Aviation safety investigations & reports

Cessna Aircraft Company 441, VH-LFD

Investigation number:
199900673
Status: Completed
Investigation completed

Summary

The pilot of the Cessna 441 reported that while checking the aircraft's flight controls during a pre-flight inspection, a rubbing sound was evident in the vicinity of the inboard section of the left aileron. The ailerons were capable of full deflection in the correct sense with no noticeable restriction of movement. After an inspection by the operator's chief pilot and the check and training pilot, the aircraft was deemed to be serviceable. A precautionary note was made in the aircraft's Maintenance Release for the aileron system to be inspected by the operator's maintenance organisation. The pilot then continued operating the aircraft. On return to the operator's main base at Jandakot, an inspection by maintenance personnel revealed that the aileron control cable was incorrectly rigged and fouling the airframe structure.

The BASI investigation revealed the following deficiencies:

  1. a maintenance oversight and inadequate procedures for the release of an aircraft after undergoing maintenance to the flight controls;
  2. sixty flying hours had elapsed since maintenance was last performed on the aileron control system. The defect was apparently not recognised during that time; and
  3. the flight crew did not consult with company engineering personnel for technical advice prior to commencing the flight.

During the BASI onsite investigation, the details of this occurrence, together with occurrences 9804343, 9900874 and 9900556, which identified similar deficiencies, were discussed with the operating company's management and staff. Concerns identified by the BASI team were translated into company recommended safety actions, which management undertook to implement. The company immediately introduced changes to the duplicate inspection procedures, and would introduce education and awareness safety notices regarding effective communication between flight and maintenance personnel. It would also emphasise the responsibilities incumbent on the crew when carrying out the daily inspection procedure. The implementation and effectiveness of these company initiatives will be monitored by BASI.

General details
Date: 11 February 1999   Investigation status: Completed  
Time: 1830 hours WST    
Location   (show map): Port Hedland, Aero.    
State: Western Australia   Occurrence type: Flight control systems  
Release date: 08 December 1999   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Cessna Aircraft Company  
Aircraft model 441  
Aircraft registration VH-LFD  
Serial number 4410164  
Type of operation Aerial Work  
Damage to aircraft Nil  
Departure point Port Hedland, WA  
Departure time 1943 hours WST  
Destination Meekatharra, WA  
Crew details
Role Class of licence Hours on type Hours total
Pilot-in-Command Commercial 1790.0 4510
Last update 13 May 2014