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Friday, August 1, 2008

Maintenance Notebook

NTSB: Boost Tour Operator Training, Oversight

U.S. accident investigators say they have evidence of air tour maintenance problems and want industry leaders and the FAA to act quickly to put an end to them.

The National Transportation Safety Board’s call is based on investigations into the March 8, 2007, Princeville, Hawaii crash of a Heli-USA Airways Aérospatiale AS350BA1 and a Sept. 11, 2002, Heli-USA AS350BA crash near Peach Springs, Ariz.

Its investigators found that a Heli-USA mechanic improperly installed a critical flight-control component, the left lateral hydraulic servo linked to the cyclic and collective, on the Hawaiian aircraft. They said the installation was never inspected, a step required by Heli-USA’s maintenance manual that likely would have uncovered the error, which was missed later in "several extensive and detailed inspections." The pilot and three passengers died as a result of the crash.

That led safety board investigators to review the 2002 Heli-USA accident. In it, the aircraft suffered a hydraulic failure because a pump installed 75 hr earlier had been lubricated improperly and suffered excessive wear. The aircraft suffered substantial damage. The safety board concluded that was the result of the pilot’s failure to maintain airspeed and main-rotor speed during landing as prescribed by emergency procedures. But it said the flawed hydraulic pump installation contributed to the accident.

More troubling was the safety board’s evidence that conditions that contributed to those maintenance errors are not unusual.

Safety board investigators found evidence that Heli-USA’s maintenance was ineffective and its quality assurance programs were inadequate, as was its model-specific maintenance training. The FAA, they said, failed to inspect Heli-USA sufficiently to identify maintenance work that did not conform to the operator’s procedures and manuals. Safety board investigators "reviewed other air tour operators’ maintenance programs and found similar issues with most of the operators."

The safety board recorded 88 helicopter air tour accidents between Jan. 1, 1996, and Oct. 1, 2007. It has determined the causes and factors in 71, of which 25 "involved mechanical failures or malfunctions in which correctly performed maintenance inspections or procedures could have prevented the accidents," the board said.

A key problem may be training or the lack of it. The NTSB investigators found Heli-USA’s FAA-approved general operating manual required mechanics to attend training as necessary to fulfill their assigned tasks. It also stated Heli-USA promotes maintenance training but makes it the responsibility of mechanics to ensure they are adequately trained.

But the mechanic who installed the Princeville helicopter’s servo had worked at Heli-USA for almost a year, the NTSB said, and had not been to formal AS350 maintenance training. The NTSB said training records showed no line mechanic at Heli-USA’s Hawaiian base had been to a model-specific maintenance training course.

NTSB investigators queried four other Hawaiian air tour operators who fly Eurocopter aircraft. Each said "their mechanics had not attended the Eurocopter-sponsored school," the NTSB said. Eurocopter said most attendees at its AS350 maintenance training school were from airborne law enforcement, medical, or corporate helicopter operators. Through that school, the board said, mechanics gain "an understanding of why procedures need to be done" and "a foundation on which on-the-job experience can be built."

The board called upon the FAA and the Tour Operators Program of Safety to act to end noncomformal practices and help prevent accidents to which maintenance error contributes. It urged the FAA to require all FAR Part 91 and 135 air tour operators to establish and maintain a system for continuously analyzing the performance and effectiveness of their inspection and maintenance program and to provide formal, model-specific maintenance training to ensure mechanics have an adequate level of competency. It called on the aviation agency to figure out how "to provide direct surveillance of air tour maintenance at all locations" where it is conducted.

It also called on the FAA to work with independent safety programs, such as the Tour Operators Program of Safety, to set up guidelines for developing and implementing "appropriate inspection and maintenance quality assurance programs and to encourage operators to participate in these voluntary programs."

The safety board called on the tour operators’ to develop with its members "requirements for establishing and maintaining a system for continuously analyzing the performance and effectiveness of their inspection and maintenance programs to ensure that all maintenance is performed with the utmost regard for quality and safety."

It also urged the program to expand its safety audit program "to ensure that operators implement an effective maintenance quality assurance program."

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