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R22/ R44 matter goes on – Robinson manual found defective

Court of Appeal – FSA 2002 – pages 55-61 R22/ R44 matter goes on, – Robinson manual found defective, with the Court of Appeal in Brisbane awarding an up-held appeal by the McDermott’s.

The original matter was reported here earlier in 2014.

This goes back to 2004, where a retraining bold let go [Bolt-4] and a series of cracks extended to a main plate. The interesting thing in this finding is that manufacturers have to keep up-grading their maintenance manuals and not just rely on the LAME to “…fix matters…”.

[8] In reaching that conclusion, the primary judge referred to the evidence of the appellants’ expert, Mr Ogier, a LAME and an airworthiness inspector, that it was difficult for a torque stripe to adhere to a surface which was not clean and dry at the time of application as the stripe might slip as the surface moved.12 His Honour noted that this concern was not raised in any other expert evidence and no other expert suggested that this prospect made torque stripes an unreliable indicator of bolt movement.

A question here is – who is the “expert” and Airworthiness inspector relied on by the plaintiffs – Mr. Ogier??

In a 2002 CASA document, FLIGHT SAFETY AUSTRALIA, SEPTEMBER-OCTOBER 2002 < 55, the following is noted:

For advice on moving to the new rules, call 131 757 (local call) and ask for one of CASA’s senior manufacturing specialists:
Alan Plumridge (Victoria, Tasmania, SA and WA),Wayne Moore (ACT and NSW) or Barry Ogier (NT and Queensland).

Ogier is also mentioned in a 1998 article on “new rules”, in a role as “trainer”.

From the Court documents:

[21] Mr Ogier, called by the plaintiffs, is an aviation safety expert. He also plays a regulatory role in relation to the issue of certifications of airworthiness for aircraft, and was formerly a LAME. He has experience in evaluating aircraft maintenance systems and maintenance manuals. Mr Lay was called by the plaintiffs to give evidence as a LAME. He is also an experienced pilot, his experience extending to pilot testing and training. He has also carried out helicopter accident investigations.

[22] The plaintiffs also called Mr Fisher, the LAME who carried out the 100 hourly maintenance inspection on 22 March 2004, and Mr Bray, the LAME who carried out the 100 hourly maintenance inspection on 12 May 2004. Robinson called Mr Cox and Mr Boyle as expert LAMEs. Mr Cox is Robinson’s Technical Support Supervisor, and a co-author of the Maintenance Manual. Mr Boyle carries on his own maintenance business.

The findings go on:

[23] For these reasons, in addition to those of Alan Wilson J, I consider that the manual did not provide adequate instructions to LAMEs performing periodic inspections.
Had those further, simple instructions been in the manual, the LAMEs would have followed them and inevitably detected movement in the incorrectly assembled bolt.
The LAMEs would have re-assembled and retorqued the bolt and the accident would have been avoided.

The case in full of McDermott & Ors v Robinson Helicopter Company Incorporated [2014] QCA 357 is at: QCA14-357

MARGARET McMURDO P: In May 2004 a Robinson 22 helicopter crashed while being used to inspect fence lines on a cattle property close to the Northern Territory-Queensland border. The pilot, Mr Kevin Norton, was killed. The appellants, Mr Graham James McDermott, the sole passenger in the helicopter at the time of the crash; his wife, Ms Juanita Carol McDermott; and his employer, NTB Pastoral Holdings Pty Ltd, brought an action for damages against a number of parties, including the respondent, Robinson Helicopter Company Inc (Robinson). This appeal is from the primary judge’s order dismissing the claim against Robinson.

[3] The following matters were common ground at the trial. The accident was caused by the failure of bolt 41 in the helicopter’s Forward Flex Plate2 and this ultimately resulted in failure of the flex plate and the destruction of the helicopter, with tragic consequences for Mr Norton and serious injuries to Mr McDermott. Bolt 4 was a critical fastener in that, if removed or lost, it would compromise the safe operation of the helicopter with the risk of catastrophic failure. 3 For that reason, the helicopter maintenance manual specified that a secondary locking mechanism, a palnut, must be placed on bolt 4 and that after the installation of the palnut, a torque stripe be applied across both bolt 4 and the palnut.4
[4] There was no dispute in this appeal with the following findings of the primary judge. At some point more than 100 flying hours before the accident, bolt 4 was incorrectly assembled and soon after began to rotate.5 If a torque stripe had been properly applied when bolt 4 was incorrectly assembled, the stripe would have been visibly damaged shortly thereafter and this damage would have been apparent on the subsequent 100 hourly inspections conducted by the Licensed Aircraft Maintenance Engineers (LAMEs), Mr Fisher and Mr Bray.6
[5] At relevant times prior to the accident, the manual required that the helicopter be inspected periodically to verify its airworthiness, with inspection intervals at a maximum 100 hours time in service or 12 calendar months, whichever occurred first.7 The manual stated in respect of the flex plate: “Inspect condition, particularly edges.

Verify security. …”.8 Elsewhere, it relevantly provided in respect of bolt 4:
“Torque seal (paint) is applied to all critical fasteners after palnut
installation in a stripe across both nuts and exposed bolt threads. The stripe should extend to the part being fastened to show bolt rotation.
Any subsequent rotation of the nut or bolt can be detected visually.

Any nut damaged due to handling or whose nut drag has deteriorated appreciably must be replaced.”9
[6] In April 2007 after the accident, the manual was relevantly amended in these terms:
“Torque seal (lacquer) is conspicuously applied to all critical fasteners after palnut … installation in a stripe across both nuts and exposed bolt threads. The stripe must extend to the component in order to detect bolt rotation (reference Figure 2-1). Any subsequent rotation of the nut or bolt can be detected visually. Position torque stripes for maximum visibility during preflight inspections. Torque
stripes are subject to deterioration and must be periodically renewed.… .” (my emphasis)
[7] His Honour found that the effect of the instructions in the manual prior to the accident required a LAME carrying out a 100 hourly inspection to examine the condition of the torque stripe for bolt 4 and, if not as specified in the manual, to check the torque of bolt 4. Had this been done, the faulty installation of bolt 4 would have been discovered and the accident averted. It followed, his Honour found, that compliance with the manual was sufficient to prevent the accident.10 The primary judge found that Robinson took reasonable care to address the risk of failure of the flex plate from an inadequately torqued bolted joint. The relevant provisions of the
manual, particularly the instruction to verify security together with the provisions relating to torque stripes, were adequate. His Honour concluded that Robinson took reasonable care to address that risk and neither the helicopter nor the maintenance manual had a defect for the purposes of s 75AD and s 75AE Trade Practices Act
1974 (Cth).11

[8] In reaching that conclusion, the primary judge referred to the evidence of the appellants’ expert, Mr Ogier, a LAME and an airworthiness inspector, that it was difficult for a torque stripe to adhere to a surface which was not clean and dry at the time of application as the stripe might slip as the surface moved.12 His Honour noted that this concern was not raised in any other expert evidence and no other expert suggested that this prospect made torque stripes an unreliable indicator of bolt movement. His Honour rejected the notion that a torque stripe would be applied to a contaminated surface in the course of the manufacture of the helicopter and found it “unlikely that a LAME, familiar with the role assigned to torque stripes in the Maintenance Manual, would apply a torque stripe to a contaminated surface.”
The primary judge did not “accept that the risk that a torque stripe might be applied to a contaminated surface, and subsequently slip, is such as to render inadequate the use of a torque stripe as an indicator of bolt movement.” His Honour considered it was likely that when bolt 4 was incorrectly assembled, the torque was not checked so that it was “quite unlikely that a torque stripe was applied at that time”. But his Honour found that there was no need to consider whether the torque stripe was in place but slipped because it was more likely that when the bolt was incorrectly assembled no torque stripe was applied.13
[9] Later when dealing with and ultimately rejecting the possibility of a missing palnut on bolt 4, his Honour apparently made a contradictory finding as to whether a torque stripe was applied to bolt 4. In discussing the evidence of the LAMEs Mr Bray and Mr Fisher, who completed the last two 100 hourly inspections on the
helicopter preceding the accident, his Honour noted:
“The weight to be given to their evidence is affected by the fact that each of them failed to detect the condition of the torque stripe for Bolt 4 which, on my findings, must have at the time of their inspections indicated that Bolt 4 had rotated.”14

and:

[22] The manual as it was pre-accident did not make clear to LAMEs verifying security in the context of a periodic service that a visual inspection of torque stripes may not be sufficient to indicate whether critical fasteners like bolt 4 were correctly assembled. The evidence established that a torque wrench or a simple spanner could be easily used to verify that a bolted joint was not loose; any movement detected meant the bolt would have to be re-assembled and retorqued.
[23] For these reasons, in addition to those of Alan Wilson J, I consider that the manual did not provide adequate instructions to LAMEs performing periodic inspections.
Had those further, simple instructions been in the manual, the LAMEs would have followed them and inevitably detected movement in the incorrectly assembled bolt.
The LAMEs would have re-assembled and retorqued the bolt and the accident would have been avoided.

In a South African accident, there was a similar occurrence:

The forward flex plate on the gearbox sheared off. The drive shaft ripped open both main and auxiliary fuel tanks, pulling all the wires off and out of loom and off the frame. The aft flex plate on the free wheel bent, but did not break. The clutch was fully engaged and was bent to one side. Both V-belts climbed off the pulleys and sheared.
The sheave alignment rod was bent and the rod end pulled off the bearing. The aft cross tube was bent from hard landing.

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