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Fatal Crash Highlights the Importance of High Quality Auditing

The Australian Transport Safety Bureau (ATSB) has found that a fatal crash of a Robinson R22 helicopter was due to a missing or inadequately torqued self-locking nut and highlights the importance of rigorous procedures and audits.

The incident, which took place on 2 August 2017 in Queensland, saw the pilot loose control about three minutes after take off with the bolt separating from a bellcrank in the Cyclic Control in flight, the helicopter breaking up mid-flight and the pilot being fatally injured.

The investigation of the crash from the ATSB have found a number of safety issues that led to this incident.

Maintenance Practices

The R22 helicopter had recently undergone a 2,200 hour overhaul (the largest scope of maintenance for this helicopter). For this overhaul all tasks are required to be progressively certified, however the aircraft work-sheets were all certified at the end of the overhaul period, on 31 July 2017 rather than on the completion dates throughout the four month period.

The ATBS noted that as well as this, abbreviated inspection checklists were being used that increased the risk of memory-related errors and omissions.

LEARNING:

Without recording and adhering to progressive certification, the work‑pack was not an accurate record of the condition of the helicopter, or of all the work performed on completion of the overhaul.

Verbal communication is important to relay problems, yet over time an accurate record needs to be kept and documented to ensure quality controls are in place.

This is where the importance of procedure writing comes into play. At Progressive Aviation Solutions we can provide you with authoring services for compliance aviation manual development to ensure your organisation is meeting it’s safety standards.

Human Error and Workload

Additional disturbances of the flight controls for adjustments and inspections were not recorded. These require an independent inspection to verify that the work was carried out in accordance with the approved maintenance data and check that the system functioned correctly. Instead, the integrity of the independent inspection process was reliant on informal methods of communicating additional work requirements and reporting their completion for re-inspection.

High workload was seen to also be a factor in reducing the capacity for errors to be picked up, as well as a drop in the level of qualifications and experience deemed necessary to undertake these inspections in the first place.

LEARNING:

Staff that are well trained and have the capacity to be fully across all the activities are needed to ensure there is low risk for a maintenance error to occur.

The need to identifying bottlenecks and areas to improve quality can be helped through our process improvement services.

Auditing

Independent Auditors were contracted to assess the work-packs in 2015 and 2016. In these the ATBS found that no requests for corrective action were included, no evidence of progressive certification, an abbreviated 100-hour inspection checklist was used, and a single certification was made for the entire 100‑hour inspection on the airframe, ground check and run up.

These oversights and discrepancies in the maintenance documentation were not picked up in the audits and meant that they were not conforming with the relevant standards. This make them of very little use to the organisation to be able to make any safety improvements.

LEARNING:

The need to have high quality Independent Audits are essential for verifying the effectiveness of the processes and procedures in place. This is true of both the documentation in place and to assess the human risk factor.

At Progressive Aviation Solution, we provide experienced auditors in all sectors of the aviation industry that will recognise opportunities for quality and service improvements above and beyond this standard offered by the audit process.

This devastating and avoidable loss, is an example to all in the aviation industry of the importance of ensuring that safety is always our number one priority.

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