FOD Damages 737 Flying Controls
Foreign Object Debris (FOD) Damages 737 Flying Controls Accident investigators in New Zealand report on damage to the flying controls of a 737 due to a trapped cleaning cloth. The Incident During routine maintenance of a Boeing 737-838, engineers found metal filings next to the stabilizer trim cable drum in the forward electronics and equipment compartment (located underneath the flight deck). While investigating further they found what they described as a cleaning ‘rag’ had been trapped in the windings on the forward cable drum. This foreign object had caused the stainless steel cable to bulge outward, contact the softer aluminium cable guides and the resulting wear had created the metal filings. In places the cables had worn right through the tubular aluminium spacer and had started to wear through the harder steel bolts that run through the spacers. The rag also resulted in increased cable tension, damaging a number of the cable pulleys between the front and rear drums. This occurrence was detected on 7 June 2013 on a B737 operated by New Zealand airline Jetconnect, a Qantas subsidiary, at Auckland International Airport. It was investigated by New Zealand’s Transport Accident Investigation Commission (TAIC). The Investigation In their investigation report, issued in March 2015, TAIC state, based on lab tests of the material, that it was “highly likely” the debris originated from the Qantas Sydney maintenance hangar. The ‘rag’ was actually a cellulosic or paper-based fibre and polypropylene material, consistent with one of the disposable tear-off paper roll products used at Sydney. TAIC concluded that: The integrity of the aeroplane’s stabiliser trim system manual control was compromised. Whilst considered unlikely, there was the potential for the stabiliser trim system manual control to become jammed or at worst disabled if a cable severed. Another Incident Interestingly Melbourne and Auckland sites use fabric rags which, due to their greater robustness, have a far greater potential to cause FOD events, such as jamming bell cranks, or jamming landing gear uplocks. The later was demonstrated by a subsequent incident involving a Jetconnect aircraft that had undergone maintenance at the Qantas Melbourne maintenance hangar in September 2013. TAIC did not investigate this incident but do comment on it: On 11 September 2013 a Jetconnect B737-838, registration ZK-ZQC, was involved in an incident that occurred during a flight to Wellington. The aeroplane had departed from Melbourne, where it had recently had maintenance carried out on the landing gear. After departing Melbourne the flight crew had difficulty raising the right main landing gear. The right main landing gear initially retracted but did not stay up, falling back down once the gear selector was moved to the off position. When the crew reselected the gear lever to the up position, the right main gear retracted and stayed up. After the aeroplane landed at Wellington the ground engineers inspected the landing gear and found a rag wrapped around the right main landing gear uplock assembly. Qantas… conducted a safety investigation into the second incident, which found that the rag had been used by an engineer to protect against an accidental head strike on the uplock during a maintenance task in the right main wheel well area. The rag was subsequently left on the uplock assembly after the maintenance task was completed, and it interfered with the retraction of the right main landing gear during the next flight. Safety Lessons TAIC make no recommendations but state, fairly self-evidently that the key lesson is that:...
read moreA320 Unstabilised Approaches: Descent Below MSA and a Runway Excursion at Lyon
A320 Unstabilised Approaches: A Descent Below Minimum Safe Altitude (MSA) and a Runway Excursion at Lyon An airline introducing a new type suffers a serious incident while training a new captain, highlighting the importance of Management of Change, Risk Assessment and good Training. UPDATE: Then within a year they have a runway excursion after an unstabilised approach at the same airfield. Descent Below MSA 2012 The French accident investigation agency, the Bureau d’Enquêtes et d’Analyses (BEA), has recently issued an English translation of a report into a Serious Incident involving a Greek Airbus A320 SX-BHV of Hermes Airlines, operated on behalf of charter carrier Air Mediterranee, on a night approach into Lyon on 11 April 2012. The Flight The flight had departed from Ajaccio, with the Captain as Pilot Non Flying (PNF) and instructor in the right-hand-side seat and a pilot-in-command under supervision as Pilot Flying (PF) in the left seat. The BEA comment: The failure to carry out checks of the RADIO NAV page on the FMGS [Flight Management Guidance System], which are normally carried out when passing FL100 in a climb and during approach preparation, did not allow the crew to detect that the FMGS had not automatically selected the ILS for runway 36L at Lyons Saint-Exupéry and that the Ajaccio AC ILS was still active on arrival. The crew had been expecting an ILS approach to runway 18L, however as they neared Lyon the approach controller reported low winds and suggested an ILS approach to runway 36L instead, which was accepted by the crew. The BEA go on: About one minute after the beginning of radar vectoring, the controller, who realized that the aeroplane was high on the glide, asked “…forty nautical […] is that OK for you, four zero?”. The crew, while programming the FMGS for an ILS approach to runway 36L, answered “Actually we… we’ll need to make a thirty six”. The controller, who interpreted the response of the crew as a confirmation of a landing on runway 36, did not understand that the crew wanted to make a late turn onto heading 360. He provided a heading of 315° to the localiser axis for runway 36L. As the Ajaccio AC ILS had not been deselected, the FMGS did not automatically select the ILS for runway 36L at Lyons. About three minutes later (at the point marked 1 on the graphic below), the controller gave a heading of 270° to extend the flight path conscious the aircraft was high. The crew tuned 30 seconds later. They were distracted by solving the inconsistency in the ILS frequency display (actually a symptom that the FMGS was set to the wrong frequency and was picking up a DME at Marseille, which shared the same frequency as Ajaccio) and by another crew’s read back error. The aircraft crossed the ILS axis twice (between points 2 and 4) with the ILS frequency being correctly set at point 3 on the graphic. Then at point 4: While the Capture mode engaged for a selected altitude of 3,000 ft at a speed of 240 kt, the crew decided to select an altitude of 400 ft on the control panel (FCU), which caused a mode reversion of the autopilot from ALT* to VS 1200 ft/min, the current vertical speed of the aeroplane at that time. They set the approach mode and engaged the...
read moreNorth Sea Helicopter Safety – Step Change in Safety Event
North Sea Helicopter Safety – Step Change in Safety Event The offshore industry safety initiative, Step Change in Safety, held a workforce engagement seminar on Helicopter Safety in Aberdeen in early March. The presentations are all available to download (click on the presenter’s name below): HSSG Update – Mark Abbey This presentation on behalf of the Helicopter Safety Steering Group highlights that 80,000 people have been had dry training to use the Category A Compressed Air – Emergency Breathing System integrated with the Survitec Mk 50 Lifejacket. Over 300,000 journeys have been made with the kit since it was introduced, with around 1 in a thousand resulting in a ‘snag’ being raised with the equipment. Five improvement actions have been identified for the lifejacket / CA-EBS. The presentation also discussed passenger sizing issued (previously discussed by Aerossurance last year). CAP1145 Update – Rick Newson This UK Civil Aviation Authority (CAA) presentation focused more on the flight operations than the wider issues discussed in the CAP1145 report published 20 February 2014 and the recent CAP1243, the Offshore Helicopter Review Progress Report. It does seem to feature more on automation than CAP1145 did (a subject discussed at the RAeS last year). HeliOffshore – Gretchen Haskins HeliOffshore, formed last year, is taking an explicitly collaborative approach to improving helicopter safety, calling for alignment amongst stakeholders. Aerossurance is a member of HeliOffshore. HeliOffshore have 6 safety priority areas. The presentation features draft material from the Flight Safety Foundation (FSF) Basic Aviation Risk Standards Offshore Helicopter Operations (BARSOHO), in the form of a bow-tie. UPDATE 27 May 2015: BARSOHO is launched. UPDATE 1 February 2017: BARSOHO Version 3, fully aligned with the HeliOffshore Safety Performance Model released in 2016, is now available. Airbus Safety Partnership – Andrew Dettl Airbus Helicopters have 11,727 helicopters in service, the highest time being an AS332L at 42,000 flying hours (almost certainly the historically significant G-TIGE, the first helicopter to fly with the pioneering IHUMS and with TCAS2). In total the company has 87 million flying hours of service experience (3.2 million in 2014). In particular Dettl discussed five safety initiatives: The preparation of an offshore Flight Crew Operations Manual for the EC225 (now the H225). The FCOM, a first for the helicopter industry was produced in cooperation with Avincis (now Babcock), Bristow and CHC. The FCOM has just been updated too. It remains to be seen if other manufacturers follow this lead. Training Standardisation across the various training organisations in relation to essential training. Maintenance Mentors: this initiative recognises that helicopter rotor, transmission and flight control systems can be more prone to undetected error and so provides greater expert support. Vision 1000, which Aerossurance has previously discussed in That Others May Live – Inadvertent IMC & The Value of Flight Data Monitoring Rig ‘n Fly automated approaches (similar to a the Rig Approach system developed by Sikorsky). Plus operator’s representatives covered background on three critical topics: Helicopter Maintenance – Lee James Pilot Training – Rob Dyas Flight Operations – Tim Glasspool Aerossurance has extensive helicopter safety, airworthiness, operations, survivability, safety analysis and contracting experience. For practical aviation advice you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
read moreIHST Update – March 2015
International Helicopter Safety Team (IHST) Update – March 2015 At the HAI Heli-Exp0 2015 in Orlando, Aerossurance attended the IHST Regional Partners Panel as one of the European representatives. The session featured presentations from different national and regional teams supporting the IHST: Introduction IHST Regional Partner Panel Introductory Slides India Rotary Wing Society of India: The RWSI presented the results of a highly successful 2014, with zero helicopter accidents in India, compared to 5 per annum in each of the previous 3 years. The key initiative was Directorate General of Civil Aviation (DGAC) Air Safety Circular 09 of 2013 that prohibited punitive action against pilots who made precautionary landings (see also this article). This concept was echoed in HAI’s 2014 Live and Land initiative. New Zealand New Zealand Helicopter Industry: Safety Update: There are 512 commercial helicopters in New Zealand, mostly light singles. The New Zealand Civil Aviation Authority (NZCAA) do, rather uniquely, require operators not only to report flying hours annually but also hours broken down into about 20 usage categories, so they do have very good rate data. According to the NZCAA, 47% of local operators have only 1 or 2 aircraft. This creates challenge for effective SMS implementation and safety promotion. The NZ CAA described their solution of analysing accidents and creating informative safety bulletins in conjunction with the New Zealand Helicopter Association. South America Safety Road Show: Airbus Helicopters‘ presentation highlighted that the accident rate in the region has been 2-4 times higher than in other areas (something sadly underscored by a mid air collision in Argentina a few days later). AH described a 2 day road show approach that they have been supporting in the region, culminating in a workshop to identify actions. Helicopter Safety Team – Brazil: In Brazil 55% of helicopters belong to owners/operators with just one helicopter. In their review of accidents, safety management and regulatory issues were even more significant than in US and European studies. North America USHST Update: Among the interesting items of data is study on night accidents. Pilots with less than 500 hours of night experience make were involved in 61% of night accidents and pilots with less than 100 hours 30% of all night accidents. The presentation also discussed the USHST’s Reel Safety audio visual safety initiative. US General Aviation & Part 135 Activity Survey: FAA contractor Tetra Tech describe the process for gathering flying hours data in the US. Canadian Update: The Helicopter Association of Canada noted that in their analysis, they noted a disproportionate number of piston-engine helicopter accidents. The HAC has been busy developing best practice guides for various specialist operations. Encouragingly they noted that in 2-14 they had no fatal helicopter accidents in Canada. Europe European Helicopter Safety Team (EHEST): Highlighted a number of engagement activities and a series of publications. The EHEST web site, with access to all EHEST publications, can be found at: www.ehest.org EHEST also has a LinkedIn Discussion Group. EHEST is part of the European Strategic Safety Initiative (ESSI), an aviation safety partnership between the European Aviation Safety Agency (EASA), other regulators and the industry. Aerossurance is a specialist aviation consultancy. For expert advice on helicopter safety, accident analysis, operations, airworthiness and contracting matters, contact us at enquiries@aerossurance.com Follow us on LinkedIn for our latest updates....
read moreOperator & FAA Shortcomings in Alaskan B1900 Accident
Operator & FAA Shortcomings in Alaskan B1900 Accident UPDATE 10 April 2018: with details below of further NTSB recommendations after a 2016 C208B accident The US National Transportation Safety Board (NTSB) has reported on a Beechcraft 1900C accident on the North Slope of Alaska on 23 Nov 2013. The B1900C was being operated by Hageland Aviation Services (doing business as [dba] ERA Alaska) on a passenger shuttle for an oil and gas company to a remote production site. The aircraft, N575X, sustained substantial damage during the landing accident, but neither crew or the single passenger were injured. The NTSB investigation identified shortcoming in procedures, training and oversight (both by the company and the Federal Aviation Administration [FAA]). This accident highlights the importance of contractual safety requirements and effective assurance when contracting in air services and operating remote airfields. The NTSB Investigation Before departure from Deadhorse on the short flight to Badami, the weather at the destination airport was reported to be wind from the northeast at 27 mph, scattered clouds with blue skies above, and 1.5 statute miles visibility with blowing snow. As the Alaska Dispatch News reported, during the short flight the airport weather observer informed told the NTSB that he notified the pilots he could “…occasionally see the cold storage camp, which was located ‘1.25 miles away,’ but he did not consistently have 1 mile visibility.” The observer further described the weather as “bad” and that he could sometimes not see the runway. He apparently he advised the pilots to “use their own judgment”. The NTSB comment that “At the time of the accident the Badami METAR reported in part: wind 120 degrees, variable 060 degrees thru 210 degrees, at 30 knots, visibility 0.5 sm in heavy blowing snow, broken clouds at 1,000 feet, and temperature -16 degrees F”. The captain told the NTSB his visibility “…was unrestricted and that he had the runway environment in sight 20 miles from the airport.” After a brief hold, apparently believing visibility was 1 statute mile, he asked the FO to load the instrument approach into the GPS and the approach commenced. The Captain described the approach as normal until he realized he “was too low.” However, the FO told the NTSB he voiced concerns multiple times while on approach, finally saying “watch out,” just prior to impact. The aircraft touched down short, the right main landing gear separated and the aircraft slid along the runway. The investigation does not appear to have reconciled the differences in Captain, FO and weather observer’s statements. This was hampered by the CVR data being overwritten by post-incident engine runs. The ADN reported that the company explained: This particular CVR issue had to do with the configuration of our BE1900C aircraft, some of which have both a CVR and an FDR and some of which only have a CVR. When the mechanic was dispatched out to retrieve the CVR, he accidentally retrieved the FDR only thinking that he had sent in the CVR. Weeks later, when it was discovered that we had pulled the FDR, the engine runs had already been completed after the replacement of the propeller. The CVR and FDR are both in similar orange boxes and everyone thought the CVR was secured. When examined, the FDR did show the accident sequence and was consistent with the reports provided by the flight crew. The company had a pre-flight risk assessment process. According...
read moreNew Airbus Helicopters Designations: A Guide
New Airbus Helicopters Designations: A Guide At the same time as revealing their new X4 medium was to be called the H160, Airbus Helicopters unveiled new marketing designations for most of their models at the HAI Heli-Expo in Orlando, March 2015. The rebranding primarily affects the more modern production aircraft (with the exception of military only production types). Aerossurance is an Aberdeen based aviation consultancy. For expert advice you can trust on helicopter design, acquisition, airworthiness, operations and safety, contact: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
read moreMultiple TAWS Warnings Reveal Safety Reporting Issue
Multiple TAWS Warnings Reveal Safety Reporting Issue An ATR 72, abruptly flown at a high rate of descent, descended to 440 feet above the ground level, while trying to remain clear of cloud during an impulsively commenced visual approach, triggering multiple Terrain Awareness and Warning System (TAWS) warnings. The Australian Transport Safety Bureau (ATSB), in the first of three investigation reports on incidents with the same individual aircraft, identified ‘significant underreporting…of…TAWS-related occurrences’ by the airline. The Incident On 15 May 2013, Avions de Transport Regional ATR72-212A, VH‑FVR, was conducting a scheduled commercial passenger flight from Brisbane to Moranbah in Queensland. The flight was operated by Virgin Australia Regional Airlines (VARA), formerly Perth, WA based SkyWest. Corporate Background: Virgin Australia had made an offer to purchase SkyWest in late 2012, which was completed in April 2013, just weeks before this Serious Incident. VARA continues to operate on a separate Air Operators Certificate to Virgin Australia. While the HQ is in Perth, WA most of their ATR operations are in the East of Australia. These ATRs, first introduced in 2011, were primarily flown on behalf of Virgin Australia, even before the purchase. The acquisition signalled a period of growth for Virgin Australia, seen as a move to challenge Qantas, although VARA did delay ATR72 deliveries in January 2014 as part of a move to cool their expansion. The crew was initially planning to perform an NDB-A approach. After finding out that a Dash 8-300, due to arrive about 2 minutes prior, was to make a visual approach, the ATR crew changed their plans to also conduct a visual approach. The ATSB reported: …after descending though an overcast cloud layer at about 6,000 ft, they [the crew] became visual with the Moranbah township and the area surrounding the airport. They noted some low cloud and patches of fog around the runway 34 threshold. The ATSB report that: During the visual approach to Moranbah, the aircraft descended to a height of 440 ft above ground level as the pilot manoeuvred to avoid cloud. As the pilot levelled the aircraft, a number of terrain awareness warning system (TAWS) ground proximity warning system alerts activated. The aircraft was climbed and the circuit was continued, with the activation of another TAWS alert prior to the aircraft landing. The recorded average vertical speed during the descent from circuit height to 440 ft AGL, the lowest recorded height before the crew initiated a climb, was 1,750 ft/min. Further warnings were triggered by high bank angles on the base leg turn. The Crew The Captain (ATPL, 4,530 hours total, 1,750 hours on type, 3.5 hours in command) had completed the command upgrade just a few days earlier and was the Pilot Flying. The First Officer (ATPL, 2,880 hours total, 610 hours on type) was Pilot Monitoring. The ATSB say: According to the operator’s requirements, the FO had sufficient experience to be paired with a captain who had recently been checked to line. The ATSB Investigation The ATSB identified the following contributing factors: 1) Approaching the circuit, the captain assessed that a descent below the standard circuit height was necessary to avoid cloud, but did not communicate this to the first officer in a timely manner, thereby preventing identification of a descent limit or appropriate approach alternatives. 2) Due to the crew’s focus on avoiding the cloud, the high rate of descent at a lower than normal altitude was...
read moreNose Gear Collapse Filmed By FOD Detection System (Beechcraft Queen Air 4X-DZY)
Nose Landing Gear Collapse Filmed By FOD Detection System (Beechcraft Queen Air 4X-DZY at Tel Aviv) An automated FODetect runway foreign object debris (FOD) detection system, built by US company Xsight Systems, captured footage of Israeli Beechcraft 65-B80 Queen Air 4X-DZY suffering a nose landing gear collapse at Tel Aviv’s Ben Gurion International Airport on 27 July 2013. The presence of fire engines and the late lowering of the nose indicate that the failure of the nose gear to lock had already been detected. Everyone on board was able to evacuate the aircraft successfully. Xsight sold FODetect to the Israeli Airports Authority in 2011: The FODetect®, a unique hybrid optical-radar sensing system, will be used to automatically detect FOD at Ben-Gurion International Airport (BGIA) in Tel Aviv, Israel. The selection of Xsight’s system places BGIA among the leading airports to adopt this automatic FOD detection technology. The IAA’s selection of the FODetect® system for BGIA followed a rigorous two year evaluation process. The IAA determined that the Xsight FODetect® system is the best fit to the airport’s runway performance requirements. Furthermore, the IAA is confident that the FODetect® system will reduce the risk of FOD damage to aircrafts and thus increase flight safety for all passengers & cabin crew members alike. The FODetect® system provides an effective FOD detection solution so that risky and costly damages incurred from FOD can, to a high degree of probability, be avoided. Continuous in-between-movement scanning of the airport runways by the FODetect® system allows for the immediate detection and removal of FOD from active runways. The FODetect® system utilizes unique hybrid high resolution optical-radar sensing technology to effectively detect the object, alert the operator and classify the FOD . Various FOD material types and sizes are reliably detected in most situations including in harsh weather and operating conditions. According to Boeing: Foreign object debris (FOD) at airports includes any object found in an inappropriate location that — as a result of being in that location — can damage equipment or injure airplane or airport personnel. The resulting damage is estimated to cost the aerospace industry $4 billion a year. The most high profile runway FOD accident was the loss of an Air France Concorde in 2000, after a tyre disintegrated after contact with debris from a prior aircraft, resulting into significant damage to a fuel tank. Variants of this system are also in use at Paris Charles de Gaulle, Boston Logan International and Bangkok Suvarnabhumi International with Seattle-Tacoma to go live later this year. Aviation Week and Space Technology reports: In addition to scouring a runway approximately every 60 sec. for FOD (FODetect) compared to several times a day by ground crews, new applications include measuring snow depth, runway temperature and contamination (SnowWize), and detecting birds and remotely harassing out of the area with a blast from co-packaged speakers (BirdWize). Last but not least, there is ViewWize, an application that turns the system into a video monitoring asset for situations like the Queen Air prang. UPDATE 28 July 2015: Dubai is also introducing new technology, in their case iFerret from Stratech. The two Dubai occurrences mentioned: A310 S2-ADE 2007 and B777 A6-EWC 2010. UPDATE 8 February 2017: The US Air Force is evaluating technology developed by Israeli company Xsight Systems to rapidly detect damage to runways at air bases outside the USA. Aerossurance has extensive air...
read moreHeli-Expo 2015 ‘Super Medium’ Photo Report
Heli-Expo 2015 ‘Super Medium’ Photo Report Amongst the news from the HAI Heli-Expo in Orlando on the new super-medium category of helicopters: Bell 525 The Bell Helicopter stand featured a mock-up of the 525 Relentless. Bell signed a letter of intent for 20 with Waypoint Leasing. Waypoint’s Chief Executive Officer Ed Washecka said: We are pleased to sign this agreement with Bell Helicopter, which will provide us with cutting-edge and versatile aircraft that we believe offer an attractive value proposition for operators worldwide. I think this year especially with oil prices coming off as much as they have, it will be tougher for some oil companies to make commitments. On the other hand it may accelerate the drive to phase out some of the older-technology aircraft that are potentially candidates to be replaced with aircraft like the Bell 525, the AgustaWestland AW189, the Airbus Helicopters EC175. Aerossurance has previously discussed the Fly-By-Wire (FBW) system being developed for 525. https://www.youtube.com/watch?v=7EAsvAsQRQ4 The first flight of the 525 has previously been reported to have slipped from Q4 2014 until at least ‘Q1 2015’. It is not clear from Heli-Expo if a further slippage is likely or if the first flight is just days away. It will be interesting to see if the Airbus Helicopters‘ new medium the H160 (formerly the X4) flies first, as both aircraft types first prototypes had their first electrical ‘power on’ close together. Airbus Helicopters H175 The Airbus Helicopters H175, formerly marketed as the EC175, was represented by an aircraft in the colours of launch customer, NHV. The main show news for the H175 was that Bristow Group raised its total firm orders for H175 to 17 and critically also signed a comprehensive support services agreement. Deliveries of the will begin in October 2016 for oil and gas operations. Jonathan Baliff, President and CEO of Bristow Group said: I issued a challenge to the industry at Helitech a few months ago. As Bristow purchases helicopters in larger volumes, we look to partner with aircraft manufacturers who will step up to more comprehensive airline-style purchase and support agreements. We commend Airbus Helicopters for being the first partner to proactively share risk and responsibilities and commit to work closely with Bristow throughout the entire lifecycle of aircraft ownership. Aerossurance previously discussed Bailiff’s Helitech comments in October which show Bristow are increasingly going to use its buying power to leverage through life support advatages. They also indicate that the efforts Airbus Helicopters put in after the EC225 (now H225) shaft failures (discussed by Aerossurance last June when the accident report was published) have been appreciated. They are particularly intriguing as while the Bristow has vowed to reduce the total number of types in their fleet, they are investing in both the H175 and AW189 (which they are the lead customer for both the transport and SAR variants) super-mediums. This order is presumably also sending a signal to other manufacturers in the run up to future purchases. NHV report positive early performance with the H175, after they received their first two aircraft in December and deployed them to Den Helder in the Netherlands. After delivery, according to Pieter Broos, NHV base manager in Den Helder: …we performed at least two commercial flights and a couple of training flights each day. Flight hours rose, the number of flights increased, and we built both the operational and technical experience of the team. It...
read moreTechnical Records – Component Overrun
Technical Records – Component Overun In its February 2015 General Aviation Mandatory Occurrence Report (MOR) Listing, the UK Civil Aviation Authority (UK CAA) summarises an MOR from a twin turboprop operator’s Continuing Airworthiness Management Organisation (CAMO). This MOR is a neat case study on technical record errors and how one CAMO now tries to prevent them. On preparing to send the log card to stores for NLG Retraction Jack, the engineer noticed that the last overhaul date on the log card was 24/9/08, more than 6 years ago. The overhaul EASA Form One is dated 25/9/08, verifying the log card. The part has a 12000 cycle/6 year overhaul life, meaning the next overhaul was due in September 2014. The Retraction Jack was removed from the aircraft in February 2015, and the overhaul therefore went overdue by approximately 5 months. The ’cause’ would appear to be the overhaul of the retraction jack being incorrectly claimed on the maintenance database from the date of first fit, 1st April 2009, rather than the date of overhaul. This would have led planning to work on the assumption that the overhaul was due by 31st March 2015, as forecast. Since 2012 [a] procedure, has been introduced for all critical components to be checked by a second member of the tech records department post fitment. This procedure should discover any errors like that made in this case, in time to rectify them before a maintenance activity is due. Therefore this is unlikely to reoccur for any critical components fitted since the procedure was introduced. It is also noticeable that this organisation had anticipated this type of error and had proactively changed its procedures already. Aerossurance has previously written about Professor James Reason’s 12 Principles of Error Management. Aerossurance is pleased to sponsor this Royal Aeronautical Society (RAeS) Human Factors Group: Engineering conference on 12 May 2015 at Cranfield University: Human Factors in Engineering – the Next Generation For support you can trust on preventing maintenance errors, continuing airworthiness management and safety assurance, contact aviation consultancy Aerossurance: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
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