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Airlines Cheating On Maintenance?  
User currently offlineCanadianNorth From Canada, joined Aug 2002, 3390 posts, RR: 9
Posted (8 years 2 months 3 weeks 5 days 15 hours ago) and read 3515 times:

Hi all

Recently I watched a show on the tv about the crash of Air Ontario flt 1363 (operated by Fokker F-28-1000; C-FONF, cn 11060) at Dryden, Ontario in 1989.

Basically what happened was they were running late and had a inoperative APU. When they made a scheduled stop at Dryden, Ontario, the facilities needed to start the engines without the use of the APU were not availible, so they opted to keep one engine running during the turn around. This worked just fine and is done by many airlines with no problems. But when it came time to take off, there was a good layer of snow on the wings. Normally, the procedure would be go to the deicing area, shut down, get deiced, fire up the engines again and you're set. Both Fokker and Air Ontario required both engines be shut off during de-icing. However, with an inoperative APU and no other options on the ground if they chose to deice then they would not have been able to start the engines, causing major delays to an already delayed flight.

So the pilots opted instead to take off the way it was, and assumed that the speed of the takeoff run would blow the snow off the wings. This almost worked, but there was also ice under the snow which prevented the wings from providing the ammount of lift that they should. They took off, but used nearly the whole runway and struggled to gain altitude. Shortly after they hit the trees and went down, destroying the aircraft and killing 24 of the 69 people on board.

Anyways, on to my question. Near the start of the show they talked about how Air Ontario was "anxious to keep the aircrafts flying for revenue purposes", and "they were in a hurry to introduce the F-28s into commercial air service and they let alot of the things that should have been attended to go by the way side." Also, they mentioned the scary fact that maintenance had logged more than 170 defects on this F-28 in the months leading up to the crash. The part that makes it scary was "Air Ontario instructed its pilots to note snags on the aircraft on scraps of paper, and these scraps were passed from air crew to air crew; and they were not to enter these snags in the log book because if they did then the aircraft, by law, would have to be grounded..."

My question is, was this what I would think is dangerous and unnacceptable way of doing things a one time thing, or is this more common than most people would think? As a pilot or maintenance person, would you ever do things this way? We do it where I work, but casually mentioning minor problems to our mechanic regarding lawn mowers and golf carts isn't the same thing as doing it with commercial airliners.


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Thanks for your time and sorry for the length
CanadianNorth


What could possibly go wrong?
29 replies: All unread, showing first 25:
 
User currently offlineSlamClick From United States of America, joined Nov 2003, 10062 posts, RR: 68
Reply 1, posted (8 years 2 months 3 weeks 5 days 15 hours ago) and read 3502 times:

I see this as two separate issues. The second one concerns maintenance procedures but, in my opinion, had nothing directly to do with the crash. That, you could simply assign to the PIC's decision to take off with snow or ice adhering the the surfaces. The rest is just details. He made a really bad judgement and I don't find the 'reasons why' to be so unusual that we can modify the system as a result of the insights gained in the investigation. We already knew about pressure to keep schedule and the inconveniences of getting 'downed' in a strange place. It ain't fun telling a planeload of passengers that they are going no further but a stick shaker on liftoff isn't my favorite thing either.

As Ops Manager there were a number of occasions when "the black phone" rang at my home in the middle of the night and I had to get up, take a few notes and start making phone calls - charter buses for passengers, hotels for crew, ground handling and fuel for airplanes, minor contract maintenance, de-icing, calls to the downline stations to tell them the plane wasn't coming and on and on. It is a mess but rule number one says you don't crash an airplane just because you don't want to spend the night in Lugnut North Dakota in February. As a crewmember who understood that my kneecaps were the front bumper I was especially adamant in not pushing a bad position.

Maintenance issues in the next post.



Happiness is not seeing another trite Ste. Maarten photo all week long.
User currently offlineBoeingFixer From Canada, joined Jul 2005, 534 posts, RR: 0
Reply 2, posted (8 years 2 months 3 weeks 5 days 14 hours ago) and read 3488 times:

Quoting CanadianNorth (Thread starter):
My question is, was this what I would think is dangerous and unnacceptable way of doing things a one time thing, or is this more common than most people would think? As a pilot or maintenance person, would you ever do things this way? We do it where I work, but casually mentioning minor problems to our mechanic regarding lawn mowers and golf carts isn't the same thing as doing it with commercial airliners.

That is a very dangerous way to operate in the aviation maintenance world and will, sooner or later, catch up to you. Some operations have a heavy top down push to get planes moving but in the end it's the maintenance person on the line and the aircrew that decide whether the aircraft is safe or not and not upper management. I've personally been in a situation where there is significant pressure to get an unserviceable plane going but if it isn't legal it won't go. I always tell our crews that if it's a snag enter it in the log book.

In our operation, we have 4 types of snags to deal with on turns.

1. Snag that can be deferred under MEL
2. Snag that can be deferred under OIL (Open Items List)(Non-airworthiness related items)
3. Snag that requires maintenance action and/or parts. Eg. cut tire, non-MEL airworthiness items
4. Snag that grounds the aircraft. Either due to the severity of the snag or lack of parts or specialized equipment.

Cheers,

John



Cheers, John YYC
User currently offlineWrenchBender From Canada, joined Feb 2004, 1779 posts, RR: 9
Reply 3, posted (8 years 2 months 3 weeks 5 days 14 hours ago) and read 3462 times:

CanadianNorth,
This particular accident is a much studied one. Particularly in a course called Human Performance In Maintenance, which is a militarized version of Transport Canada's Human Factors course.
The long chain of events leading upto this particular incident are really eye opening. Something you must remember is- hindsight is almost perfect, but if you take each decision in isolation(when each one was made) it is not unreasonable to make that same decision.
1, APU Fire detect system was inop.
2, Tech MEL'd the APU.
3, A/C was dispatched to a location without appropriate equipment.
4, The A/C was running 1 hour late, every one wanted to get on with it.
5, Decision not to de-ice was made, they could have de-iced bay shutting down 1 eng at a time retc.
6, 2 pilots onboard as pax decided against asking the flight crew if they were going to de-ice.
Other factors to consider
Recent merger of 2 companies and differing operating mentality was a significant cause factor.
Deregulation was another cited cause factor.
The subject of Aircrew not reporting snags to maint is an issue that may or may not have been a casue factor for this accident. What was reported had been dealt with ie the APU.
The rest is history

http://www.tc.gc.ca/civilaviation/sy...ety/newsletters/tp185/1-04/538.htm

WrenchBender



Silly Pilot, Tricks are for kids.......
User currently offlineSlamClick From United States of America, joined Nov 2003, 10062 posts, RR: 68
Reply 4, posted (8 years 2 months 3 weeks 5 days 13 hours ago) and read 3450 times:

By my standards most of that is merely details. It is my opinion that the passengers bet their lives on the judgement of the pilot(s) not to depart in an unsafe circumstance. The ticket price may be cheap but they deserve nothing less than excellent judgement.

This accident is not so very different from the Air Florida flight 90 that crashed into the Potomac during the Reagan adminstration. No matter what all the specific details, the pilots did not NEED to take off. You can NEED to land, for obvious reasons but you don't NEED to take off.

I ferried an airplane out of an airfield that was under seige by the Viet Cong. My alternative was to stay there and take my M-16 out to the perimeter and help the guys 'on the wire' defend or fly an airplane at night which had no cockpit lighting. There were a couple of other reasons why I did not want to fly - beginning of an epic hangover for one - but I had good incentive to take off. The airfield eventually WAS overrun by the VC but still I did not NEED to take off.

Had I crashed for any reason the accident would have been a preventable one, despite arguably being a combat loss.

Landings are mandatory, takeoffs are optional.



Happiness is not seeing another trite Ste. Maarten photo all week long.
User currently offlineStarlionblue From Greenland, joined Feb 2004, 17068 posts, RR: 66
Reply 5, posted (8 years 2 months 3 weeks 5 days 11 hours ago) and read 3410 times:

Quoting SlamClick (Reply 4):

eThis accident is not so very different from the Air Florida flight 90 that crashed into the Potomac during the Reagan adminstration. No matter what all the specific details, the pilots did not NEED to take off. You can NEED to land, for obvious reasons but you don't NEED to take off.

Air Florida 90 was my first association with this. NASA used to call the phenomenon "go fever". Basically people start disregarding the obviously problematic in their urge to get it goind.

Air Florida involved several bad judgement calls by the pilots, but ultimately the problem was "go fever".

Quoting SlamClick (Reply 1):
. It is a mess but rule number one says you don't crash an airplane just because you don't want to spend the night in Lugnut North Dakota in February. As a crewmember who understood that my kneecaps were the front bumper I was especially adamant in not pushing a bad position.

Honestly Captain Click. You should consider a career in writing and public speaking. You sure have a nice way with the written word.



"There are no stupid questions, but there are a lot of inquisitive idiots."
User currently offlineMissedApproach From Canada, joined Oct 2004, 713 posts, RR: 2
Reply 6, posted (8 years 2 months 3 weeks 5 days 5 hours ago) and read 3346 times:

Quoting WrenchBender (Reply 3):
This particular accident is a much studied one.

They also had extra passengers that had been booked, & the Captain had just gotten off the phone with dispatch- he wanted to offload the extra passengers, & the company wanted him to offload fuel- one more thing that added to his frustration & distracted him. He was also known for being very time or schedule conscious (if I'm saying that right).

Incidentally, what are the reasons for shutting down the engines for de-icing? Is the fluid that much of a problem for the engines, or is it mainly for the safety of the de-icing crew?



Can you hear me now?
User currently offlineHAWK21M From India, joined Jan 2001, 31684 posts, RR: 56
Reply 7, posted (8 years 2 months 3 weeks 5 days ago) and read 3298 times:

Quoting BoeingFixer (Reply 2):
I've personally been in a situation where there is significant pressure to get an unserviceable plane going but if it isn't legal it won't go

Thats the correct way,but I guess thats the Guys that Stick to Policy are the Unpopular Guys  Smile

Quoting Starlionblue (Reply 5):
Honestly Captain Click. You should consider a career in writing and public speaking. You sure have a nice way with the written word.

I'll say it again.Slamclick should write a book.it'll def sell well.

regds
MEL



Think of the brighter side!
User currently offlineLongHauler From Canada, joined Mar 2004, 5051 posts, RR: 43
Reply 8, posted (8 years 2 months 3 weeks 4 days 18 hours ago) and read 3253 times:

This accident was, as stated a very well studied accident.

It also was in my opinion a turning point in accident investigation. For the first time, even though "pilot error" was the cause, the investigators went further.

Yes, the Captain made an error in judgement. For the first time though, they did not just stop there. They wanted to reach some reasonable explanation for why he made those decisions. I wont bore you with conclusions, they are in the public domain and readily available.

In my opinion the major cause of this accident was not the decision to take off with contaminated wings, but to land in an airport that did not have proper support equipment for an aircraft without an operating APU.

More than once I have told dispatch, that even though an aircraft is legal, in my opinion, I wont take it on the mission they had in mind. Recently, I was to fly an A319 to BGI with no APU. There are a lot of reasons why I did not think it would be a first rate operation, although legal. I simply said to the Chief Dispatcher. "I have an F/O and 3 F/A's ready to jump on an aircraft to BGI, but if it doesn't have an APU, then we are not going. Period"

They did some switching, and we left on time .... with an APU.



Never gonna grow up, never gonna slow down .... Barefoot Blue Jean Night
User currently offlineWing From Turkey, joined Oct 2000, 1573 posts, RR: 24
Reply 9, posted (8 years 2 months 3 weeks 3 days 15 hours ago) and read 3125 times:

Quoting LongHauler (Reply 8):
More than once I have told dispatch, that even though an aircraft is legal, in my opinion, I wont take it on the mission they had in mind. Recently, I was to fly an A319 to BGI with no APU. There are a lot of reasons why I did not think it would be a first rate operation, although legal. I simply said to the Chief Dispatcher. "I have an F/O and 3 F/A's ready to jump on an aircraft to BGI, but if it doesn't have an APU, then we are not going. Period"

They did some switching, and we left on time .... with an APU.

Its ironic to read this.I was thinking this kind of things only happening in my airline.I can't decide weather to feel good that we're not alone or feel sorry for all pilots who spend more time trying to correct the bad judgements of the ground operations rather than to focus on flying.

I have seen same experiences recently.Infact more and more everyday I am thinking the ground people(technicians,dispatchers,operations staff) are walking with a BOMB in their hands and trying to hand it to you and run away.All of a sudden you may find a problem in your hands and all fingers point you when they need somebody to hang.Thats why my old man always told me "Captain is the lonely man"

If you don't insist on what you want they don't bother think about the problems you will face when you don't have APU.Thats why they don't even bother to switch the airplanes.



Widen your world
User currently offlineTristarSteve From Sweden, joined Nov 2005, 4022 posts, RR: 33
Reply 10, posted (8 years 2 months 3 weeks 3 days 14 hours ago) and read 3112 times:

Quoting MissedApproach (Reply 6):
Incidentally, what are the reasons for shutting down the engines for de-icing? Is the fluid that much of a problem for the engines, or is it mainly for the safety of the de-icing crew?

When deicing you always turn off the bleeds on running engines/APU.
While we normally deice with engines off, we have no rule against it. If there is an APU problem, then we can start the engines at the gate and then deice. Some airports have "drive through" deicing where the engines are always running. As long as the deicing crew are aware of it, and you are not doing something unusual like underwing deicing, then I would not consider running engines a problem.
But every airport is different, and perhaps it was a rule here.


User currently offlineHAWK21M From India, joined Jan 2001, 31684 posts, RR: 56
Reply 11, posted (8 years 2 months 3 weeks 2 days 18 hours ago) and read 3023 times:

Quoting TristarSteve (Reply 10):
Some airports have "drive through" deicing where the engines are always running.

Any Damage to the Engine Caused by the DeIcing Fluid.
regds
MEL



Think of the brighter side!
User currently offlineBoeingFixer From Canada, joined Jul 2005, 534 posts, RR: 0
Reply 12, posted (8 years 2 months 3 weeks 2 days 15 hours ago) and read 2997 times:

Quoting HAWK21M (Reply 11):
Any Damage to the Engine Caused by the DeIcing Fluid.

Apu's are more likely to be damaged over engines due to De/Anti-icing fluid ingestion.

Apu's have a nasty habit of bursting turbine disks due to the sudden overspeed of ingesting the fluid and having it enter the combuster as steam at high pressure and causing an overspeed that the FCU can't control. Engine ingestion is more likely to cause a flame-out(at idle power) due to the reaction of the glycol being heated in the compressor creating a lack of proper oxygen flow to maintain combustion.

There are taxi through de-ice stations at certain airports but proper training and careful de-icing is required.

Cheers,

John



Cheers, John YYC
User currently offlineCharlienorth From United States of America, joined Jun 2006, 1131 posts, RR: 5
Reply 13, posted (8 years 2 months 3 weeks 2 days 13 hours ago) and read 2968 times:

There is also a checklist for configuring an aircraft for de-icing,stab settings,bleeds closed and others depending on aircraft type.

User currently offlineHAWK21M From India, joined Jan 2001, 31684 posts, RR: 56
Reply 14, posted (8 years 2 months 3 weeks 2 days ago) and read 2873 times:

Quoting BoeingFixer (Reply 12):
Engine ingestion is more likely to cause a flame-out(at idle power) due to the reaction of the glycol being heated in the compressor creating a lack of proper oxygen flow to maintain combustion.

Wouldn't Ignition Setting be on "continous" for such purposes.
regds
MEL



Think of the brighter side!
User currently offlineAvt007 From Canada, joined Jul 2000, 2132 posts, RR: 5
Reply 15, posted (8 years 2 months 3 weeks 1 day 2 hours ago) and read 2753 times:

I too have studied this accident, indeed I worked on F28s for years. However, the title of this thread does not apply to this accident. The APU had been deffered in accordance with regulations, and although it is more complex than that, it was not a case of "cheating on maintenance".

User currently offlineCanadianNorth From Canada, joined Aug 2002, 3390 posts, RR: 9
Reply 16, posted (8 years 2 months 3 weeks 20 hours ago) and read 2725 times:

Quoting Avt007 (Reply 15):
it was not a case of "cheating on maintenance".



Quoting CanadianNorth (Thread starter):
"Air Ontario instructed its pilots to note snags on the aircraft on scraps of paper, and these scraps were passed from air crew to air crew; and they were not to enter these snags in the log book because if they did then the aircraft, by law, would have to be grounded..."

Thats where I got the idea for the title from.


Thanks for the replys sofar everyone


CanadianNorth



What could possibly go wrong?
User currently offlineHAWK21M From India, joined Jan 2001, 31684 posts, RR: 56
Reply 17, posted (8 years 2 months 3 weeks 19 hours ago) and read 2718 times:

Quoting CanadianNorth (Thread starter):
The part that makes it scary was "Air Ontario instructed its pilots to note snags on the aircraft on scraps of paper, and these scraps were passed from air crew to air crew; and they were not to enter these snags in the log book because if they did then the aircraft, by law, would have to be grounded..."

It should be.Thats how things should be run.

regds
MEL



Think of the brighter side!
User currently offlineCharlienorth From United States of America, joined Jun 2006, 1131 posts, RR: 5
Reply 18, posted (8 years 2 months 3 weeks 16 hours ago) and read 2691 times:

AAH thw famous "napkin write-up",how many time have any of us not had one handed to us,but stuck in a galley latch and the outbound crew catches it,they put you on the spot when they hand you one,I've had an employer accuse me of a "job action" for working discrepancies that were not on the inbound logbook.Anyone here ever deal with a cabin log?I imagine that can be a winner.

User currently offlineHAWK21M From India, joined Jan 2001, 31684 posts, RR: 56
Reply 19, posted (8 years 2 months 2 weeks 6 days 23 hours ago) and read 2632 times:

Quoting Charlienorth (Reply 18):
Anyone here ever deal with a cabin log?I imagine that can be a winner.

On Pax Aircraft out here in addition to the PDR in the FSR book,There is a seperate Log book mantained by the Cabin crew,covering mainly Pax Cabin related Discrepencies.

Thats why I say Freighters are Peacefull & Fun  bigthumbsup 

regds
MEL



Think of the brighter side!
User currently offlineUsair320 From United States of America, joined Nov 2003, 991 posts, RR: 2
Reply 20, posted (8 years 2 months 2 weeks 5 days 1 hour ago) and read 2554 times:

I am strongly convinsed that the now defunct Valujet cheated on maitnence. Several FAA code Violations. Look at the DC-9 that burnt up in ATL(I Think ATL correct me if im wrong) and then flight 592. Lets just say im glad VJ is gone and many precious lives are spared.

User currently offlineLMP737 From , joined Dec 1969, posts, RR:
Reply 21, posted (8 years 2 months 2 weeks 4 days 18 hours ago) and read 2544 times:

Quoting Usair320 (Reply 20):
I am strongly convinsed that the now defunct Valujet cheated on maitnence

Valuejet is not defunct, it became Airtran.


User currently offlineStarlionblue From Greenland, joined Feb 2004, 17068 posts, RR: 66
Reply 22, posted (8 years 2 months 2 weeks 4 days 18 hours ago) and read 2542 times:

Quoting Usair320 (Reply 20):
Lets just say im glad VJ is gone and many precious lives are spared.

This statement assumes the problems would have continued. As LMP737 states, Valujet became AirTran and is quite a different organization.



"There are no stupid questions, but there are a lot of inquisitive idiots."
User currently offlineHAWK21M From India, joined Jan 2001, 31684 posts, RR: 56
Reply 23, posted (8 years 2 months 2 weeks 4 days 16 hours ago) and read 2529 times:

Quoting Starlionblue (Reply 22):
Valujet became AirTran and is quite a different organization.

Did the MGMT change.
regds
MEL



Think of the brighter side!
User currently offlineStarlionblue From Greenland, joined Feb 2004, 17068 posts, RR: 66
Reply 24, posted (8 years 2 months 2 weeks 4 days 16 hours ago) and read 2526 times:

Quoting HAWK21M (Reply 23):
Quoting Starlionblue (Reply 22):
Valujet became AirTran and is quite a different organization.

Did the MGMT change.
regds
MEL

Not really sure but I would imagine so. Even before the crash, Valujet was 10 times as accident prone as the US average, with plenty of emergency landings. The FAA eventually laid down the law after the crash and oversight was beefed up significantly.



"There are no stupid questions, but there are a lot of inquisitive idiots."
25 Usair320 : I am aware Valujet became FL. But as said above it is quite a different organazation. I consider FL to be almost completely different. Just have a lo
26 Starlionblue : Average fleet age has little impact on safety. NWA is quite safe despite their DC-9s being built in the Jurassic Era.
27 Usair320 : Good point. Also look at some of (not all of) AA's S-80's almost 20 good years in service and perfectly reliable.
28 Post contains images Starlionblue : 20 years is nothing! Look at the USAF B-52s. They were built 50 years ago. As were the Russian Tu-95s. In fact, some of the Tu-95s have been piloted
29 Usair320 : True. I have actully had the privlige of taking a lesson in a 60 yr old T-6 trainer.
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