[Peetwo]

Below, from the UP is my pick for QoM.  It’s certainly Tim Tam quality; and, serves very well to highlight one of  the true culprits, identified by the ATSB Safety Recommendation.  This was a preventable accident that happened.   I have no doubt the reasons justifying the lack of CASA oversight are valid and that no blame can be sheeted home to the ‘safety system’.  But who’s safety stands, once again, as ‘the’ question.  

The integrity of 1000 part numbers now in question; even if there are only 10 of each part in stock, that is 10,000 individual items under suspicion. No problem, the Strictly No Liability policy covers all.

Penny Washers on the UP - HERE.

IFEZ is quite right – we all depend upon our maintenance outfits to an extent which we seldom appreciate, possibly because the safety record is generally very good.

But our maintenance outfits depend upon their parts suppliers (if parts are available at all.)
And the parts suppliers depend upon the manufacturers of the parts, who need meaningful design documentation to work from.
And the manufacturers depend upon their raw material suppliers who have to supply metals to the required specifications.
And on their heat treatment people.
And on the electroplaters and the NDT specialists.
And so on. They all have to operate proper inspection processes and certify the results.

That is before you start altering the basic design by bringing in substitute materials with different tensile strengths, notch sensitivities, fatigue characteristics and maybe different manufacturing techniques.

So CASA should have been monitoring all this to make sure it was being done properly, but instead seem to have abandoned their supervisory role for reasons which were no doubt good ones so far as they were concerned.

This does not just apply to old aircraft with a long (and probably very safe) history. The ATSB Report mentions over 1000 other parts made by this same company for other aircraft, some of them in the Commercial Air Transport category.

Are we going to see a general recall of all these parts for inspection?

Who wants to fly in a VH reg. Embraer EMB 120 or a Fokker F28 right now?

Yesterday courtesy of Safety Culture more dissemination of the full implications of the ATSB findings:

ATSB investigation found tie rod fracture resulted to Tiger Moth crash

Reported by Haydee | 01:43pm, Monday 25 January, 2016


Photo: mmisof, Pixabay

The Australian Transport Safety Bureau released a final report into the Tiger Moth crash at the Gold Coast in December 2013, which resulted to the death of a 26-year-old pilot and his passenger, a French tourist.

The crash happened shortly after the aircraft took off from the operator’s airstrip at Pimpama, Queensland.

A minute after the pilot commenced aerobatics, the left wing failed and the aircraft descended steeply into the water near South Stradbroke Island.

ATSB’s investigation found that both of the fuselage lateral tie rods, which help transfer flight loads through the fuselage has been fractured. The tie rods fractured during an aerobatic manoeuvre resulting in the left lower wing separating from the aircraft and subsequent in-flight break-up.

“The ATSB found that the tie rods were aftermarket parts manufactured under an Australian Parts Manufacturer Approval (APMA). In this respect, safety issues were identified in areas of the tie rods’ design and manufacture, as well as in the supporting regulatory approval processes.”

There were also safety issues identified in the maintenance and operation of the aircraft.

“The ATSB consulted with the Type Design Organisation, regulators and investigation authorities from Australia, New Zealand and the United Kingdom about the failure of the APMA tie rods, which occurred well before the published retirement life for Tiger Moth tie rods,” ATSB said in a statement.

“In response, the United Kingdom Civil Aviation Authority issued an airworthiness directive on 21 March 2014 that mandated the removal of all APMA-manufactured tie rods from service. The airworthiness directive was subsequently also mandated by the Australian Civil Aviation Safety Authority and the New Zealand Civil Aviation Authority.
Significant additional safety action is proposed by the Type Design Organisation to further enhance the safety of all Tiger Moth operations.

“In addition, the ATSB has issued a safety recommendation to the Civil Aviation Safety Authority to take action to provide assurance that over 1000 other parts approved for APMA at about the same time as the tie rods were appropriately considered before approval.

“This accident emphasises the need for the full consideration of a part’s service history when redesigning and manufacturing parts critical to the structural integrity of the aircraft. It also shows that important role of the regulator in ensuring that parts approved under an APMA have been fully considered and shown to comply with the design requirement. Further, in the context of maintenance, it shows the importance of utilising genuine or approved substitute aircraft parts that are suitable for purpose, especially in sections of the aircraft that are critical to flight.

“In addition, the ATSB cautions commercial vintage aircraft operators about the risks associated with aircraft age and the importance of understanding the originally-intended use of the design before commencing their operations.”

 The penny is slowly dropping on the implications of the SR as being evidence that even within CASA, severely delayed, overburdened, & punitive regulations leads to a tick & flick culture, & consequently poor oversight of a vital sector of the industry.

 As we know the ATSB (beyond reason) are normally extremely adverse to issuing SRs, especially to the regulator, so let's look into the guts of the SR to see what triggered it from the ATSB point of view & what has occurred in terms of response so far:

Civil Aviation Safety Authority Australian Parts Manufacturer Approval implementation approvals


Issue number: AO-2013-226-SI-07

Who it affects:

Operators of aircraft fitted with parts manufactured under those Australian Parts Manufacturer Approvals

Issue owner: Civil Aviation Safety Authority

Operation affected:

Aviation: Airspace management

Background:
Investigation Report AO-2013-226

Date:
21 January 2016

Safety issue description

Over 1,000 parts were approved by the Civil Aviation Safety Authority for Australian Parts Manufacturer Approval using a policy that accepted existing design approvals without the authority confirming that important service factors, such as service history and life‑limits, were appropriately considered.

Action organisation:
Civil Aviation Safety Authority
Date:
21 January 2016
Action status:

The ATSB provided the Civil Aviation Safety Authority (CASA) with written information about this safety issue and then followed up with a meeting on 11 February 2015 to discuss the issue. In correspondence following that meeting, CASA advised of the following safety action:

CASA has reviewed its processes and procedures applicable at the time for the appointment of CAR 35 authorised persons and concluded that although CAR 35 regulation referred to design standards and not airworthiness requirements, one of the usual limitations on all CAR 35 instruments was to consider relevant/applicable ADs and therefore the issue of AD consideration was covered in this way. Nevertheless, it appears, on the basis of the ATSB investigation, that, at least in one case, a CAR 35 design approval was given without considering applicable ADs.

In order to assess the potential scope and establish direction of any future actions, if any, CASA has made a decision to conduct a review of the approach of all former CAR 35 authorised persons, before 2003, with regards to the assessment of ADs in their approvals made under CAR 35 regulation. The data for this review will be collected during the scheduled surveillance events, for currently active design authorised persons, and via communication in writing with inactive and retired (former) CAR 35 authorised persons that were active before 2003. Once the results are received, an assessment will be conducted and further action decided. If in the course of collecting data, any adverse trends are noticed, an appropriate interim action will be initiated.

Subsequently, following their review of the draft report, CASA advised that they would not be carrying out any further safety action in respect of this safety issue. 

ATSB response:

The ATSB acknowledges CASA’s initial action to address this safety issue. However, the ATSB is concerned that this action does not specifically examine the over 1,000 Australian Parts Manufacturer Approvals undertaken by the Regulatory Reform Program Implementation (RRPI) team in 2003. The effect of the policy direction given to the RRPI team, and lack of CASA files containing records of CASA’s engineering assessments of those parts, means there is no assurance that the tie rod manufacturer’s other RPPI-approved APMA parts were not similarly affected by the issues identified with the tie rod replacement parts approval. In support of this, the ATSB has become aware that at least one other part listed on the tie rod manufacturer’s APMA approved by the RRPI, for the DHC-1 Chipmunk aircraft, is the subject of an airworthiness directive that places a life limitation on the part. Like the APMA for the tie rods, there is no mention of the airworthiness directive, or life limitation, on the associated APMA documents.

As a result, the ATSB has issued the following safety recommendation.

Recommendation

Action organisation:
Civil Aviation Safety Authority

Action number:
AO-2013-226-SR-044

Date:
21 January 2016

Action status:

Released

The ATSB recommends that the Civil Aviation Safety Authority takes action to provide assurance that all of the replacement parts that were approved for Australian Parts Manufacturer Approval by the Regulatory Reform Program Implementation team in 2003 have appropriately considered important service factors, such as service history and life‑limits.  
 
Current issue status:
Safety action pending
 



Last update 21 January 2016

 
Oh how this sounds oh so familiar..  

Nearly a year ago CASA get advised of an ATSB identified 'safety issue', to which they respond with some standard long winded preamble designed to totally obfuscate & belittle the ATSB safety concern.

Next the ATSB again draw attention to the 'safety issue' in the DIPs DRAFT report process. To which, with a standard response, CASA simply say - "up yours, nothing to see here, go away!"  

However to the ATSB credit they have formalised and got on the record a SR, which proves to me that there is still hope for the once proud State AAI (BASI/ATSB). I do wonder if perhaps the white hats at the bureau have got away with this while Dolan (CASA's go to man) is somewhat distracted by his continued obfuscation campaign (on behalf of the Malaysians) of the MH370 SIO search. 

One thing that should be noted is that all the above actions/inactions instigated by CASA in response to this 'significant safety issue' was conducted/ignored/obfuscated while under Skidmore's watch...


MTF...P2