Scandal or not? CAA rejects AAIB criticism and safety recommendations!
Thread Starter
Join Date: Jun 2001
Location: southern england
Posts: 1,650
Likes: 0
Received 0 Likes
on
0 Posts
Sadly it appears that the CAA do not wish to accept most of the recommendations from the report. 
There will now follow a bout of fisticuffs.
http://news.bbc.co.uk/1/hi/england/2786289.stm
There will now follow a bout of fisticuffs.http://news.bbc.co.uk/1/hi/england/2786289.stm
Join Date: Jul 2000
Location: London
Posts: 2,916
Likes: 0
Received 0 Likes
on
0 Posts
The AAIB's key findings include
and
Click here for the Full Report.
Tudor Owen
15. During the investigation, other instances of cracking on the original standard of clevis lugs, associated non-approved welded patch repair, and a non-approved welding repair of the outboard flange area were found on other Hughes 269 helicopters in the UK, indicating that the non-approved welding repair found on G-ZAPS was not an isolated occurrence on this helicopter type.
16. Hughes Helicopters had previously responded to the cracking problem on the clevis lugs of these centre frame rear cluster fittings with additional periodic inspections and a re-designed –3 type of cluster fitting, but it became apparent during this investigation that there was confusion within UK personnel responsible for the maintenance of Hughes 269 helicopters regarding the difference between the original and re-designed -3 standards of these centre frame cluster fittings, and which inspections applied to which standard of fitting.
17. Six previous accidents to this type of helicopter were identified which had been caused by fatigue failure of clevis lugs on the original standard of centre frame rear cluster fitting; all six accidents had stemmed from fatigue cracking of the left clevis lugs. In addition, one fatal accident had occurred in Australia in 1995 due to fatigue failure of an upper clevis lug on a re-designed -3 centre frame rear cluster fitting. No previous accidents were identified which had occurred due to failure of a clevis lug that had been weld-repaired.
18. This accident, and those which had also occurred previously due to fatigue failure of these clevis lugs on helicopters of this type, demonstrated that such clevis lug fatigue cracking could remain undetected, despite frequent opportunities and requirements for in service inspections of these readily viewed fittings, until eventual failure of such weakened lugs caused accidents. Such findings questioned the regulatory reliance placed upon such inspections to detect fatigue damage of these clevis lugs before catastrophic tailboom separation occurred.
19. A lack of logical standardisation was apparent with respect to the timespans that maintenance records and associated documentation must be kept by aircraft operators and maintenance organisations. The ANO requires operators to retain aircraft Log Books for two years after related aircraft have been permanently withdrawn from service, but JAR 145.55 only requires maintenance organisations to retain work records for a minimum of two years after the aircraft to which they refer have been released on completion of related maintenance work. In effect, the potential advantages to investigations of retaining Log Books for the life of an aircraft can thus be nullified by the absence of the detailed maintenance records to which the Log Books refer, if the related work of interest has been completed more than two years before an aircraft suffers a maintenance related accident.
16. Hughes Helicopters had previously responded to the cracking problem on the clevis lugs of these centre frame rear cluster fittings with additional periodic inspections and a re-designed –3 type of cluster fitting, but it became apparent during this investigation that there was confusion within UK personnel responsible for the maintenance of Hughes 269 helicopters regarding the difference between the original and re-designed -3 standards of these centre frame cluster fittings, and which inspections applied to which standard of fitting.
17. Six previous accidents to this type of helicopter were identified which had been caused by fatigue failure of clevis lugs on the original standard of centre frame rear cluster fitting; all six accidents had stemmed from fatigue cracking of the left clevis lugs. In addition, one fatal accident had occurred in Australia in 1995 due to fatigue failure of an upper clevis lug on a re-designed -3 centre frame rear cluster fitting. No previous accidents were identified which had occurred due to failure of a clevis lug that had been weld-repaired.
18. This accident, and those which had also occurred previously due to fatigue failure of these clevis lugs on helicopters of this type, demonstrated that such clevis lug fatigue cracking could remain undetected, despite frequent opportunities and requirements for in service inspections of these readily viewed fittings, until eventual failure of such weakened lugs caused accidents. Such findings questioned the regulatory reliance placed upon such inspections to detect fatigue damage of these clevis lugs before catastrophic tailboom separation occurred.
19. A lack of logical standardisation was apparent with respect to the timespans that maintenance records and associated documentation must be kept by aircraft operators and maintenance organisations. The ANO requires operators to retain aircraft Log Books for two years after related aircraft have been permanently withdrawn from service, but JAR 145.55 only requires maintenance organisations to retain work records for a minimum of two years after the aircraft to which they refer have been released on completion of related maintenance work. In effect, the potential advantages to investigations of retaining Log Books for the life of an aircraft can thus be nullified by the absence of the detailed maintenance records to which the Log Books refer, if the related work of interest has been completed more than two years before an aircraft suffers a maintenance related accident.
4. Safety Recommendations
The following safety recommendations were made during the course of the investigation:
4.1 Safety Recommendation No 2001-80 The CAA should forward an information notice to all Licensed Aircraft Engineers, and all approved aircraft and component maintenance organisations, reminding them of the requirement that all repairs, including weld repairs, can only be carried out to an approved repair scheme and of their responsibilities to ensure that there is an appropriate repair scheme in the manufacturer’s maintenance or repair manual, or related approval is granted by the manufacturer, before any repair is authorised.
4.2 Safety Recommendation No 2001-81 The CAA should tighten the approval process for persons granted CAA Welders Approval Certificates to ensure that before they carry out any welding repairs to aircraft or aircraft components, written assurance is obtained from the authorising Licensed Aircraft Engineer that such repairs are in accordance with an approved repair scheme.
4.3 Safety Recommendation No 2001-82 The CAA should take early action to introduce a requirement that Welding Certificates of Conformity must state details of the applicable aircraft registration, type, component, part number, serial number and approval for the related weld repair.
4.4 Safety Recommendation No 2001-83 The CAA should remind all Licensed Aircraft Engineers and aircraft maintenance organisations that maintenance should not be undertaken on aircraft without access to the associated Log Books and Technical Log (if applicable) and that all work should be recorded as required.
4.5 Safety Recommendation No 2001-84 In order to better justify assumed airworthiness assurance arising from CAA Survey Reports the CAA should require, before any aircraft or helicopter is surveyed by a CAA Surveyor for the purpose of issuing a Survey Report, that the service history of the type be carefully audited by the Surveyor to identify any critical structural areas which have been the subject of special inspections / Airworthiness Directives to ensure that such areas are closely inspected, if reasonably accessible, during these surveys.
4.6 Safety Recommendation No 2001-85 The CAA should specify who is authorised to carry out and certify a Daily Inspection (A Check), in addition to describing the initial training and continuity training required for such authorised persons, how that training should be recorded and monitored, and where the authorised person should sign to certify that a Daily Inspection (A Check) has been carried out satisfactorily.
4.7 Safety Recommendation No 2001-86 The CAA should require that all pilots use a Pre-Flight Check List from the CAA approved Pilot’s Flight Manual whenever a flight is conducted for training, conversion or testing so that only approved and fully amended Check Lists are used.
4.8 Safety Recommendation No 2001-87 The Schweizer Aircraft Corporation should amend the Pre-Flight Check List contained within the Pilot’s Flight Manual for the Hughes/Schweizer 269 and 300 helicopters to include in the Pre-Flight Inspection a visual check of the right centre frame rear cluster fitting for cracks and damage, and to include the warning that if cracking of cluster fittings is suspected then dye penetrant inspection is required before flight.
4.9 Safety Recommendation No 2001-41 In view of the finding of non-approved welding repairs to the clevis lugs of the Centre Frame Rear Cluster Fittings on two Hughes 269 helicopters, failure of one of which caused a catastrophic in-flight separation of the tailboom assembly, it is recommended that the Civil Aviation Authority and the Federal Aviation Administration take early action to issue Airworthiness Directives to require immediate visual inspections of these fittings on all Hughes/Schweizer 269 and 300 helicopters in order to check for any non-approved welded repairs to the clevis lugs, and to ground any affected helicopters until such repaired Centre Frame Rear Cluster Fittings have been replaced with new fittings. (Safety Recommendation No 2001-41, made 11 April 2001)
4.10 Safety Recommendation No 2001-45 In view of the potential for catastrophic in flight tailboom detachment on Hughes/Schweizer 269 and 300 helicopters due to fatigue fracture of the clevis lug attachments on the Centre Frame Rear Cluster Fittings, and the difficulty in reliably detecting by dye-penetrant testing all such fatigue cracking in service before related lug fracture occurs, it is recommended that the Civil Aviation Authority issues an Airworthiness Directive requiring the mandatory replacement, on all affected helicopters of these types on the UK Register, of all original Centre Frame Rear Cluster Fittings, part numbers 269A2234 and 269A2235, with the manufacturer's re-designed Cluster Fittings, part numbers 269A2234-3 and 269A2235-3; it is further recommended that the Federal Aviation Administration should implement similar mandatory modification action for all affected helicopters of these types abroad. (Safety Recommendation No 2001-45, made 11 April 2001).
4.11 Safety Recommendation No 2001-88 The CAA should conduct a review of JAR 145.55 with the aim of proposing to the JAA the improved harmonisation of maintenance document retention time requirements with those specified in the ANO, so that maintenance Worksheets and component Certificates of Release that are referred to in Aircraft, Engine and Propeller Log Books are retained until the aircraft, engine or propeller has been destroyed or scrapped.
4.12 Safety Recommendation No 2001-89 In order to avoid inadvertent omission of manufacturer’s inspections during maintenance, it is recommended that the CAA withdraw the option to use the generalised CAA Light Aircraft Maintenance Schedule for Hughes/Schweizer 269 and 300 series helicopters so that they may only be maintained to the manufacturer's Handbook of Maintenance Instructions (HMI).
4.13 Safety Recommendation No 2001-90 The CAA should conduct a review of the manufacturer’s maintenance manual requirements for all helicopter types on the UK register which are currently maintained to CAA/LAMS/H/1999 issue 1 and where there are significant additional ‘specific-to-type’ maintenance requirements in the applicable maintenance manuals, require such helicopters to be maintained only to the manufacturer’s maintenance manual.
The following safety recommendations were made during the course of the investigation:
4.1 Safety Recommendation No 2001-80 The CAA should forward an information notice to all Licensed Aircraft Engineers, and all approved aircraft and component maintenance organisations, reminding them of the requirement that all repairs, including weld repairs, can only be carried out to an approved repair scheme and of their responsibilities to ensure that there is an appropriate repair scheme in the manufacturer’s maintenance or repair manual, or related approval is granted by the manufacturer, before any repair is authorised.
4.2 Safety Recommendation No 2001-81 The CAA should tighten the approval process for persons granted CAA Welders Approval Certificates to ensure that before they carry out any welding repairs to aircraft or aircraft components, written assurance is obtained from the authorising Licensed Aircraft Engineer that such repairs are in accordance with an approved repair scheme.
4.3 Safety Recommendation No 2001-82 The CAA should take early action to introduce a requirement that Welding Certificates of Conformity must state details of the applicable aircraft registration, type, component, part number, serial number and approval for the related weld repair.
4.4 Safety Recommendation No 2001-83 The CAA should remind all Licensed Aircraft Engineers and aircraft maintenance organisations that maintenance should not be undertaken on aircraft without access to the associated Log Books and Technical Log (if applicable) and that all work should be recorded as required.
4.5 Safety Recommendation No 2001-84 In order to better justify assumed airworthiness assurance arising from CAA Survey Reports the CAA should require, before any aircraft or helicopter is surveyed by a CAA Surveyor for the purpose of issuing a Survey Report, that the service history of the type be carefully audited by the Surveyor to identify any critical structural areas which have been the subject of special inspections / Airworthiness Directives to ensure that such areas are closely inspected, if reasonably accessible, during these surveys.
4.6 Safety Recommendation No 2001-85 The CAA should specify who is authorised to carry out and certify a Daily Inspection (A Check), in addition to describing the initial training and continuity training required for such authorised persons, how that training should be recorded and monitored, and where the authorised person should sign to certify that a Daily Inspection (A Check) has been carried out satisfactorily.
4.7 Safety Recommendation No 2001-86 The CAA should require that all pilots use a Pre-Flight Check List from the CAA approved Pilot’s Flight Manual whenever a flight is conducted for training, conversion or testing so that only approved and fully amended Check Lists are used.
4.8 Safety Recommendation No 2001-87 The Schweizer Aircraft Corporation should amend the Pre-Flight Check List contained within the Pilot’s Flight Manual for the Hughes/Schweizer 269 and 300 helicopters to include in the Pre-Flight Inspection a visual check of the right centre frame rear cluster fitting for cracks and damage, and to include the warning that if cracking of cluster fittings is suspected then dye penetrant inspection is required before flight.
4.9 Safety Recommendation No 2001-41 In view of the finding of non-approved welding repairs to the clevis lugs of the Centre Frame Rear Cluster Fittings on two Hughes 269 helicopters, failure of one of which caused a catastrophic in-flight separation of the tailboom assembly, it is recommended that the Civil Aviation Authority and the Federal Aviation Administration take early action to issue Airworthiness Directives to require immediate visual inspections of these fittings on all Hughes/Schweizer 269 and 300 helicopters in order to check for any non-approved welded repairs to the clevis lugs, and to ground any affected helicopters until such repaired Centre Frame Rear Cluster Fittings have been replaced with new fittings. (Safety Recommendation No 2001-41, made 11 April 2001)
4.10 Safety Recommendation No 2001-45 In view of the potential for catastrophic in flight tailboom detachment on Hughes/Schweizer 269 and 300 helicopters due to fatigue fracture of the clevis lug attachments on the Centre Frame Rear Cluster Fittings, and the difficulty in reliably detecting by dye-penetrant testing all such fatigue cracking in service before related lug fracture occurs, it is recommended that the Civil Aviation Authority issues an Airworthiness Directive requiring the mandatory replacement, on all affected helicopters of these types on the UK Register, of all original Centre Frame Rear Cluster Fittings, part numbers 269A2234 and 269A2235, with the manufacturer's re-designed Cluster Fittings, part numbers 269A2234-3 and 269A2235-3; it is further recommended that the Federal Aviation Administration should implement similar mandatory modification action for all affected helicopters of these types abroad. (Safety Recommendation No 2001-45, made 11 April 2001).
4.11 Safety Recommendation No 2001-88 The CAA should conduct a review of JAR 145.55 with the aim of proposing to the JAA the improved harmonisation of maintenance document retention time requirements with those specified in the ANO, so that maintenance Worksheets and component Certificates of Release that are referred to in Aircraft, Engine and Propeller Log Books are retained until the aircraft, engine or propeller has been destroyed or scrapped.
4.12 Safety Recommendation No 2001-89 In order to avoid inadvertent omission of manufacturer’s inspections during maintenance, it is recommended that the CAA withdraw the option to use the generalised CAA Light Aircraft Maintenance Schedule for Hughes/Schweizer 269 and 300 series helicopters so that they may only be maintained to the manufacturer's Handbook of Maintenance Instructions (HMI).
4.13 Safety Recommendation No 2001-90 The CAA should conduct a review of the manufacturer’s maintenance manual requirements for all helicopter types on the UK register which are currently maintained to CAA/LAMS/H/1999 issue 1 and where there are significant additional ‘specific-to-type’ maintenance requirements in the applicable maintenance manuals, require such helicopters to be maintained only to the manufacturer’s maintenance manual.
Tudor Owen
Last edited by Flying Lawyer; 21st Feb 2003 at 18:40.
Join Date: Apr 2002
Location: UK
Posts: 593
Likes: 0
Received 0 Likes
on
0 Posts
Of all the things that astound me in this investigation, the delay in publishing is the worst. How many other lives have been put at risk by this delay ? If an AD is necessary, why wasn't the world told earlier ?
The only reason we have regulators (officially) is to make flying safer. Isn't it?
The only reason we have regulators (officially) is to make flying safer. Isn't it?
Join Date: Mar 2000
Location: UK
Posts: 5,197
Likes: 0
Received 0 Likes
on
0 Posts
BBC report
CAA rejects crash report
Can it be right that CAA surveyors who inspect a helicopter may little or nothing about the type?
Or that they are not properly briefed to look for known problems relating to a particular type?
"The AAIB do not understand." ??
It seems like the AAIB understands all too well the dangers/weaknesses in the existing procedures.
And, the AAIB understands that this tragedy which cost three lives might not have happened if the procedures the AAIB recommends had been in place.
Is that the reason the CAA won't accept the AAIB is right?
Whose judgement do you accept?
The AAIB which helps pilots by finding out what caused an accident, and then tries to ensure the same thing doesn't happen to us? Or the CAA?
The CAA is entitled to reject safety recommendations which the AAIB makes for our benefit - but do you think it's right that they should?
Air accident investigators and the Civil Aviation Authority (CAA) have clashed over a report into a helicopter crash which killed all three people on board.
The CAA has rejected 10 of the 13 air safety recommendations made to it by the Air Accident Investigation Branch.
The AAIB report into the crash at Hare Hatch, near Twyford, Berkshire, in March 2000 says the CAA had not detected an illegal welding job on the Hughes 269 helicopter during a survey in 1999. As a result, the aircraft was granted a certificate stating it was fit to fly.
The helicopter crashed en route from Wycombe air centre in Buckinghamshire to Shoreham in West Sussex.
During the flight, the section of the helicopter that had been welded - linking the tailboom to the rest of the aircraft - failed and the aircraft broke apart and crashed.
Dennis Kenyon, 18, of Shoreham, Brendan Loft, 38, from Reigate in Surrey and Jane Biddulph, 23, of Lancing in West Sussex all died.
The report criticised the CAA for not listing in its surveys for inspection the area of structure that needed welding - despite a history of cracking in other similar helicopters.
The AAIB also said that non-approved welding "was not an isolated occurrence on this helicopter type".
The tightening up of procedures was recommended by the AAIB but only one was accepted by the CAA - two of the others were partially accepted.
A CAA spokesman said: "We normally accept around 80% of AAIB recommendations. But in this case we felt the AAIB have highlighted areas that we feel they do not understand.
"These types of helicopters are perfectly safe if they are properly maintained."
Paul Kenward, a licensed aircraft engineer from Biggin Hill in Kent, who authorised the illegal welding in 1999, was cleared of three counts of manslaughter last year.
He was later jailed for eight months for allowing the helicopter to fly without a valid certificate of airworthiness, endangering an aircraft and failing to make an entry in the aircraft's logbook.
The CAA has rejected 10 of the 13 air safety recommendations made to it by the Air Accident Investigation Branch.
The AAIB report into the crash at Hare Hatch, near Twyford, Berkshire, in March 2000 says the CAA had not detected an illegal welding job on the Hughes 269 helicopter during a survey in 1999. As a result, the aircraft was granted a certificate stating it was fit to fly.
The helicopter crashed en route from Wycombe air centre in Buckinghamshire to Shoreham in West Sussex.
During the flight, the section of the helicopter that had been welded - linking the tailboom to the rest of the aircraft - failed and the aircraft broke apart and crashed.
Dennis Kenyon, 18, of Shoreham, Brendan Loft, 38, from Reigate in Surrey and Jane Biddulph, 23, of Lancing in West Sussex all died.
The report criticised the CAA for not listing in its surveys for inspection the area of structure that needed welding - despite a history of cracking in other similar helicopters.
The AAIB also said that non-approved welding "was not an isolated occurrence on this helicopter type".
The tightening up of procedures was recommended by the AAIB but only one was accepted by the CAA - two of the others were partially accepted.
A CAA spokesman said: "We normally accept around 80% of AAIB recommendations. But in this case we felt the AAIB have highlighted areas that we feel they do not understand.
"These types of helicopters are perfectly safe if they are properly maintained."
Paul Kenward, a licensed aircraft engineer from Biggin Hill in Kent, who authorised the illegal welding in 1999, was cleared of three counts of manslaughter last year.
He was later jailed for eight months for allowing the helicopter to fly without a valid certificate of airworthiness, endangering an aircraft and failing to make an entry in the aircraft's logbook.
Can it be right that CAA surveyors who inspect a helicopter may little or nothing about the type?
Or that they are not properly briefed to look for known problems relating to a particular type?
"The AAIB do not understand." ??
It seems like the AAIB understands all too well the dangers/weaknesses in the existing procedures.
And, the AAIB understands that this tragedy which cost three lives might not have happened if the procedures the AAIB recommends had been in place.
Is that the reason the CAA won't accept the AAIB is right?
Whose judgement do you accept?
The AAIB which helps pilots by finding out what caused an accident, and then tries to ensure the same thing doesn't happen to us? Or the CAA?
The CAA is entitled to reject safety recommendations which the AAIB makes for our benefit - but do you think it's right that they should?
I would venture that they should have that right, but I would dispute strongly in this case that they should. It certainly does not appear that they have made a good case why they should.
I've had AAIB findings "against" me, and in every case I can remember, the nearest to rejection CAA has ever accepted has been a staged plan of implementation. Whilst in retrospect, I think CAA was generally right, this tends in my view to suggest that they should take a similar line towards themselves.
So, from the view of a neutral but competent observer, I'd say this stinks. AAIB are incredibly competent, if they truly don't understand an issue it's not for want of making proper inquiries and can only mean that those who "do understand" (CAA) failed properly to explain the position. I have certainly never before heard of something as extreme as CAA rejecting such a large proportion of AAIB recommendations from an investigation. None of the recommendations are contentious from where I'm sitting, and it does read to me like a deliberate effort to protect their own backsides from a charge of CAA's own system being at fault, rather than the one individual who was jailed after making an open and honest admission of what he had done wrong.
You chaps have disagreed with me before and I said I wouldn't post again, but sod it. In my opinion, anybody who is sufficiently knowledgable in this case, and has even a tenuous relationship with the people directly affected, should in my opinion be writing to their MP about this. This reads to me as a serious failure of a safety system in the name of protecting somebody's career and that should not ever happen.
Incidentally, could somebody in the know post which three recommendations CAA DID accept, it would be interesting to know.
G
I've had AAIB findings "against" me, and in every case I can remember, the nearest to rejection CAA has ever accepted has been a staged plan of implementation. Whilst in retrospect, I think CAA was generally right, this tends in my view to suggest that they should take a similar line towards themselves.
So, from the view of a neutral but competent observer, I'd say this stinks. AAIB are incredibly competent, if they truly don't understand an issue it's not for want of making proper inquiries and can only mean that those who "do understand" (CAA) failed properly to explain the position. I have certainly never before heard of something as extreme as CAA rejecting such a large proportion of AAIB recommendations from an investigation. None of the recommendations are contentious from where I'm sitting, and it does read to me like a deliberate effort to protect their own backsides from a charge of CAA's own system being at fault, rather than the one individual who was jailed after making an open and honest admission of what he had done wrong.
You chaps have disagreed with me before and I said I wouldn't post again, but sod it. In my opinion, anybody who is sufficiently knowledgable in this case, and has even a tenuous relationship with the people directly affected, should in my opinion be writing to their MP about this. This reads to me as a serious failure of a safety system in the name of protecting somebody's career and that should not ever happen.
Incidentally, could somebody in the know post which three recommendations CAA DID accept, it would be interesting to know.
G
Join Date: Jul 2000
Location: London
Posts: 2,916
Likes: 0
Received 0 Likes
on
0 Posts
I was involved in this case from the outset - I represented the engineer.
I have no doubt whatsoever that the AAIB investigators fully understood all the issues during the course of their extremely thorough investigation and that the AAIB as a body fully understands those aspects about which the Report makes formal safety recommendations.
The Report highlights problem areas: some are specific to the helicopter type, and some are of general application to CAA procedures.
In my opinion, until the AAIB's safety recommendations are implemented, there is a very real risk that there will be more fatalities.
I have no doubt whatsoever that the AAIB investigators fully understood all the issues during the course of their extremely thorough investigation and that the AAIB as a body fully understands those aspects about which the Report makes formal safety recommendations.
The Report highlights problem areas: some are specific to the helicopter type, and some are of general application to CAA procedures.
In my opinion, until the AAIB's safety recommendations are implemented, there is a very real risk that there will be more fatalities.
Join Date: Mar 2000
Location: Bath
Posts: 243
Likes: 0
Received 0 Likes
on
0 Posts
I have the CAA press release in front of me. To make sense(?) of it you will need to refer to Tudor's post above.
The CAA have accepted safety recommendation 2001-86
The CAA have partially accepted safety recommendations 2001-82 and 2001-83
Safety recommendation 2001-87 is addressed to The Schweizer Aircraft Corporation
The CAA rejected the other safety recommendations
So the summary...
1 recommendation accepted
2 partially accepted
1 not addressed to the CAA
10 safety recommendations not accepted
Ian Seager, Flyer magazine
The CAA have accepted safety recommendation 2001-86
The CAA have partially accepted safety recommendations 2001-82 and 2001-83
Safety recommendation 2001-87 is addressed to The Schweizer Aircraft Corporation
The CAA rejected the other safety recommendations
So the summary...
1 recommendation accepted
2 partially accepted
1 not addressed to the CAA
10 safety recommendations not accepted
Ian Seager, Flyer magazine
Lu is without doubt a loud and opinionated reactionary.
However, from my own experience of the same or similar authorities, which although probably less than Lu's is considerable - he is right. I could happily introduce several company Chief Engineers or CTPs who have beat their heads against an attitude which is far more to do with protecting the authority and it's staff than with achieving what should be the two sole goals of an aviation authority, which are (1) safety, (2) allowing aircraft builders, owners, operators, etc. to operate as efficiently as possible without compromising (1).
My only disagreement with Lu's post is naming any particular aircraft when giving past history, it only starts to point at individuals which gets hackles up.
As to the individual recommendations, I've been looking at them. It frankly staggers me that most of these were necessary at-all. I did start this post by making an individual critique of them, but why? - any suitably qualified aerospace professional can see the need if any of these issues are not already addressed for doing so. One can only conject as to why CAA has not accepted them, for the time being I shall hold with my previously posted theory.
G
However, from my own experience of the same or similar authorities, which although probably less than Lu's is considerable - he is right. I could happily introduce several company Chief Engineers or CTPs who have beat their heads against an attitude which is far more to do with protecting the authority and it's staff than with achieving what should be the two sole goals of an aviation authority, which are (1) safety, (2) allowing aircraft builders, owners, operators, etc. to operate as efficiently as possible without compromising (1).
My only disagreement with Lu's post is naming any particular aircraft when giving past history, it only starts to point at individuals which gets hackles up.
As to the individual recommendations, I've been looking at them. It frankly staggers me that most of these were necessary at-all. I did start this post by making an individual critique of them, but why? - any suitably qualified aerospace professional can see the need if any of these issues are not already addressed for doing so. One can only conject as to why CAA has not accepted them, for the time being I shall hold with my previously posted theory.
G
Join Date: Mar 2000
Location: UK
Posts: 5,197
Likes: 0
Received 0 Likes
on
0 Posts
I've split this topic into two parts because I think the latest development in this curious affair deserves careful consideration.
It is highly unusual for the CAA to reject so many AAIB safety recommendations made after such a thorough investigation.
Many Rotorheads have been very suspicious about the delay in publishing the Report.
See the original thread started by Hoverman - under it's old title Something fishy going on?
Has Genghis the Engineer hit the nail on the head?
Heliport
It is highly unusual for the CAA to reject so many AAIB safety recommendations made after such a thorough investigation.
Many Rotorheads have been very suspicious about the delay in publishing the Report.
See the original thread started by Hoverman - under it's old title Something fishy going on?
Has Genghis the Engineer hit the nail on the head?
Heliport
Join Date: Jan 2001
Location: UK
Age: 71
Posts: 1,364
Likes: 0
Received 0 Likes
on
0 Posts
Is the CAA Press Release on the web?? I could not find it on the CAA website. Perhaps they are too ashamed to make their press release public ? 
I can only add to the other comments here, that having read the AAIB report carefully, it seems to be up to their normal high standard. The content of the report itself seems to me to demonstrate that the AAIB have a good grasp of the issues. To dismiss the AAIB recommendations in such a way seems pretty cavalier - although I have not been able to read the Press Releasee directly of course!
If you realised you were on a very sticky wicket this is the sort of garbage, spun response that might be generated. Their hope must be that it will go away if they keep fairly quiet about it. There are loads of routine examples of the CAA engaging in back-covering exercises - avoiding their own liability (i.e. taking responsibility for nothing)
Certainly my confidence in the engineering system that we as pilots all rely upon is undermined by looking at this report. Obviously, the actions of the engineer are worrying, but far more so is the attitude of the CAA, and their inadequate systems.
I have been musing about what we could do about it. The only thing that might just make the CAA reconsider their position would be if politicians got involved. I may be unduly cynical about politicians, but I doubt that they would be much interested, unless they saw the connection to some big fixed wing accident (i.e. a threat to lots of non-aviating voters).
Does anyone have any ideas??
I can only add to the other comments here, that having read the AAIB report carefully, it seems to be up to their normal high standard. The content of the report itself seems to me to demonstrate that the AAIB have a good grasp of the issues. To dismiss the AAIB recommendations in such a way seems pretty cavalier - although I have not been able to read the Press Releasee directly of course!
If you realised you were on a very sticky wicket this is the sort of garbage, spun response that might be generated. Their hope must be that it will go away if they keep fairly quiet about it. There are loads of routine examples of the CAA engaging in back-covering exercises - avoiding their own liability (i.e. taking responsibility for nothing)
Certainly my confidence in the engineering system that we as pilots all rely upon is undermined by looking at this report. Obviously, the actions of the engineer are worrying, but far more so is the attitude of the CAA, and their inadequate systems.
I have been musing about what we could do about it. The only thing that might just make the CAA reconsider their position would be if politicians got involved. I may be unduly cynical about politicians, but I doubt that they would be much interested, unless they saw the connection to some big fixed wing accident (i.e. a threat to lots of non-aviating voters).
Does anyone have any ideas??
Join Date: Feb 2003
Location: LEAX, Spain
Age: 62
Posts: 261
Likes: 0
Received 0 Likes
on
0 Posts
Politicians?
I doubt any politician would be of help, not least because they'd never want to get involved in such a complex issue, and because it would mean taking on a government entity - one which, if they aren't already connective with it, might be after the next election. As a journalist I can tell you the general media are also unlikely to handle this one well, not least because the CAA has every right to reject AAIB recommendations.
As a pilot I also agree the CAA's attitude is cavalier. I for one have great respect for the AAIB's work. I've never met anyone who grumbled about the AAIB, but the CAA?...
As a pilot I also agree the CAA's attitude is cavalier. I for one have great respect for the AAIB's work. I've never met anyone who grumbled about the AAIB, but the CAA?...
Join Date: Mar 2000
Location: UK
Posts: 5,197
Likes: 0
Received 0 Likes
on
0 Posts
Dantruck
I share your cynicism about politicians, but the CAA is not a government department.
I bow to your experience of the Press as a journalist, but wonder whether the Press would ignore the story if, as is widely believed, this is a cover-up with the CAA watching their own backs after a fatal crash in which three people lost their lives.
What, for example, would Joe Public think if they knew that CAA surveyors were expected to conduct surveys of aircraft types they know nothing about - and without a briefing to point them towards known problem areas?
The British Press is notorious for making 'scandal' stories and alleging cover-up when neither are true - would they not be interested if there was actually a basis for such a story?
I share your cynicism about politicians, but the CAA is not a government department.
I bow to your experience of the Press as a journalist, but wonder whether the Press would ignore the story if, as is widely believed, this is a cover-up with the CAA watching their own backs after a fatal crash in which three people lost their lives.
What, for example, would Joe Public think if they knew that CAA surveyors were expected to conduct surveys of aircraft types they know nothing about - and without a briefing to point them towards known problem areas?
The British Press is notorious for making 'scandal' stories and alleging cover-up when neither are true - would they not be interested if there was actually a basis for such a story?
Join Date: Feb 2003
Location: LEAX, Spain
Age: 62
Posts: 261
Likes: 0
Received 0 Likes
on
0 Posts
Heliport
On a slow news week a serious weekly like the Sunday Times, a UK broadsheet newspaper, might just pick up your point and run with it. However, the problem we pilots would have in convincing a news editor of the worth of the storyline you suggest lies in the fact the crash involved a helicopter, and not even one operating a scheduled service. Had it been a 737 taking holidaymakers to Malaga - ie: an aircraft and type of operation understood by Joe Public - the reaction would likely be different. This is dumb given that the aircraft type and operation do not lie at the root of your suggested (and worthy) story idea, yet, that is how any news editor would weigh it up.
Bottom line is: complex issues of minority interest don't make popular reading, especially at a time when big issues like the probability of war have everyone's attention. In an earlier post someone made a similar observation about the involvement of an airliner being more likely to attract journalistic interest. That post was spot on.
Specialist magazines like The Engineer or Flight International could pick this one up, but that would not reach Joe Public.
Didn't mean to imply the CAA is a government department, more that it comes within ministers' sphere of influence.
On a slow news week a serious weekly like the Sunday Times, a UK broadsheet newspaper, might just pick up your point and run with it. However, the problem we pilots would have in convincing a news editor of the worth of the storyline you suggest lies in the fact the crash involved a helicopter, and not even one operating a scheduled service. Had it been a 737 taking holidaymakers to Malaga - ie: an aircraft and type of operation understood by Joe Public - the reaction would likely be different. This is dumb given that the aircraft type and operation do not lie at the root of your suggested (and worthy) story idea, yet, that is how any news editor would weigh it up.
Bottom line is: complex issues of minority interest don't make popular reading, especially at a time when big issues like the probability of war have everyone's attention. In an earlier post someone made a similar observation about the involvement of an airliner being more likely to attract journalistic interest. That post was spot on.
Specialist magazines like The Engineer or Flight International could pick this one up, but that would not reach Joe Public.
Didn't mean to imply the CAA is a government department, more that it comes within ministers' sphere of influence.
Last edited by Dantruck; 2nd Mar 2003 at 10:44.
Join Date: May 2002
Location: Australia
Posts: 2,242
Likes: 0
Received 0 Likes
on
0 Posts
Well, having just read it right through I too agree with Genghis and think it stinks.
If it were possible it might answer a few questions to
find out who in the CAA gave the aircraft the 'all clear' in 1999, where are they now for instance, what position do they hold?
Flying Lawyer, you probably know what, if any, Professional Indemnity cover the CAA would have?
From a legal point of view if the CAA had agreed to the thirteen recommendations would they be laying themselves open to court action? (I would have thought they would).
Before even an interim report was published I imagine there
would have been considerable communication between the AAIB and the CAA behind the scenes so for it to have come down to this public showdown the CAA must be desparate to protect someone and/or themselves. A quick statement to
the effect that the CAA had accepted the bulk of the recommendations and had already implemented corrective action would have shown that they at least took a positive attitude towards righting wrongs, as it is, how many more unmodified -300s have fallen out of the sky since? How many more have to
before the CAA will admit changes are required?
I may not be adding anything new here, but yes, it does stink, the CAA are protecting themselves and possibly individuals and are afraid of a court case that might well cost them dear and set precedents.
If it were possible it might answer a few questions to
find out who in the CAA gave the aircraft the 'all clear' in 1999, where are they now for instance, what position do they hold?
Flying Lawyer, you probably know what, if any, Professional Indemnity cover the CAA would have?
From a legal point of view if the CAA had agreed to the thirteen recommendations would they be laying themselves open to court action? (I would have thought they would).
Before even an interim report was published I imagine there
would have been considerable communication between the AAIB and the CAA behind the scenes so for it to have come down to this public showdown the CAA must be desparate to protect someone and/or themselves. A quick statement to
the effect that the CAA had accepted the bulk of the recommendations and had already implemented corrective action would have shown that they at least took a positive attitude towards righting wrongs, as it is, how many more unmodified -300s have fallen out of the sky since? How many more have to
before the CAA will admit changes are required?
I may not be adding anything new here, but yes, it does stink, the CAA are protecting themselves and possibly individuals and are afraid of a court case that might well cost them dear and set precedents.
BlueEagle asks, not unreasonably, who would have been responsible for approving the type. I'm sure I could guess a few of the key names, but if I did, I don't suppose the moderator would be as gentle to me as he is to Lu, so I shall refrain.
However, it's worth mentioning how the aircraft gets approved, which is probably transparent to most people.
The manufacturer, who are approved by their own authority as competent to do so will submit a series of reports to CAA. These consist of two parts. One is called the "compliance checklist", showing that the aircraft should comply with each paragraph of the relevant safety standard - in this case JAR-27. The second (and rather larger) part will be all the supporting structural, test, analysis, flight test, etc. reports referred to by the compliance checklist. The company will have various specialist "signatories", but the overall compliance checklist is signed by the top-level design signatory, usually the Chief Engineer or Chief Designer.
This initially goes to somebody at CAA called a "Design Liaison Surveyor" who will go through the compliance checklist, pick up any obvious problems, then distribute the supporting reports to various specialist departments - structures, flight test, powerplant, documentation, etc. These specialist surveyors each check in their specialist areas and report back to the DLS.
The DLS, who will usually be an aeronautical Engineer and supervised by a more senior Engineer ultimately makes the approval decision based upon the reports of their specialist departments. They then issue a provisional approval (called a Draft Airworthiness Approval Note) on the basis of which a regional surveyor will go and examine an example aircraft, and probably somebody from flight test will go and spend a few hours in the type if they haven't already. Finally, if everybody's happy, they report back to the DLS whose signature will give the final approval.
So, for there to be so many errors in the approval as AAIB appear to have found, I can't see it can be anything but a complete breakdown in the management system. Although one person ultimately signed it off, I can't see that any one person at CAA could be held responsible for the technical failings. Of-course, if it's a failing of the system, the finger inevitably points at managers senior enough to refuse AAIB recommendations Having said that, everybody in the business is well aware of the problems that arise from having a DLS who is a less than exceptional Engineer.
G
However, it's worth mentioning how the aircraft gets approved, which is probably transparent to most people.
The manufacturer, who are approved by their own authority as competent to do so will submit a series of reports to CAA. These consist of two parts. One is called the "compliance checklist", showing that the aircraft should comply with each paragraph of the relevant safety standard - in this case JAR-27. The second (and rather larger) part will be all the supporting structural, test, analysis, flight test, etc. reports referred to by the compliance checklist. The company will have various specialist "signatories", but the overall compliance checklist is signed by the top-level design signatory, usually the Chief Engineer or Chief Designer.
This initially goes to somebody at CAA called a "Design Liaison Surveyor" who will go through the compliance checklist, pick up any obvious problems, then distribute the supporting reports to various specialist departments - structures, flight test, powerplant, documentation, etc. These specialist surveyors each check in their specialist areas and report back to the DLS.
The DLS, who will usually be an aeronautical Engineer and supervised by a more senior Engineer ultimately makes the approval decision based upon the reports of their specialist departments. They then issue a provisional approval (called a Draft Airworthiness Approval Note) on the basis of which a regional surveyor will go and examine an example aircraft, and probably somebody from flight test will go and spend a few hours in the type if they haven't already. Finally, if everybody's happy, they report back to the DLS whose signature will give the final approval.
So, for there to be so many errors in the approval as AAIB appear to have found, I can't see it can be anything but a complete breakdown in the management system. Although one person ultimately signed it off, I can't see that any one person at CAA could be held responsible for the technical failings. Of-course, if it's a failing of the system, the finger inevitably points at managers senior enough to refuse AAIB recommendations
Having said that, everybody in the business is well aware of the problems that arise from having a DLS who is a less than exceptional Engineer.G
Not being familiar with the a/c type, and also not really involved in this latest debacle from the CAA, makes it that much harder to get my head round it.
However, from an outsiders point of view, I would make these observations:
1. There must be mitigation behind the CAA's response and if it was something which directly affected me, then I would do everything possible to find out why they responded the way they did..
2. As the a/c type operator, I would make damn sure I acted on the AAIB recommendations within reason, to safeguard my fleet and working practices, with or without the CAA's help.
3. If I felt very strongly about this issue, I would then take matters further by advising my insurance company of the outcome. I would write to my MP. I would write to the Chairman of the CAA and I would write to the local (where the accident happened) and national newspapers.
The debating can and probably will go on - ad infinitum, but action behind the scenes cannot wait on this one.....
However, from an outsiders point of view, I would make these observations:
1. There must be mitigation behind the CAA's response and if it was something which directly affected me, then I would do everything possible to find out why they responded the way they did..
2. As the a/c type operator, I would make damn sure I acted on the AAIB recommendations within reason, to safeguard my fleet and working practices, with or without the CAA's help.
3. If I felt very strongly about this issue, I would then take matters further by advising my insurance company of the outcome. I would write to my MP. I would write to the Chairman of the CAA and I would write to the local (where the accident happened) and national newspapers.
The debating can and probably will go on - ad infinitum, but action behind the scenes cannot wait on this one.....
The CAA realised years ago that it was impossible for them to have type current surveyors for all types on the Uk register.
This was the reason why Cof A renewals became the resposibility of the operators/maintenance organisations. The CAA would otherwise have to employ hundreds of extra surveyors who would spend most of their time on the road going from airfield to airfield.
This was the reason why Cof A renewals became the resposibility of the operators/maintenance organisations. The CAA would otherwise have to employ hundreds of extra surveyors who would spend most of their time on the road going from airfield to airfield.
Join Date: May 2001
Location: London
Posts: 528
Likes: 0
Received 0 Likes
on
0 Posts
The point here is that more than 500 early-model Hughes 269 aircraft are flying around the world today with a design fault that could cause them to break up at any time, and the CAA refuses to adequately address the issue.
Hughes recognised the fault and redesigned the component concerned in the early 1970s, incorporating the new design from s/n 570. Since then, there has been only one failure of the redesigned component, but that had suffered damage.
But the helicopters with the original component are steadily falling out of the sky. Since 1972 there have been eight such accidents, and14 people have been killed.
The CAA's case has always been that regular inspections of the component, coupled with periodic dye penetrant inspections, is enough. The trail of corpses, however, should lead them to a different conclusion.
In April 2001 the AAIB, investigating this accident, made an urgent recommendation to the CAA (and via them, to the FAA) that replacement of the original component with the redesigned one be mandated immediately. The CAA refused, clinging to the claim that inspections were adequate. In November 2002, a Hughes 269 crashed in Oklahoma when the original component gave way, and the occupants were killed.
There are a hundred other aspects to this sorry saga, but the key question is why, in the face of all the evidence, does the CAA stick to its discredited line? Perhaps Flying Lawyer could enlighten us as to whether this is merely a matter of loss of face, or whether there is some liability issue to be considered.
As to interesting the mainstream media, it may be possible, but there are other shoes to drop first.
Hughes recognised the fault and redesigned the component concerned in the early 1970s, incorporating the new design from s/n 570. Since then, there has been only one failure of the redesigned component, but that had suffered damage.
But the helicopters with the original component are steadily falling out of the sky. Since 1972 there have been eight such accidents, and14 people have been killed.
The CAA's case has always been that regular inspections of the component, coupled with periodic dye penetrant inspections, is enough. The trail of corpses, however, should lead them to a different conclusion.
In April 2001 the AAIB, investigating this accident, made an urgent recommendation to the CAA (and via them, to the FAA) that replacement of the original component with the redesigned one be mandated immediately. The CAA refused, clinging to the claim that inspections were adequate. In November 2002, a Hughes 269 crashed in Oklahoma when the original component gave way, and the occupants were killed.
There are a hundred other aspects to this sorry saga, but the key question is why, in the face of all the evidence, does the CAA stick to its discredited line? Perhaps Flying Lawyer could enlighten us as to whether this is merely a matter of loss of face, or whether there is some liability issue to be considered.
As to interesting the mainstream media, it may be possible, but there are other shoes to drop first.
Join Date: Mar 2002
Location: Kings Caple, Ross-on-Wye.orPiccots End. Hertfordshire
Posts: 458
Likes: 0
Received 0 Likes
on
0 Posts
From Dennis Kenyon
To date, I have remained largely quiet on the G-ZAPS accident, since it seemed proper to await formal publication of the AAIB report even tho I received the draft over a year ago.
However in view of the very serious situation we now have as observed by many of my industry pilot friends and pprune contributors, I plan to raise the profile of my son's accident putting the spotlight where it belongs, ie the FAA/CAA. I have produced a piece that will shortly be published in aviation journals which I hope will bring the situation into the public arena. Since the AAIB report was published on 21st Feb 2003 I see the flack has been well and truly flying.
The accident history of the type is simple. A clevis component suffered a fatigue failure some thirty years ago, This was followed in succeeding years by a further five identical accidents until March 2000 when my son lost his life. Seven in thirty years so we can anticipate on an average basis - one every four years.
Following the earlier accidents, the Hughes factory produced a 're-designed' cluster commonly refered to by engineers as 'the thickwall cluster' being part no 2234 dash three. It was incorporated into all factory build helicopters after serial number 570. I have to emphasise that with the exception of a single incident for a special reason, there have been no failures to the thick wall dash three component, which includes all Schweizer built helicopters flying today.
As we know the 'regulatory authorities' ie FAA/CAA did not mandate the modification instead relying on a strategy of AD's, SB's LTO's SL's etc, being periodic inspections. to date thirteen in all !! Now one might be forgiven for thinking that a more responsible authority would have mandated the modification following say the second or third accident. But no, our CAA felt that the regular 'dye penetrant and eyeball' inspection route was sufficient. Now my view is that - yes the inspection route was correct - but patently it wasn't working for whatever reason.
So why the hell didn't someone in charge wake up, and say enough is enough. The fix is staring us in the face. Mandate the modification. Had the FAA/CAA done this my son and a few other pilots would not be dead. Had they even embarked on a programme of letting the aviation world know, I would not have purchased the early Hughes suspect type or as a minimum would have required it to be modified before putting it into service on my school.
Two years ago, I wrote a piece on the above lines, and ended by saying the CAA must do something now before we have an eighth accident. Sadly I must confirm that on Nov 1st Hughes 300 N8885F suffered an in flight break up at 500 feet in Oklahoma. How do my readers think I feel now. How will the USA relatives feel when they discover the truth.
In April 2001, one year after my son's accident, the AAIB recommended the FAA/CAA mandate the modification. The FAA said they would report back in the standard 90 days. In May 2002, the CAA replied refusing to accept the recommendation.
Yes, Paul Kenward was sent to prison for an illegal weld repair, no doubt allowing the CAA to think they were off the hook. But this was the only failure due to a weld repair. One might even argue the Kenward's repair extended the life of a clevis lug that was on its way to a failure anyway.
In October 1999, five months before the accident, a C of A was issued being overseen and routinely checked by the CAA surveyor. In my view one of the reasons, Paul Kenward was found not guilty by the Oxford Crown Court jury on three of the charges. The CAA have made a statement and I quote, the 1999 inspection was not a sign off for the safety of the helicopter. Ye Gods - and they call themselves the Safety Regulation Group !! Of course I understand the CAA's C of A involvement, but if the surveyor had only been made aware of the type's chronic history of failure, my son would be alive. If the welder had been made similarly aware of the proper procedure, my son would be alive. I'm afraid I have to find the CAA totally negligent in this matter and for them then to make a statement and I again quote. "The AAIB have highlighted areas they do not understand." How arrogant. The AAIB - with an army of the most experienced engineers and access to pilots in the world.
So to turn to some of the questions raised by Rotorhead contributors. The AAIB produced their draft on 20 th December 2001. I am advised that the report was delayed during extended legal representations by the CAA to change two of the six 'causal factors'
1. Failure to mandate the fitting of ... became, the decision NOT TO MANDATE, (my capitals) the fitting of ..........
2. Failure of the CAA surveyor ..... became, there being no requirement for the CAA surveyor ......
I plan to be constructive in a moment but must first refer to a third AAIB 'causal factor - ie the pilots failure to detect the cracked cluster in a pre flight/check A inspection.
Just to say that as a 13,500 hour rotary pilot/instructor/examiner I was last to fly the aircraft and did not detect the crack or knew about the illegal weld repair. Prior to my inspectionf, Mike Smith a higher qualified pilot inspected the aircraft five days before the accident. Leon Smith a 14,000 hour instructor/examiner flew the aircraft for twenty hours over a three week period and detected nothing. One might be forgiven for thinking the crack was not there to be seen. A view partially shared by AAIB.
So where does that leave us now. Simply that around 400 to 500 Hughes 300 helicopters are today flying around the world and if nothing is done now, accident number nine will happen in the next three to four years.
I am advising Gerald Howarth M.P (defence minister) of this situation and other persons in parliament who may decide to take things up. But no holding breath !
So what must I say to the CAA. They must do the following.
1. Mandate the fitting of the dash three component on all affected helicopters.
2. Accept the AAIB recommendation in all 14 areas, particularly those relating to authorisation of welders, access to type knowledge by surveyors, use of pilot check lists that are authorised by the manufacturer Scrapping of the usless LAMS. There are 17 early Hughes on the UK register, two of which were also found with clevis cluster cracks. I have made it my business to tell UK owners what they must do. Yes the CAA inspection system is working most of the time, but there are catastrophic consequences when it doesn't.
Finally to apologise for not being able to edit these words and my case simply due to the nature of this forum. The words come from my heart as they occur. I have tried hard to keep emotion out of this piece. Those who know me and knew my son, will appreciate how difficult it has been.
Please call on me at my Shoreham office if anyone wishes to discuss or participate in any aspects of my son's accident in an effort to stop this ever happening again.
Fly safely.
Dennis Kenyon
To date, I have remained largely quiet on the G-ZAPS accident, since it seemed proper to await formal publication of the AAIB report even tho I received the draft over a year ago.
However in view of the very serious situation we now have as observed by many of my industry pilot friends and pprune contributors, I plan to raise the profile of my son's accident putting the spotlight where it belongs, ie the FAA/CAA. I have produced a piece that will shortly be published in aviation journals which I hope will bring the situation into the public arena. Since the AAIB report was published on 21st Feb 2003 I see the flack has been well and truly flying.
The accident history of the type is simple. A clevis component suffered a fatigue failure some thirty years ago, This was followed in succeeding years by a further five identical accidents until March 2000 when my son lost his life. Seven in thirty years so we can anticipate on an average basis - one every four years.
Following the earlier accidents, the Hughes factory produced a 're-designed' cluster commonly refered to by engineers as 'the thickwall cluster' being part no 2234 dash three. It was incorporated into all factory build helicopters after serial number 570. I have to emphasise that with the exception of a single incident for a special reason, there have been no failures to the thick wall dash three component, which includes all Schweizer built helicopters flying today.
As we know the 'regulatory authorities' ie FAA/CAA did not mandate the modification instead relying on a strategy of AD's, SB's LTO's SL's etc, being periodic inspections. to date thirteen in all !! Now one might be forgiven for thinking that a more responsible authority would have mandated the modification following say the second or third accident. But no, our CAA felt that the regular 'dye penetrant and eyeball' inspection route was sufficient. Now my view is that - yes the inspection route was correct - but patently it wasn't working for whatever reason.
So why the hell didn't someone in charge wake up, and say enough is enough. The fix is staring us in the face. Mandate the modification. Had the FAA/CAA done this my son and a few other pilots would not be dead. Had they even embarked on a programme of letting the aviation world know, I would not have purchased the early Hughes suspect type or as a minimum would have required it to be modified before putting it into service on my school.
Two years ago, I wrote a piece on the above lines, and ended by saying the CAA must do something now before we have an eighth accident. Sadly I must confirm that on Nov 1st Hughes 300 N8885F suffered an in flight break up at 500 feet in Oklahoma. How do my readers think I feel now. How will the USA relatives feel when they discover the truth.
In April 2001, one year after my son's accident, the AAIB recommended the FAA/CAA mandate the modification. The FAA said they would report back in the standard 90 days. In May 2002, the CAA replied refusing to accept the recommendation.
Yes, Paul Kenward was sent to prison for an illegal weld repair, no doubt allowing the CAA to think they were off the hook. But this was the only failure due to a weld repair. One might even argue the Kenward's repair extended the life of a clevis lug that was on its way to a failure anyway.
In October 1999, five months before the accident, a C of A was issued being overseen and routinely checked by the CAA surveyor. In my view one of the reasons, Paul Kenward was found not guilty by the Oxford Crown Court jury on three of the charges. The CAA have made a statement and I quote, the 1999 inspection was not a sign off for the safety of the helicopter. Ye Gods - and they call themselves the Safety Regulation Group !! Of course I understand the CAA's C of A involvement, but if the surveyor had only been made aware of the type's chronic history of failure, my son would be alive. If the welder had been made similarly aware of the proper procedure, my son would be alive. I'm afraid I have to find the CAA totally negligent in this matter and for them then to make a statement and I again quote. "The AAIB have highlighted areas they do not understand." How arrogant. The AAIB - with an army of the most experienced engineers and access to pilots in the world.
So to turn to some of the questions raised by Rotorhead contributors. The AAIB produced their draft on 20 th December 2001. I am advised that the report was delayed during extended legal representations by the CAA to change two of the six 'causal factors'
1. Failure to mandate the fitting of ... became, the decision NOT TO MANDATE, (my capitals) the fitting of ..........
2. Failure of the CAA surveyor ..... became, there being no requirement for the CAA surveyor ......
I plan to be constructive in a moment but must first refer to a third AAIB 'causal factor - ie the pilots failure to detect the cracked cluster in a pre flight/check A inspection.
Just to say that as a 13,500 hour rotary pilot/instructor/examiner I was last to fly the aircraft and did not detect the crack or knew about the illegal weld repair. Prior to my inspectionf, Mike Smith a higher qualified pilot inspected the aircraft five days before the accident. Leon Smith a 14,000 hour instructor/examiner flew the aircraft for twenty hours over a three week period and detected nothing. One might be forgiven for thinking the crack was not there to be seen. A view partially shared by AAIB.
So where does that leave us now. Simply that around 400 to 500 Hughes 300 helicopters are today flying around the world and if nothing is done now, accident number nine will happen in the next three to four years.
I am advising Gerald Howarth M.P (defence minister) of this situation and other persons in parliament who may decide to take things up. But no holding breath !
So what must I say to the CAA. They must do the following.
1. Mandate the fitting of the dash three component on all affected helicopters.
2. Accept the AAIB recommendation in all 14 areas, particularly those relating to authorisation of welders, access to type knowledge by surveyors, use of pilot check lists that are authorised by the manufacturer Scrapping of the usless LAMS. There are 17 early Hughes on the UK register, two of which were also found with clevis cluster cracks. I have made it my business to tell UK owners what they must do. Yes the CAA inspection system is working most of the time, but there are catastrophic consequences when it doesn't.
Finally to apologise for not being able to edit these words and my case simply due to the nature of this forum. The words come from my heart as they occur. I have tried hard to keep emotion out of this piece. Those who know me and knew my son, will appreciate how difficult it has been.
Please call on me at my Shoreham office if anyone wishes to discuss or participate in any aspects of my son's accident in an effort to stop this ever happening again.
Fly safely.
Dennis Kenyon