Agency Acts to Preclude More Maintenance Mayhem

Maintenance work cards for critical flight controls need to be reviewed for accuracy to prevent loss of control and possible crashes of DC-8 aircraft. The Federal Aviation Administration (FAA) has directed its primary maintenance inspectors (PMIs) to make sure that maintenance on the aircraft is done in accordance with procedures specified in the manufacturer's maintenance manual.

The guidance is contained in a March 3 flight standards information bulletin for airworthiness (FSAW No. 04-04). The FSAW declares the action responds to five recommendations issued by the National Transportation Safety Board (NTSB) as a result of its investigation into the fatal Feb. 16, 2000, crash of an Emery Worldwide Airlines (EWA) on takeoff. The NTSB found that a retaining bolt connecting the control pushrod to the elevator slipped out of place, and when the pilots attempted to take off, the elevator control tab was jammed into the extreme nose-down position. The NTSB found that the bolt installation was vulnerable to a maintenance mishap (see ASW, Aug. 11, 2003).

Consequently, the safety board issued five recommendations to tighten maintenance of the DC-8 elevator control assembly. The FSAW basically puts those recommendations in effect, calling on primary FAA maintenance inspectors (PMIs) to make sure that elevator position indicators are properly calibrated, that steps are taken to make sure the elevator control tab is properly rigged - especially regarding the connecting bolt - which includes checking to make sure that latest illustrations of correct installation are contained in the maintenance manual. Lastly, PMIs are enjoined to make sure the fairing is removed when checking for correct bolt installation.

There is a significantly larger issue involved here with respect to maintenance. Thirteen months before the crash of the Emery DC-8 freighter, the FAA's Certificate Management office in San Jose, Calif., issued a scathing report of the prevailing attitude at Emery. This Jan. 22, 1999, report speaks volumes about the absence of a safety culture and a flagrant disregard for regulations at Emery. The missing bolt, which was never found in the scorched wreckage of the accident aircraft, was but a tiny metaphor for much more that was missing at Emery. It is instructive that the carrier no longer exists, its assets sold off after the crash, and with many lawsuits yet to be resolved. The Emery case is an object lesson in the high cost of a bad attitude.

A Culture of Noncompliance

Certificate Management Team (CMT) report of Jan. 22, 1999 (extracts):

• EWA's management representatives would rather spend their resources defending their decisions of denying that a compliance issue even exists. This gives the CMT reason for serious concern because the view on compliance appears to be ... liberal to the point that EWA acts as if they are an autonomous entity in the world of aviation.
• Internal policy directives are directly contrary to the FAR [Federal Aviation Regulations], aircraft operating limitations, and EWA manual procedures. An example is the issuance of instructions to operate the aircraft engines beyond the EGT [exhaust gas temperature] limits.
• A major area of concern for the CMT is that when we make a simple inquiry to validate a question of compliance, we are finding noncompliance that drives us directly to another area of noncompliance. This trend seems to have been increasing.
• EWA has not conducted reliability meetings for at least three months.
• The Continuing Analysis and Surveillance System (CASS) is not functional.
• EWA has increased utilization of 15 of their DC-8s to support a U.S. Postal contract beginning in January 1999. However, EWA has not increased the maintenance organization resources to support the increase in anticipated operational discrepancies.
• Operational stability has been impacted by the changes in air carrier senior management, and the vacancies of other program managers that have not been replaced:
• Director of Line Maintenance - vacant for at least 4 months, and this person was doing double duty in another position as well and held a seat on the reliability board.
• Director of Material Management - vacant for at least 6 months. This position also holds a seat on the reliability board.
• Manager of Quality Control - vacant for at least 8 months.
• EWA does not respond to requests for information, documents, or concerns without including substantial non-essential rhetoric that only serves to redirect the reader's attention away from the main issues.
• Air carrier management must take a proactive role to insure compliance and safety issues are prevented, not merely dealt with as inconveniences when they are discovered.

Source: FAA, EWA CMT report of Jan. 22, 1999