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An aviation researcher, writer, aviation participant, pilot & agricultural researcher. Author of over 35 scientific publications world wide.

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#casa called out by NSW Coroner with defective regulations and processes

Serious concerns raised by NSW Coroner into how #casa carries out it’s approvals and deals with known safety matters.

Two pilots have died from this lack of regulatory control by #casa.

There are #SR’s issued by #atsb that are being ignored by #casa

Our sympathies go out to the Black family.


HISTORY:

#atsb and first failure and SR’s issued

The Australian senate raised serious questions on the operation of Dromader’s by the RFS [Rural Fire Service] in NSW.

October 24 2013 David Black’s accident at Ulladulla

On 6th November 2013, a tweet was published by #casa

November 7th 2013, #casa grounds Dromaders

On 15th November 2013, #casa issued an AD on the Dromader.

April 10th 2014 – RFS and Senate questions

No action by #casa on SR’s [Safety Recommendations] given by #atsb

Coroners report into the death of David Black


Pilot died after inadequate inspection
Pilot died after ‘inadequate’ inspection

David Black, 43, died when his M18 Dromader aircraft crashed in an isolated and mountainous area of the Budawang National Park, in the state’s south, on October 24, 2013.

The experienced pilot was preparing to attack a bushfire when the left wing of his aircraft suddenly broke off, causing the aircraft’s rapid descent, Deputy State Coroner Derek Lee wrote in his inquest findings released on Monday.

Mr Black left behind his wife of 12 years, Julie, and three young children.

“David and Julie had worked together as a team, industriously, to reach a stage in life where their business was successful, their family was nurtured and cared for, and they were simply able to enjoy life,” Mr Lee wrote.

“To lose David in sudden circumstances is heart-rending.”

The plane Mr Black was flying was owned by his company, Rebel Ag, which provided aerial support to the NSW Rural Fire Service.

It was tested and inspected just over two months earlier by two companies, Aviation NDT and Beal Aircraft Maintenance, but Mr Lee said the work was inadequately done.

He wrote in his findings that testing by Aviation NDT used an unauthorised method and did not comply with the mandatory requirements of the Civil Aviation Safety Authority.

Further, the plane’s wings were not removed during a visual inspection by Beal Aircraft Maintenance, meaning that corrosion and cracking on one of the left wing’s attachment lugs was not detected.

By the time Mr Black crashed in October, the Australian Transport Safety Bureau found that cracking on the inner surface of the lug had reached a critical length of 10.4 millimetres and at least 32 secondary micro cracks were also identified.

The engineer behind the visual inspection, Donald Beal, told the inquest the manufacturer’s service bulletin did not mandate removal of the wings, so he didn’t see any need to remove them.

Mr Beal also said there was ambiguity about what visual inspections actually involved, Mr Lee recalled in his findings.

At the NSW Coroner’s Court on Monday, Mr Lee recommended that CASA consider issuing a directive that wings be removed during inspections of M18 Dromader planes.

He also recommended they consider a different way of calculating fatigue damage, which did not just rely on flight hours but also looked at other factors that age an aircraft, such as its speed and the weight of loads that it carries.

A CASA spokesman said they would consider the recommendations carefully.


Inquest:
Inquest into the death of David Black
Hearing dates:
27 February 2017
to 1 March 2017, 6 March 2017
Date of findings:
13 March 2017
Place of findings:
NSW State Coroner’s Court, Glebe
Findings of:
Magistrate
Derek Lee, Deputy State Coroner
Catchwords:
CORONIAL LAW
aviation, non-destructive testing
, eddy currentinspection, magnetic particle inspection, M18 Dromader, airworthiness directive, CAR 2A approval,
Australian TransportSafety Bureau (ATSB), Civil Aviation Safety Authority (CASA)
File number: 2013/322207
Representation:
Mr A Casselden SC, Counsel Assisting, instructed by Ms M
Katawazi (Office of the General Counsel)
Mr D Lloyd instructed by GSG Legal (Mrs Julie Black and the
children of David Black)
Mr J Ribbands instructed by Maitland Lawyers (Aviation NDT
Services Pty Ltd, Mr Travis Tuck & Mr Neil Joiner
)
Mr R Clifford instructed by Sam Hegney Solicitors (Beal Aircraft
Maintenance, Mr Donald Beal & Mr Bruce Beal)
Mr P Hornby (Australian Transport Safety Bureau)
Mr A Carter (Civil Aviation Safety Authority)
Non
publication orders:
Pursuant to section 7
4(1)(b) of the
Coroners Act 2009
and section
60(7) of the Transport Safety Investigation
Act 2003, the ATSB
PowerPoint p
resentation
titled
, “ATSB In
flight breakup involving
a PZL Mielec M18A Dromader”
,
is not to be published.
Findings:
I find t
hat
David
Black
died on 24 October 2013 in an area of the
Budawang National Park, about 37km west of Ulladulla, New
South Wales.
The cause of death was multiple
injuries, which Mr
Black suffered
when
the
aircraft that he was piloting impacted
terrain following an i
n
flight separation of the aircraft’s
left wing
.
The wing separation was caused by corrosion pitting and fatigue
cracking in the lower left wing attachment fitting leading to the
fracture and critical failure of the attachment lug.
Recommendations:
To the Civil Aviation Safety Authority
:
(a)
I recommend that consideration be given to
the issuing of
an airworthiness directive pursuant to regul
ation 39.001 of
the
Civil Aviation Safety Regulations 1998
requiring that
visual inspections and magnetic particle inspections of the
wing attachment joints of M18 Dromader aircraft, and its
variants, be performed with the
outboard wings removed.
(b)
I recomm
end that consideration be given to the issuing of
an airworthiness directive pursuant to regulation 39.001 of
the
Civil Aviation Safety Regulations 1998
, or a direction
given under regulation 43 of the
Civil Aviation
Regu
lations
198
8
, that
aircraft
factore
d
time in service should be
recorded on all maintenance releases
in order to accurately
determine an aircraft’s time in service for service life
limitation considerations and maintenance scheduling
purposes.
Table of Contents
Introduction
…………………………..
…………………………..
…………………………..
…………………………..
…………………………..
………………….
1
Why was an inquest held?
…………………………..
…………………………..
…………………………..
…………………………..
……………………..
1
David’s life
…………………………..
…………………………..
…………………………..
…………………………..
…………………………..
…………………….
1
What happened on 24 October 2013?
…………………………..
…………………………..
…………………………..
…………………………..
2
What investigation was conducted after the accident?
…………………………..
…………………………..
…………………………..
..
3
What do we know about VH
TZJ and its history prior to the accident?
…………………………..
…………………………..
..
4
What caused the wing to separate in
flight?
…………………………..
…………………………..
…………………………..
…………………..
4
How was TZJ’s aircraft fatigue managed?
…………………………..
…………………………..
…………………………..
……………………….
5
What is non
destructive testing?
…………………………..
…………………………..
…………………………..
…………………………..
………….
6
What significant events occurred in the year 2000?
…………………………..
…………………………..
…………………………..
…….
6
Wha
t maintenance, inspection and testing procedures were in place for TZJ?
…………………………..
……………….
7
(a) What were the two procedures?
…………………………..
…………………………..
…………………………..
…………………………..
.
8
(b) Which procedure was submitted to, and approved by, CASA?
…………………………..
…………………………..
…….
8
(c) What was the effect of the approval?
…………………………..
…………………………..
…………………………..
………………….
12
What occurred during the inspection of TZJ on 8 August 2013?
…………………………..
…………………………..
………….
14
Was the August 2013 inspection adequate?
…………………………..
…………………………..
…………………………..
………………..
15
(a) Was corrosion pitting present?
…………………………..
…………………………..
…………………………..
…………………………..
.
15
(b) Was fatigue cracking present?
…………………………..
…………………………..
…………………………..
…………………………..
..
16
(c) Why was the corrosion pitting not removed and the fatigue cracking not detected?
……………………
1
6
Should any recommendations be made?
…………………………..
…………………………..
…………………………..
………………………
18
(a) Removal of aircraft wings during inspection
…………………………..
…………………………..
…………………………..
……
18
(b) Service life factoring of aircraft
…………………………..
…………………………..
…………………………..
…………………………..
19
(c) Pre
2009 service life factoring
…………………………..
…………………………..
…………………………..
…………………………..
..
19
(d) Auditing cond
ucted by CASA airworthiness inspectors
…………………………..
…………………………..
……………..
20
(d) Continuing education for licensed aircraft maintenance engineers
…………………………..
…………………….
21
Findings
…………………………..
…………………………..
…………………………..
…………………………..
…………………………..
………………………
21
Identity
…………………………..
…………………………..
…………………………..
…………………………..
…………………………..
…………………..
22
Date of death
…………………………..
…………………………..
…………………………..
…………………………..
…………………………..
…………
22
Place of death
…………………………..
…………………………..
…………………………..
…………………………..
…………………………..
………..
22
Cause of death
…………………………..
…………………………..
…………………………..
…………………………..
…………………………..
………
22
Manner of death
…………………………..
…………………………..
…………………………..
…………………………..
…………………………..
……
22
Recommendations
…………………………..
…………………………..
…………………………..
…………………………..
…………………………..
……
22
Epilogue
…………………………..
…………………………..
…………………………..
…………………………..
…………………………..
………………………
22
1
Introduction
2.
On 24 October 2013 David Black
was
flying an agricultural aircraft in an area of national park in
the south coast region
of New South Wales
carrying out
firebombing duties for the Rural Fire
Service
. He
was doing something which he loved to do
and
, at the same time,
performing an
important
and valuable
civic
service
.
As David was about to
embark on a firebombing run the
left wing of his aircraft separated, causing the aircraft’s rapid descent and an unsur
vivable
impact
with the ground below.
Why
was an inquest
held
?
3.
All unnatural deaths are reportable to a Coroner. When a person’s death is reported there is an
obligation on the Coroner to
investigate
matters
surrounding the death
. This is done
so that
ev
idence may be gathered
to allow a Coroner
to answer questions about the identity of the
person who died, when and where they died, and what the cause and the manner of their death
was. The manner of a person’s death means the circumstances in which that pe
rson died.
4.
In David’s case, there is ample evidence
to establish
his identity, where and when he died, and
what the medical cause of his death was. The inquest primarily focused on the manner of David’s
death. That is, what caused the wing separation duri
ng flight, and what were the circumstances
which l
ead to that catastrophic event.
5.
The inquest focused on two main issues, namely:
(a)
Whether the inspection, maintenance and testing procedures in relation to
David’s
aircraft, including the wing fittings
, wer
e implemented and followed; and
(b)
Whether the inspection, maintenance and testi
ng procedures in relation to David’s
aircraft, including the wing fittings, were adequate.
6.
As a Coroner also has the power to make recommendations to improve public health safet
y in
order to reduce the possibility that a similar death might happen in the future, the inquest also
examined whether
any such recommendations could be made arising from the investigation into
David’s death.
David’s life
7.
The inquest necessarily examined
a number of complex and technical aspects associated with
aircraft maintenance and engineering. In the midst of such
evidence there is the potential to lose
sight of the person at the centre of the inquest and
how his
family and friends
have been affected
by his tragic loss
.
8.
For that reason it is extremely important to
briefly
say something about David’s life
, as well as
to
recognise and
acknowledge the
tremendous
pain and grief that his
passing
has caused to his
family and those who knew him well.
9.
At th
e conclusion of the evidence in the inquest the court was privileged to hear some heartfelt
and moving words spoken by David’s wife, Julie, and David’s parents, Sarah and Andrew. I
10
Airworthiness Secti
on Manager. Mr
Van Dijk identified a
number of anomalies with the E
procedure
, some of which are set out below:
the
procedure
i
s
not
signed;
the
procedure
contains
paging
errors, for example one page i
s number
ed
Page 10 of 9
”;
the procedure
contains
i
nconsistences with respect to the way in which it
was to be
performed such as notch sizes, characteristics, and expected responses; and
the procedure incorrectly referred to “
CASA Service Bulletin AD/PZL/5
” in circumstances
where no such document of this
kind exists, and a CASA service bulletin and CASA
airworthiness directive are two different and distinct documents.
59.
Taking the above into account Mr Van Dijk stated
with a high degree of certainty that approval
from CASA would not be forthcoming for an
unsigned document containing such fundamental
deficiencies
”.
20
60.
Apart from the identified anomalies CASA also pointed to the fact that both the September 2000
email and the September 2000 letter
specifically referred to the EC procedure as the one
approved
by CASA. No mention was made of the E procedure in either the letter or the email.
61.
However, counsel for Mr Joiner submitted that the identified anomalies with the E procedure
could not persuasively resolve the question of which procedure was submitted a
nd approved
because the EC procedure itself also contained a number of anomalies. Some of these are set out
below:
the procedure
i
s
missing page 2;
the fax timestamp on page 1
(11 September 2000 at 9:08am)
i
s different to the
timestamps on the subsequen
t pages (8 September 2000, between 3:50pm and
3:53pm);
and
S
ection 4.0
of the procedure
directs a reader to Figure 2 in the procedure’s appendix
which purportedly contains
a reference standard for the eddy current procedure
.
However, Figure 2
contain
s
no
such
reference standard but instead an exploded view of a
centre wing section. It was noted
by counsel for Mr Joiner
that
F
igure 2 of the E procedure
did, in fact, contain the appropriate reference standard.
62.
Apart from the anomalies identified with the E
C procedure, counsel for Mr Joiner also drew
attention to the fact that
following the accident CASA issued two amendments to the CASA AD.
The purpose of the amendments was to
mandate that NDT of the wing attachment joints for M18
Dromader aircraft could on
ly be performed using MPI.
The first amendment
was issued on 15
November 2013 and the second was issued on 22 November 2013. It was
identified
that in both
amendments
there was
a note referr
ing
to the fact that
the approval by CASA of [the E
procedure] or
other revision, as an alternative inspection procedure to use in lieu of the non
20
Exhibit 1, page 135
7.