefor not "Approved" data.
It was also clear in the report that several other aircraft were found to be affected by this AD but were not in compliance by the statement that "paint and other grime precluded any visual inspection being able to be carried out".
What's wrong with this picture? Or is it something geographical or cultural?
No I do not work for any manufacturer, authority or other similar entity. I am an LAME of 20 odd years and this is my profession that others are possibly not taking much care with.
Apologies for the long winded post but some may have trouble locating the pertinent info.
Sorry to sounds dense, but...
(1) Is it not part of the problem that this FAA AD hasn't been mandated by UK CAA? Or am I missing something?
(2) I think we all accept that the LAE in this case was still negligent. How negligent, and whether his punishment was appropriate is a separate question. Given that, would the changes to procedure, proposed by AAIB, and rejected by CAA, not have given a much better chance of his failure of procedure being picked up and prevented from causing this tragedy?
G
(1) Is it not part of the problem that this FAA AD hasn't been mandated by UK CAA? Or am I missing something?
(2) I think we all accept that the LAE in this case was still negligent. How negligent, and whether his punishment was appropriate is a separate question. Given that, would the changes to procedure, proposed by AAIB, and rejected by CAA, not have given a much better chance of his failure of procedure being picked up and prevented from causing this tragedy?
G
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Genghis,
1/ I am not that familiar with the UK CAA requirements.
Do they have a web site like other authorities, i.e. FAA, CASA (AUS), NZCAA etc. where the AD Schedule is listed?
If so I can't find it.
Surely the maintenance schedule in the UK mandates the use of the manufacturers maintenance data or Instructions for Continuing Airworthiness. This would include the SIN's which are MANDATORY and cover everything in the AD's most of the time.
The level of maintenance as required by the authorities will always be the "minimum" standard.
2/ Maybe the term LAE should re-include the term "maintenance" to become LAME. This might preclude the perception that we are engineers which in most cases we are not. What made the LAE in question think he had any idea that he could just dream up a repair scheme?
Of note, was this LAE responsible for the lack of maintenance on the other aircraft found not to comply? If not those responsible for these other aircraft should be held to account and possibly prosecuted the same way. There is a clear case.
Most of the items in the AAIB report and CAA response are possibly relevant and you are right you can be pedantic and address each issue but the facts simply remain.
For whatever reason an AD and Mandatory Service Instruction Notice were not complied with.
An "unapproved" repair was carried out for whatever reason.
The component failed as it was known to be capable of. It was obviously not known by all concerned. The net result was as is known.
How long has this persisted? Relying on the regulatory authority standards is no guarantee and is, I will say it again, a minimum standard. Is there a culture of minimum standard = minimum cost? More than 3 people appear to have paid the ultimate cost.
1/ I am not that familiar with the UK CAA requirements.
Do they have a web site like other authorities, i.e. FAA, CASA (AUS), NZCAA etc. where the AD Schedule is listed?
If so I can't find it.
Surely the maintenance schedule in the UK mandates the use of the manufacturers maintenance data or Instructions for Continuing Airworthiness. This would include the SIN's which are MANDATORY and cover everything in the AD's most of the time.
The level of maintenance as required by the authorities will always be the "minimum" standard.
2/ Maybe the term LAE should re-include the term "maintenance" to become LAME. This might preclude the perception that we are engineers which in most cases we are not. What made the LAE in question think he had any idea that he could just dream up a repair scheme?
Of note, was this LAE responsible for the lack of maintenance on the other aircraft found not to comply? If not those responsible for these other aircraft should be held to account and possibly prosecuted the same way. There is a clear case.
Most of the items in the AAIB report and CAA response are possibly relevant and you are right you can be pedantic and address each issue but the facts simply remain.
For whatever reason an AD and Mandatory Service Instruction Notice were not complied with.
An "unapproved" repair was carried out for whatever reason.
The component failed as it was known to be capable of. It was obviously not known by all concerned. The net result was as is known.
How long has this persisted? Relying on the regulatory authority standards is no guarantee and is, I will say it again, a minimum standard. Is there a culture of minimum standard = minimum cost? More than 3 people appear to have paid the ultimate cost.
UK CAA's website is at www.srg.caa.co.uk
Up to a point, it's not a bad website. However, one of their more bizarre balls-ups of recent years was when CAA privatised it's publications department (now known as Documedia). When they did this, stacks of airworthiness data was surreally transferred to Documedia's copyright. So, being now a commercial company, they make you pay for this data, and will only provide printed copies at a price.
So, BCARs, STCs, AANs, ADs, MPDs, TCs, and various other documents are not readily available to the casual investigator. This is despite many of these still being CAA copyright, the excuse that some of these aren't seems to be used for not giving us any of this data online. Of course, it helps them keep using this dreadful phrase "the authority must be consulted", giving them the right to keep changing goalposts, rather than making policy clear, public and universal.
Regarding implementation of overseas ADs, the requirement for compliance isn't automatic. What normally happens is that CAA is notified of an overseas AD, reviews it, and then decides whether or not to issue it's own. This case, if I read it correctly, is rather odd. AAIB issued the same recommendation 2001-45 to CAA and FAA. FAA have implemented it, CAA haven't.
Regarding LAE/ LAME issues. The UK has a particular problem over the term Engineer which just about everybody feels is theirs exclusively. But you are quite right, somebody qualified to do maintenance, hasn't necessarily been equipped to make those sort of decisions (and of-course, vice-versa). Separately to that, much of UK aviation tries to work in a "no blame culture". In that, most Brits would consider the appropriate treatment for the negligent LAME would have been suspension and retraining / requalification, not emprisonment. AAIB does not allocate blame, it recommends ways to make things safer, an approach we're quite happy with - but at odds with many other countries (and in this case at odds with UK CAA). Whilst you are right that there probably are grounds for similar prosecution of other LAME where other faults have been found, to most of us here the treatment of the chap who serviced G-ZAPS was the anomaly.
And as to minimum standard = minimum cost, I think this occurs everywhere. I've seen it far worse in the US than anywhere in the UK, but let's face it, accountants rule the roost and also few customers will go for the safer operator, they'll go for the cheaper. Which is exactly why safety measures must be mandatory - when nobody is allowed not to comply, it ceases to be a commercial issue.
G
Up to a point, it's not a bad website. However, one of their more bizarre balls-ups of recent years was when CAA privatised it's publications department (now known as Documedia). When they did this, stacks of airworthiness data was surreally transferred to Documedia's copyright. So, being now a commercial company, they make you pay for this data, and will only provide printed copies at a price.
So, BCARs, STCs, AANs, ADs, MPDs, TCs, and various other documents are not readily available to the casual investigator. This is despite many of these still being CAA copyright, the excuse that some of these aren't seems to be used for not giving us any of this data online. Of course, it helps them keep using this dreadful phrase "the authority must be consulted", giving them the right to keep changing goalposts, rather than making policy clear, public and universal.
Regarding implementation of overseas ADs, the requirement for compliance isn't automatic. What normally happens is that CAA is notified of an overseas AD, reviews it, and then decides whether or not to issue it's own. This case, if I read it correctly, is rather odd. AAIB issued the same recommendation 2001-45 to CAA and FAA. FAA have implemented it, CAA haven't.
Regarding LAE/ LAME issues. The UK has a particular problem over the term Engineer which just about everybody feels is theirs exclusively. But you are quite right, somebody qualified to do maintenance, hasn't necessarily been equipped to make those sort of decisions (and of-course, vice-versa). Separately to that, much of UK aviation tries to work in a "no blame culture". In that, most Brits would consider the appropriate treatment for the negligent LAME would have been suspension and retraining / requalification, not emprisonment. AAIB does not allocate blame, it recommends ways to make things safer, an approach we're quite happy with - but at odds with many other countries (and in this case at odds with UK CAA). Whilst you are right that there probably are grounds for similar prosecution of other LAME where other faults have been found, to most of us here the treatment of the chap who serviced G-ZAPS was the anomaly.
And as to minimum standard = minimum cost, I think this occurs everywhere. I've seen it far worse in the US than anywhere in the UK, but let's face it, accountants rule the roost and also few customers will go for the safer operator, they'll go for the cheaper. Which is exactly why safety measures must be mandatory - when nobody is allowed not to comply, it ceases to be a commercial issue.
G
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John: I'm getting my part numbers mixed up here.
The original version of the AD required periodic inspection, and replacement if cracks were found.
Mr Kenyon's case is that it should have specified replacement with the redesigned "thick-wall" cluster, rather than allowing another thin-wall cluster to be installed.
Schweizer specified replacement with a thick-wall cluster, but the FAA (and the CAA) did not.
It's clear that the inspection regime didn't cure the problem, as people kept on being killed regularly for decades thereafter, and are still dying.
The original version of the AD required periodic inspection, and replacement if cracks were found.
Mr Kenyon's case is that it should have specified replacement with the redesigned "thick-wall" cluster, rather than allowing another thin-wall cluster to be installed.
Schweizer specified replacement with a thick-wall cluster, but the FAA (and the CAA) did not.
It's clear that the inspection regime didn't cure the problem, as people kept on being killed regularly for decades thereafter, and are still dying.
The FAA AD is automatically mandated, as the basis of all certification of this product is based upon the original (and current/revised) FAA Type Certificate Data Sheet (TCDS) and any changes mandated to that product via Airworthiness Directive. This does not preclude any other Airworthiness Authority from issuing their own AD (in the case of the CAA) or through other mandatory medium, to address an airworthiness issue that they believe compromises the safety or airworthiness of the product whilst operated under their jurisdiction and oversight; which could include mandating SIN's, SB's, etc should they determine this would be beneficial.
The AAIB report does address the matter of origination, determination and implementation of changes to the basic Airworthiness basis of the product in paragraph 2.3 of their report.
As the report correctly states, the determination and classification of any publication to be mandatory, is only deemed so by the mandate of the certifying authority. A manufacturer does not have the ability to determine mandatory action to a certificated product, without regulatory oversight and approval by either an AD, change to the TCDS, or directly referenced data contained within the TCDS. An AD is mandatory, but a SIN, SB or whatever else is not unless specifically countenanced by the authority it is operated under.
The FAA Airworthiness Directive Manual provides a complete reference to the process and system for the issuance of AD's.
As regards the availability of CAA documentation and reference materials, I think this is an absolutely disgraceful state of affairs. Quite how aviation safety can be promoted and served by a total lack of transparency to source documentation (and the myriad of means of conveying this information) defies my simple logic. In contrast, refer to the basic FAA website where every single piece of documentation we have discussed is freely available, along with every pre-requisite regulatory and interpretive source required to comprehend the system and the contents contained therein.
The AAIB report does address the matter of origination, determination and implementation of changes to the basic Airworthiness basis of the product in paragraph 2.3 of their report.
Note: Although the above SINs and SB B-263 were stated to be 'mandatory' by Hughes and Schweizer in the text of these documents, only the relevant regulatory agency has the authority to make such documents legally 'mandatory' and thus binding upon the owners/operators of aircraft. In the case of SINs N-217, N-220 and N-221, these therefore only became legally mandatory when the FAA issued AD 88-17-04. The current system thus relies heavily upon the regulators recognising the importance, from a flight safety standpoint, of certain inspections and modifications recommended by manufacturers in order that associated Airworthiness Directives can be issued to ensure compliance, as far as legally possible.
Schweizer stated the following in this context:
'Schweizer Aircraft Corporation strongly emphasises that Red Border Service Notices and Service Bulletins are mandated by SAC and must be complied with as specified within the directives. Compliance with FAA AD Notices is required by law. It is the operator's responsibility to ensure that all applicable Red Border Service Notices, Service Bulletins and FAA AD Notes have been complied with prior to the first flight of the day (FAR 91.403). Any pilot who operates a 269 Series Helicopter against which mandatory Service Notices, Service Bulletins or FAA AD Notes are outstanding, does so at his own risk.'
Schweizer stated the following in this context:
'Schweizer Aircraft Corporation strongly emphasises that Red Border Service Notices and Service Bulletins are mandated by SAC and must be complied with as specified within the directives. Compliance with FAA AD Notices is required by law. It is the operator's responsibility to ensure that all applicable Red Border Service Notices, Service Bulletins and FAA AD Notes have been complied with prior to the first flight of the day (FAR 91.403). Any pilot who operates a 269 Series Helicopter against which mandatory Service Notices, Service Bulletins or FAA AD Notes are outstanding, does so at his own risk.'
The FAA Airworthiness Directive Manual provides a complete reference to the process and system for the issuance of AD's.
As regards the availability of CAA documentation and reference materials, I think this is an absolutely disgraceful state of affairs. Quite how aviation safety can be promoted and served by a total lack of transparency to source documentation (and the myriad of means of conveying this information) defies my simple logic. In contrast, refer to the basic FAA website where every single piece of documentation we have discussed is freely available, along with every pre-requisite regulatory and interpretive source required to comprehend the system and the contents contained therein.
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From Dennis Kenyon.
Sirs,
I'm happy to see some very qualified engineers taking part in this discussion. But can I reduce the matter to simple terms. The constant quoting of various AD's SB's etc, is all very well, but the bones of my taking issue with the CAA is simple.
One accident is happenstance, a second may be a coincidence, but when a third occurs something is going wrong.
My contention is that following the third accident a more responsible and aware authority, (be it FAA or CAA or uncle tom cobley) should have accepted the fact that the flow of AD's, SB's being released etc, while being a proper course of action - WERE SIMPLY NOT WORKING.
In such circumstances the obvious fix was to mandate the fitting of the re-designed (dash 3) clevis cluster. Had the FAA/CAA done this, my son and others would not have lost their lives.
Then when the AAIB formally recommended the mandating of the
later component, it is totally and absolutely unacceptable for the FAA/CAA to refuse. So an eighth accident occurs and another pilot loses his life.
Do I now have to formally advise the CAA that if another fatal occurs, I WILL RAISE a manslaughter charge against the individual responsible for the CAA's decision. Perhaps that might concentrates someone's mind.
Paul Kenward made a mistake relying on memory and the weld work in front of him. Negligent yes, but had the regulatory authorities acted properly when the problem became apparent, he would not have found himself in that invideous position. It is significant that the AAIB found six 'causal factors' for the accident, one directed to the engineer, and two to the CAA.
Also note that of the nine accidents I have tracked down, only one, (G-ZAPS) was the subject of a weld repair. One might even argue, (although not backed up by the metallurgist) that Kenward's weld repair actually prolonged the cluster life which was on its way to a failure anyway.
Please continue the contributions which I am following avidly.
Dennis Kenyon.
Sirs,
I'm happy to see some very qualified engineers taking part in this discussion. But can I reduce the matter to simple terms. The constant quoting of various AD's SB's etc, is all very well, but the bones of my taking issue with the CAA is simple.
One accident is happenstance, a second may be a coincidence, but when a third occurs something is going wrong.
My contention is that following the third accident a more responsible and aware authority, (be it FAA or CAA or uncle tom cobley) should have accepted the fact that the flow of AD's, SB's being released etc, while being a proper course of action - WERE SIMPLY NOT WORKING.
In such circumstances the obvious fix was to mandate the fitting of the re-designed (dash 3) clevis cluster. Had the FAA/CAA done this, my son and others would not have lost their lives.
Then when the AAIB formally recommended the mandating of the
later component, it is totally and absolutely unacceptable for the FAA/CAA to refuse. So an eighth accident occurs and another pilot loses his life.
Do I now have to formally advise the CAA that if another fatal occurs, I WILL RAISE a manslaughter charge against the individual responsible for the CAA's decision. Perhaps that might concentrates someone's mind.
Paul Kenward made a mistake relying on memory and the weld work in front of him. Negligent yes, but had the regulatory authorities acted properly when the problem became apparent, he would not have found himself in that invideous position. It is significant that the AAIB found six 'causal factors' for the accident, one directed to the engineer, and two to the CAA.
Also note that of the nine accidents I have tracked down, only one, (G-ZAPS) was the subject of a weld repair. One might even argue, (although not backed up by the metallurgist) that Kenward's weld repair actually prolonged the cluster life which was on its way to a failure anyway.
Please continue the contributions which I am following avidly.
Dennis Kenyon.
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Cyclic Hotline,
I beg to differ on your opinion that SIN's etc. are not mandatory.
Given that the aircraft maintenance statement declares the schedules to be used in maintaining an aircraft normally involve use of the Instructions for Continuing Airworthiness (read Maintenance Manual) as required by the Type Certificate, the SIN or SB's are part of that data. Where the SB or SIN or whatever terminology is used states that it is mandatory this is the case, it is not optional. The aircraft is declared to be maintained IAW data that is in the statement and that shall be the case. Where the authority comes in to play is that certain items outside this criteria having an effect and which may not be an SB or SIN is their perogative.
I don't know where the "optional" SB issue came from. On the 269 it starts with the Basic HMI and then the model appendixes and incudes all other pertinent data of which SB's form a part. Granted an AD is the definitive statement, but just because there is no AD does not mean a mandatory bulletin may not be complied with. It is part of ICA of the TC.
It appears that this accident is possibly attributed to a broad systemic misunderstanding of what is required.
That's the way I've interpreted things from day one - I'll accept that I may be wrong and will stand corrected if it is the case.
I beg to differ on your opinion that SIN's etc. are not mandatory.
Given that the aircraft maintenance statement declares the schedules to be used in maintaining an aircraft normally involve use of the Instructions for Continuing Airworthiness (read Maintenance Manual) as required by the Type Certificate, the SIN or SB's are part of that data. Where the SB or SIN or whatever terminology is used states that it is mandatory this is the case, it is not optional. The aircraft is declared to be maintained IAW data that is in the statement and that shall be the case. Where the authority comes in to play is that certain items outside this criteria having an effect and which may not be an SB or SIN is their perogative.
I don't know where the "optional" SB issue came from. On the 269 it starts with the Basic HMI and then the model appendixes and incudes all other pertinent data of which SB's form a part. Granted an AD is the definitive statement, but just because there is no AD does not mean a mandatory bulletin may not be complied with. It is part of ICA of the TC.
It appears that this accident is possibly attributed to a broad systemic misunderstanding of what is required.
That's the way I've interpreted things from day one - I'll accept that I may be wrong and will stand corrected if it is the case.
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To add:
Transport Canada agree's with me.
AIRWORTHINESS NOTICE - B055 EDITION 1 - 4 JULY 2000
SERVICE BULLETIN COMPLIANCE
The purpose of this notice is to clarify to Aircraft Maintenance Engineers and operators the need to comply with manufacturers’ service bulletins, service letters, etc.Ê
Leaving aside publications made mandatory by airworthiness directives or equivalent mandatory notices issued by the airworthiness authority responsible for the initial type design of the product, manufacturers’ publications may be considered under three general headings:
(i)ÊÊÊÊÊÊ Recommended methods and practices for the performance of work;
(ii)ÊÊÊÊ Recommended modifications, inspections, and times between overhaul;
and
(iii)ÊÊÊ Mandatory actions established as part of the type certification process.
Although a single publication may in practice deal with more than one topic, in this notice each group will be dealt with separately:
1.ÊPublications specifying methods and practices for the performance of work
Publications under this heading may be considered as amendments to the instructions for continued airworthiness (ICA).Ê As such, pursuant to Canadian Aviation Regulation (CAR)Ê571.02, they constitute one of three acceptable sources for such data (the other two are equivalent methods and standard industry practice).
2.ÊPublications recommending the incorporation of modifications, the performance of inspections, or times between overhaul
Except where otherwise specified in Std 625, Appendix C, compliance with publications dealing with these topics is optional.Ê However, aircraft owners have a duty to be aware of the contents of these publications, and to evaluate the need for compliance in light of their own circumstances.Ê Commercial operators should have a formalized process for conducting this evaluation, as part of the evaluation program required by CARÊ706.
3.ÊPublications providing information regarding airworthiness limitations established as part of the type certification process
On occasion the communication of airworthiness limitations, such as component life limits or maintenance requirements is accomplished by referring to service bulletins or equivalent notices.Ê When used in this manner the content of the bulletin is a condition of the type certificate; and, except where Transport Canada has granted approval to deviate, compliance is mandatory.
The above explanation should assist AMEs and operators in deciding on the need for compliance with service bulletins, service letters, etc.Ê Further guidance in individual cases may be obtained from Transport Canada Centres.
Transport Canada agree's with me.
AIRWORTHINESS NOTICE - B055 EDITION 1 - 4 JULY 2000
SERVICE BULLETIN COMPLIANCE
The purpose of this notice is to clarify to Aircraft Maintenance Engineers and operators the need to comply with manufacturers’ service bulletins, service letters, etc.Ê
Leaving aside publications made mandatory by airworthiness directives or equivalent mandatory notices issued by the airworthiness authority responsible for the initial type design of the product, manufacturers’ publications may be considered under three general headings:
(i)ÊÊÊÊÊÊ Recommended methods and practices for the performance of work;
(ii)ÊÊÊÊ Recommended modifications, inspections, and times between overhaul;
and
(iii)ÊÊÊ Mandatory actions established as part of the type certification process.
Although a single publication may in practice deal with more than one topic, in this notice each group will be dealt with separately:
1.ÊPublications specifying methods and practices for the performance of work
Publications under this heading may be considered as amendments to the instructions for continued airworthiness (ICA).Ê As such, pursuant to Canadian Aviation Regulation (CAR)Ê571.02, they constitute one of three acceptable sources for such data (the other two are equivalent methods and standard industry practice).
2.ÊPublications recommending the incorporation of modifications, the performance of inspections, or times between overhaul
Except where otherwise specified in Std 625, Appendix C, compliance with publications dealing with these topics is optional.Ê However, aircraft owners have a duty to be aware of the contents of these publications, and to evaluate the need for compliance in light of their own circumstances.Ê Commercial operators should have a formalized process for conducting this evaluation, as part of the evaluation program required by CARÊ706.
3.ÊPublications providing information regarding airworthiness limitations established as part of the type certification process
On occasion the communication of airworthiness limitations, such as component life limits or maintenance requirements is accomplished by referring to service bulletins or equivalent notices.Ê When used in this manner the content of the bulletin is a condition of the type certificate; and, except where Transport Canada has granted approval to deviate, compliance is mandatory.
The above explanation should assist AMEs and operators in deciding on the need for compliance with service bulletins, service letters, etc.Ê Further guidance in individual cases may be obtained from Transport Canada Centres.
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Most of this is irrelevant.
There is only one question to be answered.
Why is the CAA refusing the AAIB's urgent request to mandate the fitting of the safe cluster?
Is it just loss of face?
Or are they worried about legal action?
There is only one question to be answered.
Why is the CAA refusing the AAIB's urgent request to mandate the fitting of the safe cluster?
Is it just loss of face?
Or are they worried about legal action?
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From Dennis Kenyon.
Gentlemen,
Just another small pint to place in the pot.
Today I attended the CAA Display Pilots seminar at Cranfield. A good day of course and its always interesting to exchange views with other professionals dispaly pilots.
But when the topic of display safety came up, I was intrigued to hear the CAA point out that one of their targets was to spot, 'trends' Yes of course and we all agreed.
But where was any effort made to spot a 'trend' during the previous and continueing occurrence of clevis cluster component fatigue failures to the Hughes 269's ?? Other than to issue more 'pieces of paper'
Trailing the history of previous failures - these extend over a thirty years period, but as follows.
1972 G-AWVL, Ser No 0234 England.
1974 JA-7552 Ser No 0438 Japan.
1974 ZK-HEV Ser No 0351 New Zealand
Then a 16 year gap to ...
1990 N403SD Ser No 071 USA
1991 N8955F Ser No 0172 USA
1993 N7032U Ser No 0327 USA
1994 N64732 Ser No 0341 USA
2000 G-ZAPS Ser No 041 England
2002 N8885F Ser No TBA USA
Is there anyone out there who has any doubt that a tenth will happen ? (unless the FAA/CAA act now. There is also the possibility of other unrecorded failures.
Again many thanks for the fund of professional advice coming in.
Dennis Kenyon.
Gentlemen,
Just another small pint to place in the pot.
Today I attended the CAA Display Pilots seminar at Cranfield. A good day of course and its always interesting to exchange views with other professionals dispaly pilots.
But when the topic of display safety came up, I was intrigued to hear the CAA point out that one of their targets was to spot, 'trends' Yes of course and we all agreed.
But where was any effort made to spot a 'trend' during the previous and continueing occurrence of clevis cluster component fatigue failures to the Hughes 269's ?? Other than to issue more 'pieces of paper'
Trailing the history of previous failures - these extend over a thirty years period, but as follows.
1972 G-AWVL, Ser No 0234 England.
1974 JA-7552 Ser No 0438 Japan.
1974 ZK-HEV Ser No 0351 New Zealand
Then a 16 year gap to ...
1990 N403SD Ser No 071 USA
1991 N8955F Ser No 0172 USA
1993 N7032U Ser No 0327 USA
1994 N64732 Ser No 0341 USA
2000 G-ZAPS Ser No 041 England
2002 N8885F Ser No TBA USA
Is there anyone out there who has any doubt that a tenth will happen ? (unless the FAA/CAA act now. There is also the possibility of other unrecorded failures.
Again many thanks for the fund of professional advice coming in.
Dennis Kenyon.