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Safety Action

Summary

SAFETY ACTION

As a result of this occurrence, the aircraft operator took immediate action and issued a company memorandum to all engineering staff clarifying the requirements of Civil Aviation Regulation 42G in regard to flight control system maintenance and inspections requirements. This memorandum reiterated the requirement for duplicate inspections inclusive of all trim systems.

The aircraft operator also advised the ATSB that the maintenance control and engineering procedures manuals had been revised and that the following corrective action had been taken:

  • a new engineering procedure has been introduced, which addresses hand over of maintenance co-ordination of tasks between shifts that involve multiple personnel across those shifts, and hand over procedures for maintenance tasks between engineers completing separate portions of the one task.
  • The Engineering Procedures Manual (EPM) has been revised to include procedures for certification of stages of maintenance within a task and now incorporates a procedure to identify when duplicate inspections are required, and ensures the incorporation of duplicate inspection entries in maintenance documentation for those tasks deemed by civil aviation legislation and company policy to require them. This EPM Section also identifies personnel responsible for ensuring that duplicate inspection requirements are invoked when maintenance activities require them.
  • All maintenance documentation has been reviewed and the layouts amended to address the appropriateness of maintenance log sheets, work cards and other such documents to facilitate these procedural changes.

The operator also advised that they had reviewed the company induction and training program for maintenance engineers and now emphasise the sections of the Fairchild Aircraft Maintenance Manual that relate to the pitch trim and control maintenance practices. The sonalert unit in the aircraft was replaced after the incident. This aircraft’s sonalert operation now conforms to that of the operator’s fleet.

RECOMMENDATION

As a result of this and previous occurrences, the Australian Transport Safety Bureau issues the following safety recommendation:

R20040078

The Australian Transport Safety Bureau recommends that M7 Aerospace Pty Ltd review and amend its Fairchild SA-227 series maintenance manual to ensure that notes on operational tests, with regard to horizontal stabiliser movement versus trim switch position referred to in Section 27-40-10 for removal of the pitch trim switch, are included in Section 27-10-10 for related maintenance activities, or references to them are clearly noted in that part.

 
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