Coroner's Findings - microlight incident 2005

[seb7701]

For those who are interested, I just started reading the findings in relation to this incident which are available via this link:

 

http://www.courts.qld.gov.au/SchollPH20090127.pdf

 

The recommendations of interest/concern are these:

 

34. CASA should implement a system of maintenance release forms as

 

 

used in the general aviation industry.

 

 

 

 

 



35. CASA and the RAAO’s should implement a system of mandatory

 

 

 

 

 



recorded annual pass/fail Bettsometer tests in respect of microlight

 

 

 

 

 



weight shift aircraft.

 

 

 

 

 



36. CASA and the RAAO’s should review current requirements for the

 

 

 

 

 



keeping of aircraft maintenance records and develop and promulgate

 

 

 

 

 



an objectives based Industry Code of Practice to ensure aircraft

 

 

 

 

 



maintenance is properly undertaken, recorded and the record kept

 

 

 

 

 



available for inspection.

 

 

 

 

 



37. CASA and the RAAO’s should review the situation where a Level

 

 

 

 

 



One maintenance authority is regarded as competent to carry out

 

 

 

 

 

personal aircraft maintenance.'

 

 

 

Any thoughts?

 

 

 

 

 

 

 

[Guest Maj Millard]

34. does nothing other than create additional paperwork. Read BS.

 

The annual fabric test may be a good idea. Should be carried out and signed off by a Level 2.

 

We are already supposed to be keeping maintenance log books.

 

The Level 2 annual maintenance/condition inspections with recommendations, should be implimented to enhance the normal Level 1 maintenance. Problem with Level 1 maintenance is it doesn't get done on many aircraft. A once a year Level 2 sign off would check that the aircraft is being maintained on some level.

 

 

[Guest Cloudsuck]

Maj, I'm sure there may be some good level 2's out there but I haven't found any that I would let touch my aircraft EVER! The day they bring in mandatory level 2 inspections is the day I throw it in and head back to GA.

 

 

[Spriteah]

Cloud,

 

Based on your comments you should apply for an L2. Or you should go back to GA.

 

Jim

 

L2

 

(An Opinion that will create talk Im sure).

 

 

[Guest Cloudsuck]

Ooooo... Nasty. I have a mechanical trade background and would not take my car to the level 2's I know (Except Richard Eacott but he only does engines). Like I say there are likely to be some good ones out there. There is no reason for me to be a level 2 as I don't want to work on anyone’s plane except my own. I think that if we brought in 1. medicals or 2. mandatory level 2 inspections, there would be a mass exodus over night. That would be a shame.

 

 

[BLA82]

level 2 inspections, there would be a mass exodus over night. That would be a shame.

Then you would have to ask why and if they have something to hide?

 

 

[Guest Cloudsuck]

The why is easily answered. If I have to pay for maintance, I might as well stay with GA and get a real qualified mechanic rather than someone who got a couple of his mates to recommend him as a level 2.

 

I saw a level 2 at in my hangar one day working on a client's lane. The plane was a brand new Storch and it had a slightly bent leg. The level 2 removed the leg and had one end propped up on a block of wood and the otner end on the ground. He was flogging the leg with a sledge hammer trying to staighten it. Now how the hell did this guy get a level 2 and who recommended him?

 

 

[Guest Andys@coffs]

.....The level 2 removed the leg and had one end propped up on a block of wood and the otner end on the ground. He was flogging the leg with a sledge hammer trying to staighten it. Now how the hell did this guy get a level 2 and who recommended him?

Now come on thats really unfair, if you'd stayed long enough you would have seen that he did the same to the otherside, after all we dont want just one side breaking due to stress fractures at an in opportune moment we want both to depart at the same time...

 

Seriously though thats not good at all.... did you say anything to anyone? Or is it still an accident waiting to happen?

 

Andy

 

 

[Guest Rocko]

Quote:

 

Throughout this inquiry it became obvious that a weakness in the current

 

system is the regulatory regime and the enforcement of the rules applicable to

 

the recreation aviation industry. Put simply, the regulator is CASA. CASA

 

delegates some authority to RA-AUS and HGFA although this delegation

 

does not extend to prosecutions. It became obvious the level of

 

communication and co-operation between HGFA, RA-AUS, ATSB and CASA

 

is such that the community at large could have no confidence that the

 

regulatory regime, being the legislation and the rules of the delegated

 

unincorporated bodies, are being adequately administered and enforced.

 

Ouch! That's pretty much to the point!

 

 

[Guest Rocko]

I have a question on this, that perhaps a L2 or otherwise technical person can answer.

 

One of the findings in the report suggested a Bettsometer be included with every aircraft sold.

 

Now, being a spring-based item, whats to stop them losing calibration over time, thereby affecting their accuracy? Do they require recalibration during their lifespan?

 

 

[Guest ozzie]

you should all know by now that you don't use force ...you use a bigger hammer.

 

It seems that "they" are applying patches to fix what really needs a overhall. The standards developed for aircraft developed way back is now lacking due to natural progression in the development of todays product. The future will be an increased level of standards for procedure both for the actual work and papertrail.hopefully seeing the level of knowledge required to avoid theabove type senarios, running close to the current GA system.The seperate paths of Ultralight and GA are converging.

 

ozzie

 

 

[Guest Rocko]

37. CASA and the RAAO’s should review the situation where a Level

 

 

 

One maintenance authority is regarded as competent to carry out

 

 

 

 

personal aircraft maintenance.'

 

Isn't this an interesting one.

 

Just what is competence? I remember talking to a guy who had an aircraft who's muffler support bracket kept working loose during flight. He had it attached with a single metal bolt. Not wired, or anything else. Just a plain old bolt.

 

So, wanting to fly ASAP, he asked to borrow a spanner from my work kit I had with me to tighten it.

 

Said to him "Well, why not try some Loctite?"

 

His answer was "What's Loctite?"

 

He's qualified for a L1.

 

I'm perfectly comfortable stripping down and rebuilding car engines, and such. Mainly, because if anything was to ever fail after, the engine would stop, and the car/bike.PWC/whatever would stop. Plane engine? Wouldn't touch with a 40 foot pole, apart from change plugs, oil and filters. Stops, and you're having a less than fun day. So, always left anything more technical to L2's.

 

But it's a pretty vague area, isn't it. Why would having a pilots license qualify you to be able to perform basic mechanical work on your own aircraft, or even build one? I see they're running basic L1 courses now. Why should a L1 qualification be automatic, without justifying a persons capabilities to meet it?

 

Good food for thought there.

 

However, I agree, that if all mechanical work required L2, then it'd bring the costs up substantially, and put many out of flying.

 

Perhaps it's a human factors thing. That's the current catch phrase, isn't it? Stay within your capabilities, and seek help when it's beyond them?

 

 

[Thruster87]

The why is easily answered. If I have to pay for maintance, I might as well stay with GA and get a real qualified mechanic rather than someone who got a couple of his mates to recommend him as a level 2.Being a level 2 myself, the above comment is definitely a bit over the top.Sure like in any industry, not all have the same experience on specific types out there and you do need to find people with that expertise.Doing inspections is a different ball game to overhauling.In my experience [being a non current LAME Engines/Airframes retired] I had to certify work done by way more experienced sheet metal workers but I was more aware of the total requirements.Level 2's have this knowledge so they can do competent inspections and that is what is needed.Cheers T87

[jetjr]

What is the process for someone to become a L2 and whats involved in keeping that qualification?

 

JR

 

 

[Guest brentc]

To be a level 2 you need to be recommended by another level 2 (or LAME) and have a couple of references. You must also have suitable experience, aka vehicle machanic to be restricted to engines, experience as an AME, experience working on your own aircraft under supervision etc etc.

 

 

[Guest TOSGcentral]

In my view it is not what the Coroners are saying (because it is not just one and they are all singing similar songs) it is the fact that they are saying it and not aiming their comments at individuals but directly at the quality of control by organisations themselves.

 

 

I have been saying the following for years and will repeat it once more. I personally do not give a stuff if you want your de-facto and actual GA aircraft – good on ya – but DO NOT trample on the freedoms of people who do not and wreck their movement for them!

 

 

Nobody is going to be selective! If there is a perceived threat to the public then the entire movement will be mandated equally and it will get worse. A new mandatory annual inspection will become 100 hourlies. Maintenance releases will become a whole paperwork structure with inspections of that. It is not the costs that people will run away from it is the loss of freedom or even a locality that makes this level of control impractical for the individual.

 

 

There is nothing mysterious about Airworthiness – it has been around for a long time and the almost total lack (until very recently) by AUF and then RAAus to lift our act had to end the way it is now going.

 

 

Aviation is a responsible area of activity that demands compliance with what has proven to be necessary over decades.

 

 

Who could have been insane enough to believe that you could hand out leave to totally rebuild airframes with no demonstrated competence at all but simply because you have got your pilot’s certificate?

 

 

Who could have been silly enough to not, over 20 years, be making some efforts to improve that situation?

 

 

Who could have been that blind that an assumption was made that we would get away with taking aircraft types that for decades had been under a legal, highly trained, and licensed GA Airworthiness system and overnight put them in the total control of anybody with no checks or anything else?

 

 

We could get away with this sort of thing if we were working with just humble 95.10 single seaters and their 95.25 supporting trainers. It is a different matter with fast, heavy, complex system and construction aircraft that ARE GA in essential nature and are obviously so!

 

 

The point was that we had time to steadily build an airworthiness system that would have credibility at member level for ultralight aircraft – it that time had not been wasted. But it has all been left to ‘member responsibility’ and we all know what sort of attitudes come out of any given sample of humanity.

 

 

By what Coroners are now starting to say you can realistically envisage 95.10s going under formal annual inspections and full paperwork history etc etc. Pilots currently cannot and do not even fill in basic log books for their own protection! You are not looking at a few people, or even a lot of people, walking out – you are looking at the death of an entire movement.

 

 

Well done chaps – we did once have a movement that was starting to work really well!

 

 

[Guest Rocko]

Exactly.

 

 

[Guest Cloudsuck]

Seriously though thats not good at all.... did you say anything to anyone? Or is it still an accident waiting to happen?Andy

Had a quiet word to the aircraft owner who purchased a new leg.

 

 

[Guest Cloudsuck]

I'm perfectly comfortable stripping down and rebuilding car engines, and such. Mainly, because if anything was to ever fail after, the engine would stop, and the car/bike.PWC/whatever would stop. Plane engine? Wouldn't touch with a 40 foot pole, apart from change plugs, oil and filters. Stops, and you're having a less than fun day. So, always left anything more technical to L2's.

Yet anyone can legally work on the brakes of their car and without qualification, then put their family of five in it and go down the road at 110 kph. Not even a second thought. The potental for multiple deaths is way beyond that of a two seat aircraft.

 

The problem is this, the level 2 system is flawed. I see it first hand. And people with no mechanical aptitude or training believe that level 2's are some kind of LAME. Well they are not even close.

 

 

[hihosland]

Tony did say that coroners are questioning the quality of control by organisations.

 

From which a reasonable conclusion is that regulations will be imposed that will obligate full airworthiness compliance on recreational aircraft.

 

It seems to me that the AUF model is appropriate to sub 540kg and 100kt aircraft.

 

Beyond that when recreational aircraft are overlapping GA aircraft in their potential to cause damage/injury by virtue of their speed/mass then the argument that they should comply with the GA airworthiness obligations is becoming irrefutable.

 

A situation that we have brought upon ourselves.

 

 

 

[Guest ozzie]

As usual Tony puts it much clearer as to what i have been yarping on about for years. once again i am afraid of losing more of my freedoms due to those who want bigger faster and more complicated aicraft. we should really be looking at going for the US system of either LSA or part 101.

 

ozzie

 

 

[Guest Maj Millard]

Cloudsuck, Firstly if you go back and correctly read my post, you'll find that I was not advocating ALL maintenance to be done by L2s. Mearly a once yearly overview/check to back up what a L1 might /might not be doing, with his aircraft. If you question what it takes to get an L2 licence you should try sometime. What does it take to get an L1, nothing, it comes as a privelage of your pilots license, regardless of wether you may be mechanically inept or not, as many are

 

During the once a year check/signoff, the L2 wouldn't even have to touch the aircraft, unless of course the owner requested a further indepth check and/or service, or closer look.

 

I can tell in a minute by walking around an aircraft, or asking the owner a few questions, wether an aircraft is correctly maintained or not. As an L2 I could then talk with the owner/s outlining my concerns, and observations, and suggest they seek additional help in the future with their maintenance. Doesn't have to be me that gets the work. Frankly there are some aircraft out there that I wouldn't want to touch with a ten foot pole, but somebody else may be more conversant with the type.

 

I have seen so called GA LAMEs do damage to UL aircraft, because they simply don't have a UL maintenance background, or experience on the aircraft, or engines they're working on.

 

Classic example is GA LAMEs putting Aviation grade aeroil into Rotax 912 engines. Oh, it must be better than auto oil they say. Fact is the Rotax service manual specifically says not to use anything but auto grade oils in the 912, as it is not compatable with the gear box, and also may contaminate the sprague clutch, which will then require replacement at considerable cost. Don't they take the time to read the service manual ?.

 

I smile when I see them use Aero-oils instead of auto grade oil, and I go over and make sure the owner has one of my cards !.

 

Granted there may be some L2s out there who shouldn't be carrying the rating, but overall most will have the backup experience, and are well qualified to be considered a capable L2.

 

The worst examples of under maintained aircraft I have come across by the way, are aircraft owned in a partnership, or by multiple owners. The poor aircraft simply gets the ring flown off it, and nobody wants to get thier hands dirty, or be the one to pay for maintenance.........................

 

R Millard..Proud practising RAA Level 2, Professional Aircraft Maintenance Eng (AME), FAA (US) Licensed Airframe and Powerplant Mechinic # 619186857., experienced homebuilder with one flying original-designed UL to credit, Level 2 license in Advanced composit structures (US), Certificate in Non-destructive testing (NDT), and active pilot.

 

 

[Guest Cloudsuck]

Tony did say that coroners are questioning the quality of control by organisations. From which a reasonable conclusion is that regulations will be imposed that will obligate full airworthiness compliance on recreational aircraft.

 

It seems to me that the AUF model is appropriate to sub 540kg and 100kt aircraft.

 

Beyond that when recreational aircraft are overlapping GA aircraft in their potential to cause damage/injury by virtue of their speed/mass then the argument that they should comply with the GA airworthiness obligations is becoming irrefutable.

 

A situation that we have brought upon ourselves.

It matters little whether you are in a 530 kg aircraft doing 95 knots or a 600 kg aircraft doing 105 knots. The ground is hard and the human body can not withstand a sudden change in velocity of 50 kph. It is unsurvivable. It is just a silly argument used by rag and tubers.

 

 

[Guest Cloudsuck]

Cloudsuck, Firstly if you go back and correctly read my post,

R Millard..Proud practising RAA Level 2, Professional Aircraft Maintenance Eng (AME), FAA (US) Licensed Airframe and Powerplant Mechinic # 619186857., experienced homebuilder with one flying original-designed UL to credit, Level 2 license in Advanced composit structures (US), Certificate in Non-destructive testing (NDT), and active pilot.

Oh no I read it ok. I just don't want any mandatory level 2 inspection at all. Not even an annual. I don't agree with it. Clearly you have some qualifications so are over and above a level 2. The ones at my field which I would be forced to use are incompetent. It sounds like another push by people looking to make little retirement businesses.

 

Cloudsuck ... RAA Level 1, Under 8 soccer best and fairest winner, Year six fastest boy over 100 meters, 8/10 on my year one spellioing test.

 

 

[eastmeg2]

If I read the report correctly, the aircraft was not even registered at the time of the accident. Yes there were questionable practises during the previous ownership transfers of the aircraft which shows that there were gaps in the process, but people don't go attacking the RTA (or other state road authority) when people drive and crash unregistered unroadworthy cars now do they? Of course not, the driver is the one who is held liable.