Transport Canada decision led to deadly crash: safety board

[Widow]

The link to this article was broken when I got my google news alert last night, but it's up now. It has been posted in the heli forum, but I think it should be seen by all.

Transport Canada decision led to deadly crash: safety board
Larry Pynn, Vancouver Sun
Published: Monday, January 21, 2008

Transport Canada allowed a Winnipeg company to repair a "critical part" on a Bell 206B helicopter despite the aircraft manufacture's advice not to, a decision that led to three deaths in a helicopter crash on B.C.'s north coast, a federal transportation safety board report concludes.

Bell Helicopter issued a safety notice in 1999, after a helicopter crash in 1998 in Indonesia, indicating the company did not approve of repairs to the part, a transmission mount spindle critical to the operation of the aircraft.

The report found that Transport Canada, as the regulator of aircraft operations, looked into the safety notice, but "closed the file without formally reviewing or cancelling" Cadorath Aerospace Inc.'s approval repair certificate, thus "allowing the repair to continue."

Cadorath is authorized by Transport Canada to repair and overhaul a wide range of aircraft, including the Bell 206B helicopter.

The report says the Winnipeg company introduced a "stress concentration" during the repair, which led to a "fatigue crack" and the subsequent failure of the spindle.

That directly caused the crash of the Quantum Helicopters Ltd. aircraft early Sept. 19, 2006, in an estuary one kilometre from departure, the report found.

The crash occurred near the village of Alice Arm on the province's north coast.

The pilot, 56-year-old Randy Hildebrandt of Duncan, an ex-RCMP inspector and helicopter pilot, died in the crash of the Canada-built helicopter, along with two passengers engaged in resource drilling in the area.

The pilot didn't stand a chance, Bill Yearwood, regional manager for the safety board, said in an interview from his Richmond office. "Full nose down into the ground," he said. "There was nothing the pilot could do. You couldn't control the aircraft."

Cadorath built a total of 43 defective spindles; Transport Canada issued an airworthiness directive in February 2007 ordering the removal of all such components from other helicopters.

Yearwood said it is unfortunate the Indonesia crash did not sufficiently serve as a warning, and that it took yet another crash and the loss of three lives in B.C. for action to be taken.

"They were aware of it," he said of Transport Canada officials before the crash, "but didn't take any regulatory action...."

Transport Canada spokesman Rod Nelson said in response Sunday from Vancouver that safety notices are "advisory in nature" and fall short of "safety alerts for immediate or mandatory action."

Bell Helicopter uses them to distribute safety information to their customers, he said, and did not cite "any evidence of a safety deficiency" in Transport Canada's approved design repair for the transmission support spindle.

He added it is not unusual for aircraft manufacturers to prefer the use of their parts rather than supporting the use of approved repair designs from third-party repair companies.

(Companies such as Quantum can save money repairing a worn part rather than buying a new one. Yearwood estimated the difference would be approximately $1,000 versus $2,300.)

Nelson said departmental officials are reviewing the safety board report to determine if further safety action is required.

Neither Cadorath general manager David Haines in Winnipeg nor Quantum owner Ian Swan in Terrace could be reached to comment.

Vancouver Sun

[carholme]

Widow;

I am sure CID will be along soon enough to thwart any efforts by the rest of us "alarmists".

What would be interesting is to review TC's SMS programme to see why they did not take the appropriate maximum saftey consideration in view of the previous accident in Indonesia. No doubt though, that they have a short term correction action in place.

carholme

[Cat Driver]

Transport Canada spokesman Rod Nelson said in response Sunday from Vancouver that safety notices are "advisory in nature" and fall short of "safety alerts for immediate or mandatory action."

They always have an out.

[CID]

The headline is a bit misleading. Did Transport Canada "decide" to do the repair or did the repair facility "decide" to do it. There is certainly cause for TC's procedures to be reviewed here to authorize it (or fail to prohibit it) but ultimately the repair facility is on the hook to restore the part without weakening it or in this case developing a stress point.

Special authorizations to repair aircraft parts are quite common. They are usually based on justification prepared by the specialists employed by the overhaul facility. If Transport Canada refused to allow this sort of thing, there would be a great deal of outcry from the industry.

Should we make everyone send their engines to the manufacturer for overhaul?

Perhaps the question here is where TC should draw the line in authorizing special repairs outside the factory. Should they be banned altogether or should they start demanding much more technical information for certain parts.

Personally, I don't like to see major helicopter transmission parts overhauled or repaired outside the manufacturer unless there is very close coordination with the manufacturer. On the other hand, entire engines are overhauled and repaired at third party shops all the time and often much better and cheaper than the manufacturer.

Carholme,

Nice of you to think of me. Your SMS/corrective action rant is misplaced however. The overhaul/repair company in question should be thinking that over.

Cheers!

[carholme]

CID;

Clever deflection, but read who made the statement in the first place, TSB. Waiting for your next which should be really good.

carholme

[CID]

CID;

Clever deflection, but read who made the statement in the first place, TSB. Waiting for your next which should be really good.

So you're saying the repair facility should be blameless?

By the way, nice trolling.

[Widow]

CID, of course they shouldn't be blameless. But neither should TC ...

[Cat Driver]

TC can only be as trustworthy as those who are in charge at the top.

With the present top management only a fool would believe that we can trust what TC says or does.

[GilletteNorth]

In the overall picture, and not using those fabulous 20/20 hindsight glasses that so many people have...

Transport Canada issued an airworthiness directive in February 2007 ordering the removal of all such components from other helicopters.

Are you saying they should have done this immediately after the first crash occurred in India? Despite the inability of Bell Helicopter to

cite "any evidence of a safety deficiency"

and knowing

it is not unusual for aircraft manufacturers to prefer the use of their parts rather than supporting the use of approved repair designs from third-party repair companies

Any company can make authorized repairs to aircraft parts as long as they have the technical specifications and ability. Cadorath in Winnipeg was supposed to have that ability and use it correctly but they failed to do so, not Transport Canada. Just wondering if in your view then, whenever a part breaks in any aircraft (anywhere in the world), we immediately ground all concerned aircraft, remove all the suspected defective parts, have Transport Canada conduct a full investigation as to why the part broke before allowing anyone to resume flying etc etc. The way I see it, there wouldn't be a plane in the sky. It is unfortunate a second crash occured, but since it was a Canadian aviation accident, it did prompt Transport Canada to investigate Cadorath overhaul techniques closely and discover there was a problem with the refurbishment of the part. But if you are going to blame them for not investigating after the first crash, you should also blame yourself for not demanding the Canadian government spend more on manpower to allow Transport Canada to investigate every part breakage everywhere in the world. We (the aviation community) KNOW Transport Canada is undermanned and unable to investigate every single incident that occurs daily, yet we continue flying. Are we using the "appropriate maximum safety consideration" by allowing this condition to continue then blaming Transport Canada for not finding and correcting errors prior to accidents?

[Widow]

Of course, NOW they've fixed the problem ... but if Bell was unable to

cite "any evidence of a safety deficiency"

, then why did they

issue(d) a safety notice in 1999 ... indicating the company did not approve of repairs to the part, a transmission mount spindle critical to the operation of the aircraft.

I thought "you" were ALWAYS supposed to follow the manufacturers instructions

I'd like to see a copy of TSB's A06P0190 report. Not online, guess it hasn't been translated yet.

[carholme]

Everyone will notice, I am sure that TC issued the approval of the Cadorath repair scheme. Was this done by consulting Bell Helicopter? After Bell's Safety advisory, I rather doubt they would have approved.
Bell Helicopter is very aware of the PMA market in North America and have stringent approvals for those manufacture parts under license.

This arm is used to support the transmission in place and is a key component. Back in the 70s a similiar arm broke on a 206 helicopter in the Gulf of Mexico killing all on board. They had decided to re-manufacture the arms from aluminum as a weight savings measure. This was quickly changed again after the accident to the steel arms that are used today.

Reading the words of the TC spokesman, he is obviously thinking of becoming a politician.

carholme

[CID]

widow,

It's not uncommon for manufacturers to issue statements that they don't recommend third party repairs in order to protect their commercial interests. As far as following manufacturer's instructions, if it was an issue potentially effecting safety, they should have used something stronger than a "safety notice" to air their concerns. Manufacturer's "instructions" come in many forms. Some are mandatory, some aren't.

[Widow]

OSN 206-99-35 “Revision B”

TO: All Owners/Operators of Bell 206 Helicopters
SUBJECT: REPAIRS OR ALTERATIIONS NOT APPROVED BY BELL HELICOPTER

Bell Helicopter has been advised of a second 206B accident in which the transmission and pylon assembly separated from the aircraft due to in-flight structural failure of a transmission support spindle, 206-031-554. Laboratory investigation results indicate that a repair not recommended by Bell by metal plating had been performed on the failed spindle.

This Operations Safety Notice is being revised to advise Bell 206 Owners/Operators of this second occurrence involving fatalities which appears to have been caused by inappropriate field repair. Bell Helicopter does not approve dimensional restoration by plating of the spindle 206-031-554, as this is a structural component. Application of metal spray, electroplating or other means of metal deposit would require re-qualification. Repair methods not recommended by Bell Helicopter result in parts that no longer meet the original design criteria and the published maintenance and overhaul recommendations and may not assure continued safe operation of the helicopter.

Transport Canada has since issued an Airworthiness Directive (CF-2007-02) mandating the removal of 43 such spindles that were altered by Cadorath Aerospace Inc. Owners/Operators of Bell Helicopter products are reminded to adhere to the maintenance and repair procedures published in the applicable maintenance, overhaul and repair manuals. Bell Helicopter Product Support Engineering remains available to assist with damage evaluation and repair guidance where applicable. For addresses, telephone and fax numbers, refer to Information Letter Gen-98-61, 12 June 1998.

http://www.bellcustomer.com/files/Stora ... _Rev_B.pdf

[GilletteNorth]

Sorry Widow, but you highlighted it yourself...

may not assure continued safe operation of the helicopter

Doesn't mean it won't. Again, they will try to protect their own commercial interests by issuing "safety notices" that contain cautions and induce doubt but do not specifically state "DO NOT USE THESE PARTS, THEY'RE UNSAFE" because they know some refurbished parts are perfectly safe.

[2milefinal]

So Bell says they did not like this kind of repair PUT TC says its OK.
Can anyone find another example of this sort of thing. From any other product or a/c.??
Does happen often?

[the_professor]

Widow, I feel for you. You are going to live a miserable existence if you insist -- as you have done relentlessly since joining this board after your husband's death -- on seeking out every instance where someone at some authority (TSB, TC, FAA) or company MAY have done something to contribute to the significant risk that is inherent in aviation.

AVIATION IS DANGEROUS, AND IT ALWAYS WILL BE.

Look at the 777 that crashed the other day: One of the world's most advanced airliners, jammed with redundancy, crewed by highly trained pilots and a reputable no-BS operator. And yet they ended up skidding across the grass & onto the runway threshold at the end of their flight.

That scenario is perhaps the most "risk-free" type of aviation example you will find (except for the plane parked in a hangar, or course), and yet something still went terribly wrong.

What witch hunt are you in the process of conducting into British regulatory agencies and Boeing?

[Widow]

Uh-huh, they issue notices to protect their a$$ if someone sues. Sounds like a good reason to follow the recommendation.

Oh and professor -

[GilletteNorth]

Why would they issue notices to avoid being sued from accidents resulting from parts failures produced by third parties? They didn't produce the part so it wouldn't affect them? It is extremely unfortunate the part in question failed in the BC crash and resulted in fatalities. It might have failed while the aircraft was running on the ground resulting in no loss of life.
I would rather use this report to congratulate Transport Canada on seeing a trend developing immediately (the first crash could have been a fluke), and issuing an airworthiness directive in February 2007 ordering the removal of all (43) such components from other helicopters. This fast action probably saved numerous lives.

[Widow]

That's pretty simple. Because if they hadn't issued something after the crash in Indonesia, and something had happened again (as it did) they could be accused of NOT having done anything.

If they had adhered to the manufacturers recommendation, Randy Hildebrandt and his two pax might still be alive.

Very interesting quote from back in Feb. '07 ...

If the truth comes out along the line this thread is suggesting, I prophesy another "Widow" tilting at Transport's windmills. His widow, similar to our "Widow", is not a shrinking vilolet and would not let sub-standard maintenace just drop I'm sure!

http://www.avcanada.ca/forums2/viewtopi ... 76&t=22844

[CID]

Uh-huh, they issue notices to protect their a$$ if someone sues. Sounds like a good reason to follow the recommendation.

I don't think the "commercial interests" referred to were to do with litigation. Bell, and any other manufacturers highly recommend that you use original parts and use them for all your overhaul needs. They simply want you to spend as much money possible in their facility.

Car dealers do the same thing. They want you to use original parts and have them do all the repairs. Do you take your car to the dealer whenever it needs an oil change? Chances are they won't do any better job than any quick oil change place and it will cost more.

Of course that's not always the case but I don't know of anyone who blames TC because they got a bad oil change from some crook.

If they had adhered to the manufacturers recommendation, Randy Hildebrandt and his two pax might still be alive.

You're assuming that manufacturers don't make mistakes and that there are no accidents that have been caused by a bad repair or overhaul by the manufacturer. Sorry, but you're wrong. The same processes that cause things to fail outside the manufacturer exist inside the manufacturer.

[Widow]

Yeah, except that the notice WAS issued AFTER and as a result of an accident.

[carholme]

For any of you who may feel that the manufacturers only issue safety notes so that you have to buy your parts from them, feel free to continue thinking that way. Obviously they want you to buy parts from them but overhaul and repair is usually not one of their main lines of business. In many cases as with Bell Helicopter and others, overhaul/repair work is farmed out to organizations who meet their standards and are approved by them.

Here is the notice from Bell which some of you may feel does not require appropriate attention but which I would be paying strong attention to if any other agency decided to proceed in light of it.
Previous deaths resulted resulted from two acccidents involving these parts, so I would question why anybody would ignore the advice given by the manufacturer in this case.

The Safety Notice is not mandatory but neither is stupidity.

Below is a revision to the initial Safety Notice


OPERATIONS SAFETY NOTICE
A Subsidiary of Textron Inc.
MAY 19, 1999
Revision B MAR 09, 2007
OSN 206-99-35 “Revision B”
TO: All Owners/Operators of Bell 206 Helicopters
SUBJECT: REPAIRS OR ALTERATIIONS NOT APPROVED BY BELL HELICOPTER
Bell Helicopter has been advised of a second 206B accident in which the transmission and pylon assembly separated from the aircraft due to in-flight structural failure of a transmission support spindle, 206-031-554. Laboratory investigation results indicate that a repair not recommended by Bell by metal plating had been performed on the failed spindle.
This Operations Safety Notice is being revised to advise Bell 206 Owners/Operators of this second occurrence involving fatalities which appears to have been caused by inappropriate field repair. Bell Helicopter does not approve dimensional restoration by plating of the spindle 206-031-554, as this is a structural component. Application of metal spray, electroplating or other means of metal deposit would require re-qualification. Repair methods not recommended by Bell Helicopter result in parts that no longer meet the original design criteria and the published maintenance and overhaul recommendations and may not assure continued safe operation of the helicopter.
Transport Canada has since issued an Airworthiness Directive (CF-2007-02) mandating the removal of 43 such spindles that were altered by Cadorath Aerospace Inc. Owners/Operators of Bell Helicopter products are reminded to adhere to the maintenance and repair procedures published in the applicable maintenance, overhaul and repair manuals. Bell Helicopter Product Support Engineering remains available to assist with damage evaluation and repair guidance where applicable. For addresses, telephone and fax numbers, refer to Information Letter Gen-98-61, 12 June 1998.
B

[CID]

Carholme,

The revised service letter refers to an AD which is mandatory. So what's your point? Based on your statements, I assume you've applied all manufacturer's service memos, letters and advisory wires to your aircraft and have all your components overhauled and/or repaired by the component manufacturer or repair facilities recommended by the airframe manufacturer.

If not, why?

[carholme]

CID;

I don't wish to engage you in lessons how to maintain our aircraft.
Whether you choose to pay attention to the safety notices by the manufacturer is entirely up to you. Prior to issuance of the TC AD, anyone who ignored this safety information was quite right in doing so.
Those who did not suffer as a result of it are lucky. Those who did, were not. I am just glad I am not in their shoes, having to question whether my decision was based on dollars.

carholme

[CID]

I don't wish to engage you in lessons how to maintain our aircraft.

Well, you set the troll line and you got me hook line and sinker. Don't pack your fishing gear and go home now. It was just getting interesting.