AIRWORTHINESS REPORT

Transcription

1 Aircraft Airworthiness & Sustainment Conference! Brisbane! July 2014 AIRWORTHINESS REPORT Accidents, incidents,! news and opinion Steve Swift! Airworthiness Training and Consulting! Slides include extra material from speaking notes

2 History repeats itself because no one was listening the first time.

3 SPONSORS Steve Swift PTY LTD ABN AIRWORTHINESS TRAINING AND CONSULTING AUSTRALIA PHONE: MOBILE: International Federation of Airworthiness Disclaimer: Steve Swift s opinions in this presentation are not necessarily the IFA s.

4 ACCIDENTS still a safety issue 186 total Period: 23/7/13-18/7/14! Source: ATSB

5 AIRWORTHINESS ACCIDENTS middle for quantity but worst for severity the cause of both fatal accidents Period: 23/7/13-18/7/14! Source: ATSB

6 FIRST FATAL ACCIDENT Left wing broke here ATSB Transport Safety Report! Aviation Occurrence Investigation AO Interim 23 December 2013 PZL Dromader, 24 Oct 2013 Photo from ATSB report

7 FAILURE Wing attach lug! - Fatigue! Aircraft weight?! Fatigue Inspection method?! - EC v MPI Photo from ATSB report

8 REMINDERS * Fatigue affected by operation, especially! Weight! Manoeuvres! Turbulence! Comparing inspection methods is more than comparing minimum detectable crack sizes! PoD! Scope! Other factors * General advice only. The ATSB may find it not relevant to this accident.

9 POD Probability of detection (PoD) Method A Method B If A and B have the same minimum detectable crack size, a DTA * might not discriminate. But, A is safer than B because it is more likely to find smaller cracks. 0 Crack size * Damage tolerance analysis

10 SCOPE Method A Method B Again, If A and B have the same minimum detectable crack size, a DTA might not discriminate. But, A is safer than B because it inspects more area, so is more likely to find unexpected cracks, like this one.

11 SECOND FATAL ACCIDENT Tiger Moth,16 December 2013 Photo from ATSB report ATSB Transport Safety Report! Aviation Investigation AO Preliminary 24 February 2014

12 PRELIMINARY REPORT Tie rods! - Connect lower wings! Broke in threads! - Fatigue Photo from ATSB report

13 FAILURES 2000-hour safe life but broke at 1300 hours. Photo from ATSB report

14 OEM V APMA Photo from DH Support web site Photo from ATSB report Cad plated alloy steel OEM tie rod! (approved by UK CAA) APMA * tie rod! (approved by CASA) Stainless steel Tie rods APMA not OEM. ATSB investigating:! Material difference! Thread design and quality.!! Also amount of aerobatics. * Australian Parts Manufacture Approval

15 REMINDERS * Reverse engineering is hard for fatigue! - Small design changes = big fatigue differences! - Fatigue-sensitive features not always obvious (e.g. Cx)! - Verify by fatigue test! Fatigue affected by operation! - Specify operational assumptions in maintenance manual. * General advice only. The ATSB may find it not relevant to this accident.

16 CONSOLATION Metal fatigue in wing Last fatal airliner accident, 1968: consolation but not complacency Photo from Eric Allen

17 INCIDENTS Not accidents! But could have been

18 INCIDENTS 158 Serious 6527 Minor Airworthiness! important again Other Period: 23/7/13-18/7/14! Source: ATSB

19 LUCKY CESSNA 210 Tailplane nearly detached Cessna 210N, 12 September 2011 Photo from ATSB report ATSB Transport Safety Report! Aviation Occurrence Investigation AO Final 16 August 2013

20 FAILURES Horizontal Stabiliser Elevator Right lug cracked Left lug broken Fuselage Spar cracked Photos from ATSB report

21 ATSB REPORT Regs misunderstood! - CASA clarifying! SIDs misunderstood! - More education and enforcement needed! Flight control system event Insert involving document Cessna 210N, title VH-JHF Location 48 km West Date of Bourke Airport, New South Wales 12 September Not just for Cessnas! - Some even think supplemental means optional. * Investigation ATSB Transport Safety Report [Insert Aviation Mode] Occurrence Occurrence Investigation Investigation XX-YYYY-#### AO Final 16 August 2013 * SID = Supplemental Inspection Document

22 E-190 ENGINE BOLTS Loose bolts! - Airline found unexpectedly on one E-190! - Airline then found more on others! Reported! - Embraer! - CASA! Fixed! - Embraer Alert SB! - Other airlines are finding! System worked well!! Aussies should watch for unexpected! - Because our aircraft work so hard, problems often occur here first.

23 NEWS & OPINION Forsyth Review! CASA s AAMP! Frustrated technologies

24 FORSYTH REVIEW Coverage! - Affects airworthiness! Competence! - CASA appears to encounter difficulties in attracting and retaining suitably qualified and skilled staff. *! Aviation Safety Regulation Review Communication! - Clearer standards! - Plain English MAY 2014 Click here to download report * on page 37 of report

25 MISCOMMUNICATION Engineers often think communicating is less important than calculating. But, confusing technical jargon in a Boeing manual helped ruin Ansett Australia Airlines. See the ATSB s report (link below) and my paper, Sticks and Stones, on my web site, ATSB Transport Safety Report! Aviation Safety Investigation BS November 2002

26 CASA S * AAMP Good! - Attention! - Education! Airworthiness and Ageing Aircraft Unfinished! - Still missing something simple but vital. * AAMP = Ageing Aircraft Management Plan

27 SUB-STANDARD If the problem is substandard maintenance programs The photo is from an early AAMP presentation. The AAMP often uses cars as comic analogies. My commentary continues that theme.

28 STANDARD? MSG! 3 AAMP then what is the standard? * Photo from Wikipedia. * For the young, the pun is that this is a 1959 Standard 10.

29 GREAT DEAL Pedigree! Simple! Popular! Versatile! MSG! 3 Variety! Enforceable

30 PEDIGREE MSG! 1 MSG! 2 MSG!

31 SIMPLE Deterioration Deterioration Undetectable Inspect Danger As well as telling you the inspection interval, this simple analysis will also tell you if there s no green zone. If inspection won t work, you have to try something else, such as a life limit. This is common in general aviation aircraft. So, although simple, this is powerful. The rest of this section is for structure, the most serious threat to ageing aircraft safety, as the ATSB s records show. But, the standard is also simple and good for engines and systems.

32 POPULAR! IN AVIATION Safety-by-inspection! (SBI) Damage tolerance analysis! (DTA) Reliability centred maintenance (RCM) Different names in different sectors.! Similar standards. * * Differences are minor.

33 POPULAR! ELSEWHERE Other engineering Health Agriculture Similar standards. * * Same concepts.

34 VERSATILE Deterioration Detection Danger Same Ds! (just determined less rigorously) It s always the same three Ds! * * For progressive deterioration.

35 VARIETY MSG-3 FAR CS FAA AC FAA AC Etc The standard comes in different models for different purposes. Some are only for structure. Similar range for engines and systems.

36 ENFORCEABLE Good balance! - Prescription v outcome! Expertise available! - CASA! - Industry! The catch! - Need designers! - As well as maintainers! - See A Collective Approach to Aircraft Structural Maintenance Programs, Steve Swift and Beth Gamble check if Cessna s SIDs meet standard.

37 REPLACE INDIRECT TOOL AGEING AIRCRAFT PROTOTYPE MATRIX TOOL Tako a Clossr Look The Prototype Matrix Tool provides feedback to the owner of the likelihood their aircraft may be susceptible to ageing related issues. All feedback is provided on a relative scale, dependent on the inputs provided. The colour scale provides an indication to the owner as to the urgency and degree to which they may wish to "take a closer look at how their aircraft may be affected by the ageing process. The initial location of the bar reflects the impact of the existing information on the database only. It does not reflect the impact of how the aircraft is operated, maintained or stored. By the user selecting the Take a Closer Look button and progressively selecting those options for each heading that are most applicable to their aircraft, the indicator bar will move incrementally to reflect the impact of those selections made. Likewise, the selection of alternative options under each heading will provide the user with feedback as to how the likelihood of their aircraft being susceptible to ageing issues may be altered and improved. CASA gives assurance that no information entered while using the Prototype Matrix Tool will be retained. Unlikely H i g h l y Likely Below is information relating to your aircraft as available on the CASA database. Please select the Take a Closer Look button above and complete all the questions to calculate the likelihood your aircraft may be impacted by ageing issues. Mark: J H F Manufacturer Name: C E S S N A AIRCRAFT COMPANY Aircraft Type: Aircraft Model: N Aircraft Serial No: MTOW: Screenshot from CASA web site

38 WITH DIRECT QUESTION Does your maintenance program meet the standard?! Answer! MSG! 3 - TCDS! - TCH

39 SOM 42M System of maintenance: approval (1) If: (a) CASA or an authorised person receives a request for approval of a system of maintenance; and (b) CASA or the authorised person is satisfied that: (i) the system includes the matters set out in regulation 42L; and (ii) the system adequately provides for the continued airworthiness of the aircraft; CASA or the authorised person must approve the system. CAR 42M already asks the question by this word, highlighted in yellow.

40 ADEQUATE Adequate = to a standard! Which standard?! MSG! 3 This standard? * Federal Register, September 11, 1980

41 FAA: YES II Federal Register / Vol. 45, 79, No / September Monday, August 11, 19804, 2014 SUBSCRIPTIONS AND COPIES the FAA has found that the recommended maintenance procedures made available under current regulations are frequently inadequate in scope and content, and often do not provide a sound basis for the operator/owner to maintain the airworthiness of the aircraft. Yes, said the FAA in 1980 when mandating a standard similar to MSG-3 for US maintenance programs. Anything less is inadequate. It will be interesting to see if an Australian court agrees.

42 CAAP 42M-1(0) format that can be cross-referenced. 4.6 Provision for Continuing Airworthiness Regulation 42M of CAR 1988 requires that an SoM must adequately provide for the continued airworthiness of the aircraft. If applicable, details of specific structural maintenance programs such as the following are included in the SoM: Corrosion prevention and control program(cpcp); Supplemental structural inspection documents (SSID); Structural integrity inspection program (SIIP); Ageing aircraft or similar program issued by the TC holder. CASA could clarify by listing adequate standards for maintenance programs here in CAAP 42M-1. And, point out that not all programs from manufacturers, which approvers must have regard to [CAR 42M(3)], meet those standards.

43 SCHEDULE 5 Schedule 5 CASA maintenance schedule Part 2 Periodic inspection (ii) a person to whom the owner has provided the aircraft without receiving any remuneration from the person. 2.7 Unless otherwise indicated in the table, where the table requires a thing to be inspected, the inspection is to be a thorough check made to determine whether the thing will continue to be airworthy until the next periodic inspection. Even Schedule 5 has this underused jewel, highlighted in yellow. It is an outcome-based expression of the standard. Again, CASA could clarify by listing, in CAAP 42B-1(1), the standards that a maintenance program must meet to be thorough enough.

44 FRUSTRATED New technologies for ageing aircraft safety! - Cx! - SPD! - SHM! - Composite patches! Awaiting CASA standards! - Challenge for AAMP? Cx graphic from Fatigue Technology

45 STANDARD Path! End! Clear! v Flexible Stan Salot told the conference how new technologies are challenging maintainers. They are also challenging regulators, who should lead by their standards.

46 DISCLAIMER Check facts! - Happy to be corrected! Pardon shock jock persona! - To entertain and challenge * Photo from Sydney Morning Herald * To keep everyone awake during the last presentation before lunch on the last day!

47 THANKS For helpful reports and databases For helping me attend the conference

48 MORE AIRWORTHINESS IFA s next conference! - Dubai Sep 2014! WORKSHOP & TECHNICAL FORUM SEPTEMBER 2014 DUBAI, UNITED ARAB EMIRATES CHALLENGES FOR MANAGING GROWTH AND TECHNOLOGICAL ADVANCEMENTS Register! - Free for members! - Nominal fee for others! Maintaining Airworthiness Standards and Inves ng in the Most Important Asset The Human Element Please contact me! This conference is FREE to IFA Members & 50.00GBP to non-members To book your place, contact the IFA Secretariat by phone on +44 (0) or at sec@ifairworthy.com

49 THANKS for helping to keep our skies safe! Photo from Louisville Regional Airport Authority