B1900D Emergency Landing - Maintenance Standards & Practices - Aerossurance

15/12/2019 B1900D Emergency Landing: Maintenance Standards & Practices - Aerossurance
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B1900D Emergency Landing: Maintenance Standards &

Practices
Posted by Aerossurance on Jun 24, 2018 in Accidents & Incidents, Fixed Wing, Human
Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Regulation,
Safety Culture, Safety Management | 0 comments
Home Accidents & Incidents B1900D Emergency Landing: Maintenance Standards & Practices
B1900D Emergency Landing: Maintenance Standards & Practices

On 12 July 2016 an Air Georgian Beechcraft 1900D, C-GORF, made an emergency landing
after its Nose Landing Gear (NLG) could not be lowered at the end of an Air Canada Express
Search for:
ight in Alberta from Lethbridge to Calgary. The resulting Transport Safety Board of Canada
(TSB) safety investigation report (released on 29 May 2018) posses many questions on the Search
management and oversight of aircraft maintenance and maintenance standards & practices.
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Resting Position of Air Georgian Beech 1900D C-GORF on Runway 35R (Source: Calgary Airport Authority via TSB) Fall From Stretcher During
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Air Georgian was formed in 1984 and operates a eet of B1900Ds and Bombardier CRJ-100
Austrian Police EC135P2+
and -200s, that carry over 500,000 passengers per annum. It is one of four carriers operating Impacted Glassy Lake
for Air Canada under the Air Canada Express brand.
History of the Flight Recent Comments
The TSB explain that:
Archives
aerossurance.com/safety-management/b1900d-maintenance-standards-practices/ 1/21
December 2019
When the landing gear was selected down for the approach into Calgary, the ight crew
November 2019
observed that there was no gear-safe indication for the NLG. The ight circled east of
October 2019
Calgary for about an hour while the pilots attempted to rectify the problem. An emergency
September 2019
was declared. The aircraft landed at 0720 Mountain Daylight Time, during daylight hours,
August 2019
with the nose gear in a partially extended position.
July 2019
The nose gear was held o the runway with progressive aft control‑column input until the
June 2019
nose settled on the runway about 28 seconds after main gear contact…at approximately
May 2019
52 knots indicated airspeed.
April 2019
March 2019
The aircraft came to a stop 6050ft from the threshold.
February 2019
January 2019
No re occurred, and there were no injuries. Emergency vehicles reached the aircraft in 30 December 2018
seconds, and all passengers and crew deplaned within 1 minute. Damage to the aircraft November 2018
was limited to the nose landing gear components, the nose gear door and gear light, as October 2018
well as 2 propeller tips on each side of the aircraft that contacted the runway. September 2018
August 2018
B1900D Landing Gear Description and Lab Findings July 2018

The B1900D landing gear assemblies are retracted and lowered hydraulically. The TSB
June 2018
explain that:
May 2018
April 2018
During extension and retraction, the nose gear actuator exerts pressure through an March 2018
aluminum yoke tting attached to the end of the actuator piston (see gure below). This February 2018
yoke is attached to the middle of the upper and lower drag braces, and causes the drag January 2018
braces, when folding or unfolding, to extend or retract the nose gear. The yoke (item 8) is December 2017
attached and pivots through the braces by means of a pivot/stop bolt, part number 114- November 2017
820107-1 (item 34). October 2017
September 2017
August 2017
July 2017
June 2017
May 2017
April 2017
March 2017
February 2017
January 2017
December 2016
November 2016
October 2016
September 2016
August 2016
July 2016
June 2016
May 2016
April 2016
March 2016
February 2016
January 2016
December 2015
November 2015
October 2015
September 2015
August 2015
July 2015
B1900D NLG (Source: Beechcraft Corporation via TSB: AMM, 32-20-01, Figure 201)
June 2015
May 2015
The failure of the retract-and-extend mechanism of the nose landing gear was initiated by a
April 2015
yoke lubrication problem. The bolt with part number 114-820107-1 (item 34)…was not
March 2015
lubricated as required.
February 2015
The yoke should turn freely around the yoke’s pivot/stop bolt; however, the occurrence
January 2015
yoke’s pivot/stop bolt was seized in the yoke due to deteriorated grease and corrosion for 2
December 2014
reasons:
November 2014
First, the deteriorated grease did not provide lubrication.
October 2014
Second, insu cient lubrication allowed the penetration of moisture between the bolt and
September 2014
the bore surface, causing corrosion on both surfaces.
August 2014
The bolt seizure resulted in abnormal loading on the yoke’s pivot/stop bolt and the
July 2014
actuator clevis during retraction and extension of the nose landing gear. This led to fatigue
June 2014
cracking and failure of the yoke’s pivot/stop bolt ends.
May 2014
From 31 August to the end of September 2016, the operator examined the condition of
nose landing gears in its eet and found 5 more Beechcraft 1900D aircraft with non-
Categories
airworthy nose landing gear yoke pivot/stop bolts, as well as several other nose landing
gear bolts.
Accidents & Incidents
Air Georgian Maintenance Schedule, Process and Practices Air Tra c Management /

Airspace
The TSB say that Air Georgian maintenance personnel were required to lubricate and inspect
Air elds / Heliports /
the failed bolt as follows: Helidecks
Lubrication schedule: Aircraft Maintenance Manual (AMM) Chapter 12 documented the Business Aviation
lubrication schedule to be performed at every 400-hour interval. This required personnel

Crises / Emergency
to “grease ttings” using speci c greases. Response / SAR
Bolt inspection: AMM Chapter 32 documented the bolt inspection to be performed at
Design & Certi cation
every fth 200-hour interval. Para C(4) required the technician to “[l]ubricate the drag brace
grease ttings with grease” and then, in paragraphs C(11) to C(13), to disconnect the FDM / Data Recorders
relevant parts of the occurrence bolt to test for “free rotation.” If the yoke did not rotate
Fixed Wing
freely, “determine the cause and replace parts as necessary.”
Detailed inspection: AMM Chapter 05 documented a detailed inspection to be performed Helicopters
at every fth 200-hour interval. Subpara C(9)(b) required the technician to “inspect for Human Factors /
proper lubrication of bolts” in accordance with the lubrication schedule. Subpara C(9)(c) Performance
required the technician to “inspect bolts for freedom of movement” in accordance with the
HUMS / VHM / UMS / IVHM
bolt inspection.
Logistics
The bolt was also required to be lubricated after each aircraft external wash: Maintenance / Continuing
Airworthiness / CAMOs
Airplane washing: AMM Chapter 12, Section 3F, stated that “the landing gear [...] should
be washed with low pressure and mild detergent as soon as is practical following operation Military / Defence
on salty or muddy runways.” General instructions in Chapter 12, Section 3, included “use Mining / Resource Sector
special care to avoid washing away grease from any lubricated area” and “lubricate after
News
cleaning as necessary.” This requirement was restated below the lubrication instruction
table in Chapter 12 : “After washing airplane, lubricate all lubrication points.” O shore
Oil & Gas / IOGP / Energy

The TSB don’t speci cally describe how Air Georgian translated this into their own
Regulation
Maintenance Programme. They do say that the lubrication process at Air Georgian was the
Resilience
same for each of these tasks, and senior maintenance personnel described this as follows:
Safety Culture
1. Wipe away the old grease.
Safety Management
2. Attach the tube of the grease gun to the bolt nipple and manually squeeze the grease
gun handle until su cient grease is expressed. Special Mission Aircraft
3. Monitor for old grease seeping from all applicable seams of the bolt, indicating that the
Survivability / Ditching
bolt is lubricated and serviceable.
Unmanned (Drone / RPAS /
4. Monitor for new grease seeping from all applicable bolt seams, indicating that new
UAS / UAV)
grease is successfully expressed and has penetrated all relevant areas.
5. Wipe away excess grease as necessary.
Meta
The TSB also say:
Log in
Some senior maintenance personnel reported that bolt lubrication de ciencies could be
Entries RSS
monitored during the lubrication task by performing step 3, above. If no old grease was
seen being expelled, or if it was not possible for the new grease to enter the lubrication Comments RSS
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point in step 2, this could indicate that the bolt or part was dry and/or blocked with old,
hardened grease, and therefore unserviceable. The defect would then be recorded and
actioned on an additional work card.
It is therefore apparent that some personnel did have an understanding of good greasing
practices.
As part of the periodic bolt inspection and detailed inspection, technicians and [licensed
Aircraft Maintenance Engineers] AMEs were required to perform the lubrication. Technicians
and AMEs were then required to test the pivot/stop bolt (and others) for free rotation to
determine whether the bolt was su ciently lubricated and serviceable. This required
technicians and AMEs to dismantle the bolt and use their ngers to freely rotate it. If any
inspection discrepancies were found, technicians and AMEs were required to “determine the
cause and replace parts as necessary.” If any new parts were required, an additional work
card was to be completed.
The TSB say:
If the maintenance manual is followed correctly, the occurrence bolt is required to be
greased every 400 hours, at every fth 200-hour interval, and after airplane washing, as
necessary.
Documentation indicated that the occurrence aircraft received its most recent 400‑hour
lubrication at the Calgary sub-base in May 2016 and its most recent detailed inspection at
the Toronto main base in March 2016. There was no record of any lubrication conducted
after washing.
At Air Georgian’s Toronto main base, there were pre-loaded, labelled grease guns that did
not necessarily contain the grease type matching the label on the gun. This occurred so
frequently that there was an informal practice whereby technicians would remove the
cartridge before each use to make sure the gun contained the correct grease. This
equipment issue could have contributed to errors…by increasing the probability of selecting
the wrong grease. The technician or AME may not have been able to detect the error, given
that many types of grease are the same colour.
Some maintenance personnel commented on the di culty and inconvenience of the grease
guns: certain grease guns required much more force than others to express the required
grease. This equipment issue could have contributed to potential errors….by masking the
e ect of a blocked grease nipple and leading the technician to attribute the additional
pressure to the typical usability issues of the grease gun.
Workload
At the time of the occurrence, Air Georgian had recently procured more CRJ-200s,
increasing the number of aircraft within the eet. It was not uncommon for a shift to
experience high workload, which could include a combination of scheduled and
unscheduled tasks on the Beechcraft 1900D and the CRJ‑200.
…unscheduled aircraft serviceability issues often took priority, and scheduled tasks were
interrupted.
Examples taken from the Air Georgian computer-tracking program indicated multiple task-
extended entries, primarily due to workload and personnel shortage.
There was no standardized practice or procedure for transitioning between a deferred task
and a new task. Technicians had a varied approach to task progress tracking. Some would
initial each step, some would initial each section, and some checked o each page as a
whole.
If a scheduled task was interrupted and temporarily suspended, for example when a
technician was halfway through lubricating the nose-wheel gear, it was not always possible
to determine what had been done when the technician returned or a new technician took
over the task
Supervision
It was common for a shift at the Toronto main base to be made up of a majority of junior
technicians, with only 1 or 2 senior AMEs [with] [Aircraft Certi cation Authority] ACAs [i.e.
certifying sta ]. One or both of these senior AMEs with ACA status could be sick or assigned
to tasks elsewhere, for example at the airport departure gates.
It was typical practice not to supervise tasks that were considered basic, such as lubrication,
or to check the lubrication of easy-to-reach or easy-to-lubricate bolts, such as the
occurrence bolt, prior to signing the maintenance release. The focus was on the more
complex tasks or bolts that were harder to lubricate or reach. Depending on workload, it
was common for ACAs to sign o on tasks for which they had not been present and had
not inspected, or to sign o on tasks many hours after multiple tasks had been completed.
There were no standardized supervision practices.
Maintenance Personnel Training & Competence

The TSB investigation discovered a lack of standardised training and “several gaps in
knowledge and training”:
…investigation interviews and observations indicated that there was a diverse standard of
knowledge and performance concerning the lubrication task, and some technicians were
not aware of a requirement to lubricate the aircraft following cleaning.
Aviation maintenance technician students in Canada usually attend a [Transport Canada]
TC-approved training organization (ATO) to complete basic training prior to starting work
at an [Approved Maintenance Organisation] AMO.
During maintenance education, [Canadian Aviation Regulations] CARs…require students to
be taught about “human factors in maintenance” and the “classi cations, functions,
principles and properties of lubricants,” and to perform “servicing of lubrication, fuel, oil
and hydraulic systems.”
The CARs do not specify the level or details for each subject taught; it is up to each
individual ATO to determine how and what to teach. The investigation queried 9 ATOs to
determine how lubrication tasks were taught. No standard methodology was found and
the information taught varied among the ATOs. The investigation could not nd any
description of a training standard for a lubrication technique taught in typical student
training material….or other records, other than the instruction to “grease aircraft.”
Therefore, not all technical competencies are standardized, and, as a result, it is not
possible to determine a student’s technical competencies related to the lubrication and
inspection tasks unless these competencies were tested and validated when the student was
hired at an AMO.
Technicians then received further training on joining an AMO:
As with initial education, the CARs do not specify the level or details for each subject taught;
it is up to each AMO how and what to teach in order to train employees on applicable
tasks.
[The] Air Georgian maintenance documentation did not contain any grease ttings
procedure, training standards, examination, or validation process.
Air Georgian’s Maintenance Policy Manual stated the following:
On the Job training shall be accomplished under the direction of a quali ed individual,
normally in the everyday working environment, utilizing demonstration and practice
techniques.
There was no requirement or provision for [these quali ed] individuals…to receive
instructor‑based training related to the competency and validity of their “demonstration
and practice techniques,” nor was this required by regulation.
The knowledge, rules, and skills required for teaching, demonstrating, and assessing the
lubrication and inspection tasks were not detailed in any Air Georgian documentation or
taught as part of any Air Georgian instructor-based training syllabus. There were also [for
example] no training or supervision-related competencies listed on the ACA Occupational
Standard Assessment form or the ACA Nomination form.
Air Georgian B1900D (Credit: BriYYZ)
More generally, in Canada there is no requirement for a type rating on aircraft as large as the
B1900D. The TSB found that at Air Georgian…
…in practice, for the Beechcraft 1900D eet, an AME was required to complete on-the-job
ACA training and a Beechcraft 1900D technical exam, which contained 15 randomly
generated questions on the Beechcraft 1900D. When the applicant was considered ready
for ACA status, an ACA Nomination form was to be completed and sent to the corporate
training department. This form included a checklist of training, such as “initial training,” “6
months experience on type,” and “company training requirements current.”
Such a tick box approach might be acceptable if there were:
1. Competent assessors
2. Clear assessment standards
3. Good records of the basis of the assessment.
As discussed above, on the rst point, the ‘quali ed individuals’ who oversaw OJT and
assessment were not speci cally developed for that role. On the second point:
There were no details in either the Maintenance Policy Manual or Maintenance Procedures
Manual on what constituted an ACA’s “combination of training and experience appropriate
to that aircraft” or “required competencies,” or on what was included in ACA on-the-job
training.
Finally, when it comes to the third point:
Maintenance training was managed by the ight operations training department, which
lacked detailed maintenance training programs and records. There were few detailed
records…other than for the in-house, computer-based training. No records, except for
summary sheets, were provided to the investigation to show the quali cations of
maintenance personnel. The training summary sheets for the range of personnel examined
in this investigation did not re ect accurate training, certi cations, or signing authorities.
Additionally, human factors (HF) training was delivered online.
Each online course was followed by an exam that required a passing grade of 100% within
3 attempts.
The TSB say that if the trainee failed, senior sta would “coach and counsel” them until they
achieved 100% in the exam, which of course is not the same as being able to successfully
apply the techniques in the workplace. They note that:
There was no opportunity for maintenance personnel to participate in group discussion on
recent maintenance errors.
This is an important learning technique if properly facilitated (and not just faux-interactivity to
break up a one-way lecture). Also:
It was not possible to determine the degree of standardization of online learning
outcomes…
This is because with only the immediate success rate in the on-line exam to go on, there
would have been no real feedback on actual understanding or application of the key
principles. Similar problems occur when classroom HF training:
1. is delivered by third parties with minimal oversight and/or minimal knowledge of the
local environment, and /or is
2. a box-ticking exercise to present content with no veri cation of individual learning
outcomes in the workplace, and / or
3. merely highlights where the organisation itself is poor at managing HF, without any
connection to a means to reliably facilitate change
We saw an advert recently that asked: “Is your Human Factors programme just a ‘tick-box’ exercise
to comply with the regulations?” When we read on we realised this dubious marketing justly
deserves scorn for claiming a promoted maintenance HF course would “ensure compliance with
EASA Part 145.A.30.(e) “. What is more ‘tick-box’ than booking a course that allegedly “ensures
compliance” with a rule that is actually written around competence?! The Acceptable Means
of Compliance (AMC) for this EASA rule on maintenance personnel requirements explicitly
de nes competence as:
…a measurable skill or standard of performance, knowledge and understanding, taking
into consideration attitude and behaviour” (AMC1 145.A.30(e) – emphasis added).
This sort of advert, typical of training factories who are desperate to ll their classrooms to
o set their high overheads, is part of the problem. It reinforces an inappropriate cultural
norm of associating mere course attendance with actual competence. It can be inadvertently
encouraged too by inept regulators who take the lazy route of simply counting course
certi cates without examining course content, competence assessment and the outcome in
the workplace.
Enlightened and progressive organisations take a more sophisticated approach to learning
and development: Coaching and the 70:20:10 Learning Model – Beyond Training
The US Navy has recently raised concerns about the level of competence of their
maintenance personnel after a series of maintenance related incidents.
Resulting Maintenance Practices and Analysis of Potential Task Errors

The end result was variability in maintenance standards and practices, identi ed by TSB
through interviews and observations:
For example…only some [personnel] used a ashlight, only some checked for the expression
of old grease as an indicator of a dry bolt, and only some correctly checked for the
expression of new grease.
The investigation observed a technician performing the lubrication task when old grease
did not expel before the new grease, indicating that the bolt was dry. The technician did not
consider this a reason to report it or to perform a more detailed inspection.
There were also discrepancies in what was understood if it was di cult to push new grease
into the bolt and di erent criteria for what constituted free rotation during an inspection
task.
Some technicians assumed that the aircraft was lubricated following airplane external
cleaning, although they were not aware of who performed this task. Some did not know
that this was a requirement.
The TSB conclude that even what might be perceived as simple tasks (such as greasing) are
vulnerable to knowledge-, rule- and skill-based errors.
Knowledge-based performance is largely conscious, occurring as technicians learn new
situations and outcomes. As they progress, rules are learned, producing a more regulated
“if/then” performance.
Knowledge- and rule‑based mistakes may occur as a result of insu cient education,
training, or experience. Technicians and AMEs may not know how to deal with certain
scenarios, they may apply inappropriate rules to the task, or they may not apply
appropriate rules, such as following known procedures.
As technicians and AMEs gain experience and practice, they may execute more automatic
skilled performance, such as in the application or inspection of grease. During this time,
technicians and AMEs may make skill-based errors, such as missing de ciencies or omitting
tasks, especially if they are interrupted, tired, or biased by pre-conditions such as
expectation and assumptions.
They say that:
Performance errors can be mitigated by appropriate defences, such as suitable education,
training, procedures, equipment, operating environment, scheduling, supervision, and
safety management. These defences can reduce the likelihood of errors and detect errors
should they occur.
We discuss the concept further in our perennially popular article: James Reason’s 12
Principles of Error Management
The investigators conducted an analysis of the steps that should typically be performed to
ensure e ective lubrication and avoid errors. The following TSB table summarises the typical
errors that can occur and their pre-conditions (e ectively Performance In uencing Factors
[PIFs]) and consequences:
The only weakness of this table is that it reverts to inputs (‘Education’ and ‘Training’, but
excluding ‘Experience’) rather than outcomes (‘Competence’).
Quality Assurance (QA) and the Safety Management System (SMS)

The Air Georgian QA programme consisted of internal audits and Corrective Action Plans
(CAPs) to address items of “non-conformity”. The TSB make no comment on the e cacy of
internal audits, other than they did no detect the issues highlighted by TSB. As audits are
sampling exercises it can be unfair to claim that all weaknesses detectable with hindsight,
were detectable beforehand. In this case, it is however reasonable to expect some of the
weaknesses to have been identi able in advance during audits.
However, TSB have more to say on the CAP process:
The CAP is required to list immediate, short‑term (30-day), and long‑term (90‑day) actions…
To evaluate the e ectiveness of Air Georgian’s audit system, the investigation examined 14
of the company’s previous CAPs. The investigation determined that 12 of the CAPs did not
meet the timelines speci ed in Air Georgian’s Maintenance Policy Manual.
Additionally, as of 30 January 2017, more than 6 months since the date of this occurrence,
Air Georgian’s related internal SMS investigation report…remained at the short-term action
stage (30 days). Air Georgian stated that it was waiting for the results of the TSB
investigation before concluding the short‑term action of the internal SMS investigation.
Air Georgian’s campaign to inspect the rest of the eet for the bolt that failed during this
occurrence was not initiated until approximately 7 weeks following the incident.
The TSB describe the CAP process as ine ective.
The operation and maintenance of B1900Ds would nor require an SMS under Canadian
regulations. However Air Georgian does have a TC approved SMS for its air operator and
maintenance organisation because the company operates larger CRJs.
The company’s SMS Manual stated that “principal method for identifying both potential
(proactive) and actual (reactive) hazards is the use of aviation safety reports (ASRs)”. That
sort of statement is not uncommon, but can result in a simplistic and blinkered approach.
That’s because it tends to imply that the organisation only reacts to reports raised by workers
(reports are rarely entered by supervisors or managers in such reporting programmes) and
that the reports have to be submitted in a speci c way (in the case of Air Georgian this was
via a web interface) even when issues are being openly discussed or fully documented in
other formats. The TSB note that:
…some maintenance employees considered only aircraft system issues or health and safety issues to
be maintenance-related reportable events.
Any maintenance event that resulted in additional work was captured using additional work cards.
There was no process or practice to follow up on an additional work card with an ASR…if
appropriate.
Everyday maintenance hazards were occasionally reported to the crew chief, although they were not
captured by any ASR…. For example, TSB investigators observed an instance in which incorrect
grease cartridges had been loaded into grease guns, and this was [only] reported to the crew chief.
There was also not documented process or practice to follow-up hazards recorded in the
crew chief handover log with an ASR. When an SMS only relies on input from limited sources,
the SMS will be myopic.
There is also no mention in the TSB report of any other SMS activities prior to the occurrence
(such as risk assessment / risk management, management of change or safety promotion).
TSB comment too that:
Key safety roles at Air Georgian included the [Person Responsible for Maintenance] PRM,
quality assurance manager, SMS manager, and safety o cer.
In the 2 years before the occurrence, there were 2 di erent vice presidents of maintenance
holding the delegation of PRM. During transitions, there were 3 other instances in which
other individuals assumed the role of PRM on an interim basis. From time to time, for short
periods, the quality assurance manager held the PRM delegation and the SMS manager
assumed the responsibility of the safety o cer.
Air Canada / IOSA Oversight
Air Canada requires all of its Tier III operators to be compliant with the International Air
Transport Association (IATA) Operational Safety Audit (IOSA) and IOSA standards and
recommended practices.
To meet this requirement, Air Georgian undergoes an IOSA audit approximately every 2
years. The details of the audit are not made available to Air Canada. Through IATA, Air
Canada is informed as to whether Air Georgian meets the standard.
Air Georgian passed the last 2 IOSA audits. These 2 audit reports were requested from Air
Georgian but were not made available to the investigation.
This does beg the questions:
1. Are IOSA audits e ective in assessing actual maintenance standards and practices?
2. Do airlines receive adequate assurance on their code share partners and branded
regional operators from the IOSA scheme?
Transport Canada
The investigation examined the last 6 years of TC’s surveillance of Air Georgian. From 2011
until the occurrence, TC conducted several surveillance activities. The activities that were
relevant to the investigation included 2 program validation inspections (PVIs), 1 process
inspection (PI) and 1 SMS assessment.
A PVI is TC’s “primary surveillance tool” used to determine if “all the requirements of a
particular component of the SMS model or other parts of the regulations are documented,
implemented, in use and e ective.” Similar to a PVI, a PI is however focused on a single
process only. Despite being assessed by TC as being in in the second highest (‘orange’)
category of the TC Surveillance Interval Matrix, Air Georgian only required a PVI ever two
years and an SMS assessment every four.
TSB comment:
While an e ective SMS will help, companies vary in degrees of ability or commitment to
manage risk e ectively. Some are more e ective than others. Less‑frequent surveillance that
is solely focused on an operator’s safety management processes can be su cient for some
companies. However, the regulator must be able to vary the type, frequency, and focus of
its surveillance activities to provide e ective oversight to companies that are unwilling or
unable to meet regulatory requirements or e ectively manage risk. This could include
regulatory compliance inspections. Further, the regulator must be able to take appropriate
enforcement action in these cases.
Weaknesses in TC’s approach to oversight have been raised in other TSB investigations. We
have looked at three previously:
Culture + Non Compliance + Mechanical Failures = DC3 Accident TSB raise issues with the
TC approach to regulation of a DC3 operator, concerned that “unsafe conditions went
unidenti ed when the surveillance remained focused on systems”.
HEMS Black Hole Accident: “Organisational, Regulatory and Oversight De ciencies” The
operator had insu cient resources to e ectively manage safety say TSB (like this case with
the warning sign of a high management turnover and di culty producing acceptable CAPs
and meeting the implementation time frames). The regulator had concerns but as TSB say:
“when faced with an operator that is unable to address identi ed safety de ciencies, TC
has di culty adapting its approach to ensure that de ciencies are e ectively identi ed and
that they are addressed in a timely manner, or at all.”
Performance Based Regulation and Detecting the Pathogens Devastating rail accidents in
the US and Canada highlight the challenges for regulators introducing Safety Management
System rules and/or PBR.
Following a 2016 TSB recommendation, the TSB has…
…acknowledged TC’s e orts to nd the right balance between planned and reactive
oversight activities, as well as in the use of the various types of oversight tools available.
Although TC has implemented numerous improvements, it is too early to assess whether or
not TC’s actions will adequately address the safety de ciency associated with this
recommendation.
Safety Action Taken

TSB report that Air Georgian have taken the following safety actions (two continuing
airworthiness and two maintenance training):
In September 2016, a eet campaign was carried out to address the greasing and bolt issue. Many
bolts, including the pivot/stop bolts, were found to need replacement and servicing.
As a result of this eet campaign, Air Georgian advised Transport Canada that an additional
inspection item has been added into the company’s maintenance tracking system, reducing the bolt
inspection interval from 1200 hours to 600 hours.
In January 2017, Air Georgian hired a manager for maintenance training.
Human-factors training on distraction covers the need to track and document steps in the work ow.
In August 2017, Air Georgian launched a communication and awareness campaign called “Flag It,
Tag It and Snag It!”
The Canadian National Post newspaper reported that:
Air Georgian red back at the safety agency itself, complaining that the investigator pre-
judged the case, bullied some Georgian employees and was discriminatory toward workers
whose rst language was not English, according to a company memo obtained by the
National Post.
[John] Lee [ the TSB’s Western regional manager] said the safety board reviewed the
complaints thoroughly, but did not change any of its ndings as a result.
UPDATE 22 October 2018: the TSB report on yet another incident at Air Georgian, this time
involving B1900D, C-GZGA at Calgary International Airport, Alberta on 9 April 2018. This
su ered a nose wheel failure:
Air Georgian B1900D C-GZGA 9 April 2018 (Credit: Calgary Airport Authority via TSB)
At 81.5 hours prior to the occurrence, the nose bearing set was serviced at the Air Georgian
maintenance base at CYYC. The investigation learned that the MPM-AWR-017 form was
signed o during this service, but the procedure used did not follow the instructions
provided on the form. New grease was used to push out the old grease and no cleaning or
detailed inspection of the bearing was carried out. The old grease was then inspected for
contamination. The bearings were rotated to check for freedom of movement and then
installed.
The investigation learned that although the company procedure re ects the manufacturer’s
requirement, the aircraft maintenance engineer who performed the work on the occurrence
aircraft adapted one of the elements of the procedure.
Air Georgian has taken the following actions in response
The work card has been modi ed to provide clearer guidance and additional notes referencing the
bearing-cleaning methodology.
A general (all maintenance employees) Maintenance Technical Bulletin was published describing
cleaning, inspection, and lubrication best practices. The bulletin was to be posted for 6 months and
required that all maintenance employees sign o after having read it.
The aircraft maintenance engineer who performed the work was coached on the proper procedure to
follow.
Our Observations
TSB could have simply stopped their investigation after the lab analysis of the failed bolt,
concluded that the bolt was inadequately lubricated and gone no further. Sadly, many
investigations, even from large accident investigation agencies, rarely examine the
circumstances in which the maintenance was done.
Furthermore the UK Civil Aviation Authority (CAA) report CAP1367: Aircraft Maintenance
Incident Analysis, published in 2016 commented that the “industry’s commitment to error
investigation has waned”. This is perhaps unsurprising when one large commercial provider
of investigation training has been quoted recommending that only around 10-20% of reports
actually need investigation!
Even when company investigations are initiated, many would focus on who should have
greased the bolt last and gathered evidence to judge if they deserved some kind of
disciplinary action. Ironically such an approach is often done in the name of a ‘ Just Culture‘
using ‘decision aids’ that are designed to determine culpability (from the Latin concept of fault
or guilt, culpa). Sometimes this is semantically renamed ‘accountability’, but still unhelpfully
focused exclusively on judging on the front line individual(s) and the level of reproach they
should receive. One such tool is ominously marketed as “bridging the gap between the
investigation and an organisation’s disciplinary processes”. We have previously discussed the
corrosive misapplication of these as bureaucratic tools by managers to routinely ‘judge’…
…individuals not the system, with the potential to inadvertently reduce trust rather than
enhance it. The circumstances that in uenced an individual’s performance are seen as
factors that mitigate culpability rather than systemic opportunities to improve.
Inappropriate use of these mechanisms help normalise failure at the expense of collective
improvement.
So we should be grateful that TSB did dig further in this case and look at the circumstances in
which the maintenance was being performed and the systemic opportunities. Its noteworthy
that a signi cant proportion of the extra insight appears to have come from a short visit to Air
Georgian’s main base, in Toronto, from 30 January to 1 February 2017 for interviews and
observation of maintenance. This leads to one of the opportunities discussed below.
Opportunities for Safety & Performance Improvement

If the TSB can gain insight by observing maintenance standards and practices after an
accident, can organisations do something similar, without waiting for an accident, to identify
improvement opportunities? We think the answer is yes.
Aerossurance worked with the Flight Safety Foundation (FSF) to create a Maintenance
Observation Program (MOP) requirement for their contractible BARSOHO o shore helicopter
Safety Performance Requirements to help learning about routine maintenance and then
to initiate safety improvements:
Applying the MOP principles in this case could have (for example) helped:
1. identify the variability in maintenance standards and practices that the TSB highlight.
2. identify that senior engineers did have a clear understanding of what good looked like
for greasing but that this was not something currently de ned in procedures or covered in
formal training.
3. stimulate improvements in the grease guns arrangements by identifying the informal
work-around in place.
4. compare and contrast practices and resources at di erent lines stations.
5. capture issues being discussed but not recorded as ASRs.
The very di erent process, that of competence assessment, both before
authorising maintenance personnel and as a routine activity, is also vitally important.
Whereas as MOP is systemic focused, competence assessment is person-centric and provides
assurance that personnel have been equipped with the skills, knowledge and understanding
necessary for their work and that they are able to demonstrate they can successfully apply
these. Competence assessment however needs clear assessment standards for both
technical and non-technical skills and needs to conducted systematically in a standardised
way.
An excellent initiative Human Hazard Analysis (HHA) is described in Designing out human
error
HeliO shore, the global safety-focused organisation for the o shore helicopter industry, is
exploring a fresh approach to reducing safety risk from aircraft maintenance. Recent trials
with Airbus Helicopters and HeliOne show that this new direction has promise. The
approach is based on an analysis of the aircraft design to identify where ‘error proo ng’
features or other mitigations are most needed to support the maintenance engineer during
critical maintenance tasks.
Other manufacturers and MROs are expanding the use of HHA during 2018.
Aerossurance and its partners can provide proven, practical expertise to successfully
implement a MOP, introduce an e ective competence assessment process or analyse the
hazards of maintenance tasks. We can also help you ensure your learning and development
programme is e ective and that audits are rigorous & improvement activities robust and
timely. We can also help you develop the leadership and supervisors skills within your
organisation.
Other Safety Resources

Aerossurance has previously written on these associated topics:
Airworthiness Matters: Next Generation Maintenance Human Factors Over the last 10-15
years, much attention has been focused on maintenance human factors training and
reporting & investigating errors. While we could concentrate on simply doing more of these
and certainly can nd ways to do these things better, perhaps the next generation
approach needs to include a much wider range of activities.
Aircraft Maintenance: Going for Gold? Should we start treating maintenance personnel
more like athletes who need to achieve peak performance every day?
The Power of Safety Leadership
Leadership and Trust
Safety Performance Listening and Learning – AEROSPACE March 2017
How To Develop Your Organisation’s Safety Culture
James Reason’s 12 Principles of Error Management
Back to the Future: Error Management

B747 Landing Gear Failure Due to Omission of Rig Pin During Maintenance
When Down Is Up: 747 Actuator Installation Incident
Lost in Translation: Misrigged Main Landing Gear
Maintenance Human Factors in Finnish F406 Landing Gear Collapse Safety investigators
discuss the associated maintenance human factors and inadequacies in the type’s
maintenance instructions.
Hoist Assembly Errors: SAR Personnel Dropped Into Sea Taiwanese investigators
determined that the hoist hook had been inappropriately assembled during maintenance 2
days earlier, raising questions on the technical knowledge of hoist maintenance.
UPDATE 8 July 2018: Distracted B1900C Wheels Up Landing in the Bahamas
UPDATE 22 July 2018: Fire After O-Ring Nipped on Installation
UPDATE 25 August 2018: Crossed Cables: Colgan Air B1900D N240CJ Maintenance
Error On 26 August 2003 a B1900D crashed on take o after errors during ying control
maintenance. We look at the maintenance human factor safety lessons from this and
another B1900 accident that year.
UPDATE 3 November 2018: A Lufthansa MD-11F Nose Wheel Detached after Maintenance
Error
UPDATE 13 November 2018: Inadequate Maintenance, An Engine Failure and Mishandling:
Crash of a USAF WC-130H: investigators discuss a strong cultural overtone in this accident
that killed 9.
UPDATE 18 December 2018: USAF Engine Shop in “Disarray” with a “Method of the
Madness”: F-16CM Engine Fire
UPDATE 27 December 2018: Inadequate Maintenance at a USAF Depot Featured in Fatal
USMC KC-130T Accident
UPDATE 9 February 2019: Meeting Your Waterloo: Competence Assessment and
Remembering the Lessons of Past Accidents: No one was injured in this low speed
derailment in London after signal maintenance errors but investigators expressed concern
that the lessons about maintenance errors from the fatal triple collision at Clapham in
1988 may have been forgotten.
UPDATE 14 February 2019: AS350B2 Accident After Vibration from Unrecorded
Maintenance
UPDATE 23 March 2019: Maintenance Misdiagnosis Precursor to Tail Rotor Control Failure
UPDATE 30 March 2019: Contaminated Oxygen on ‘Air Force One’ Poor standards at a
Boeing maintenance facility resulted in contamination of two oxygen systems on a USAF
Presidential VC-25 (B747).
UPDATE 1 April 2019: Tree Top Autorotation for B206L1 After Loose Fuel Line B-Nut Leaks
UPDATE 19 April 2019: FAA Rules Applied: So Misrigged Flying Controls Undetected in an
accident to a Cessna 172 in Bermuda.
UPDATE 24 May 2019: Loose Engine B-Nut Triggers Fatal Forced Landing
UPDATE 6 October 2019: Glider Controls Fail After Non Compliant Maintenance
Embodying an AD
UPDATE 12 October 2019: ATR72 VH-FVR Missed Damage: Maintenance Lessons Unclear
communications, shift handover & roles and responsibilities, complacency about fatigue
and failure to use access equipment all feature in this serious incident.
UPDATE 30 October 2019: ‘Crazy’ KC-10 Boom Loss: Informal Maintenance Shift
Handovers and Skipped Tasks
UPDATE 6 December 2019: Dash 8 Q400 Return to Base After Pitot System Contaminated
By Unapproved Test Kit Lubricant
UPDATE 7 December 2019: Luftwa e VVIP Global 5000 Written O After Flying Control
Assembly Error
UPDATE 31 May 2019: The Portuguese accident investigation agency, GPIAAF, issued a safety
investigation update on a serious in- ight loss of control incident involving Air
Astana Embraer ERJ-190 P4-KCJ that occurred on 11 November 2018. The aircraft was landed
safely after considerable di culty, so much so the crew had debated ditching o shore.
GPIAAF conformed that incorrect ailerons control cable system installation had occurred in
both wings during a maintenance check conducted in Portugal.
Misrigged Flying Control Cable, Air Astana Embraer EJ-190

P4-KCJ (Credit: GPIAFF)
GPIAFF note that: “By introducing the modi cation iaw Service Bulletin 190-57-0038 during
the maintenance activities, there was no longer the cable routing and separation around rib
21, making it harder to understand the maintenance instructions, with recognized
opportunities for improvement in the maintenance actions interpretation”. They also
comment that: “The message “FLT CTRL NO DISPATCH” was generated during the
maintenance activities, which in turn originated additional troubleshooting activities by the
maintenance service provider, supported by the aircraft manufacturer. These activities, which
lasted for 11 days, did not identify the ailerons’ cables reversal, nor was this correlated to the
“FLT CTRL NO DISPATCH” message.”
GPIAFF comment “deviations to the internal procedures” occurred within the maintenance
organisation that “led to the error not being detected in the various safety barriers designed”
in the process. They also note that the error ” was not identi ed in the aircraft operational
checks ( ight controls check) by the operator’s crew.”
UPDATE 1 June 2019: Our analysis: ERJ-190 Flying Control Rigging Error
Aerossurance is pleased to be both sponsoring and presenting at a Royal Aeronautical Society
(RAeS) Human Factors Group: Engineering seminar Maintenance Error: Are we learning? to be
held on 9 May 2019 at Cran eld University.
Aerossurance has extensive air safety, operations, airworthiness, human

factors, aviation regulation and safety analysis experience. For
practical maintenance standards and practices support you can trust,
contact us at: enquiries@aerossurance.com
Follow us on LinkedIn and on Twitter @Aerossurance for our latest updates.
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B1900D Emergency Landing: Maintenance Standards &

B1900D Emergency Landing: Maintenance Standards & Practices

management and oversight of aircraft maintenance and maintenance standards & practices.

Fatal Taiwanese Night SAR

Luftwa e VVIP Global 5000

Dash 8 Q400 Return to Base

for Air Canada under the Air Canada Express brand.

History of the Flight Recent Comments

The TSB explain that:

B1900D Landing Gear Description and Lab Findings July 2018

820107-1 (item 34). October 2017

Accidents & Incidents

Air Georgian Maintenance Schedule, Process and Practices Air Tra c Management /

lubrication schedule to be performed at every 400-hour interval. This required personnel

Oil & Gas / IOGP / Energy

actioned on an additional work card.

card was to be completed.

The TSB say:

If the maintenance manual is followed correctly, the occurrence bolt is required to be

that many types of grease are the same colour.

pressure to the typical usability issues of the grease gun.

experience high workload, which could include a combination of scheduled and

unscheduled tasks on the Beechcraft 1900D and the CRJ‑200.

extended entries, primarily due to workload and personnel shortage.

over the task

to tasks elsewhere, for example at the airport departure gates.

or to check the lubrication of easy-to-reach or easy-to-lubricate bolts, such as the

There were no standardized supervision practices.

Maintenance Personnel Training & Competence

knowledge and training”:

not aware of a requirement to lubricate the aircraft following cleaning.

Aviation maintenance technician students in Canada usually attend a [Transport Canada]

at an [Approved Maintenance Organisation] AMO.

During maintenance education, [Canadian Aviation Regulations] CARs…require students to

and hydraulic systems.”

description of a training standard for a lubrication technique taught in typical student

possible to determine a student’s technical competencies related to the lubrication and

Technicians then received further training on joining an AMO:

procedure, training standards, examination, or validation process.

Air Georgian’s Maintenance Policy Manual stated the following:

normally in the everyday working environment, utilizing demonstration and practice

instructor‑based training related to the competency and validity of their “demonstration

and practice techniques,” nor was this required by regulation.

example] no training or supervision-related competencies listed on the ACA Occupational

Standard Assessment form or the ACA Nomination form.

Air Georgian B1900D (Credit: BriYYZ)

B1900D. The TSB found that at Air Georgian…

months experience on type,” and “company training requirements current.”

Such a tick box approach might be acceptable if there were:

Manual on what constituted an ACA’s “combination of training and experience appropriate

to that aircraft” or “required competencies,” or on what was included in ACA on-the-job

Finally, when it comes to the third point:

Additionally, human factors (HF) training was delivered online.

apply the techniques in the workplace. They note that:

There was no opportunity for maintenance personnel to participate in group discussion on

recent maintenance errors.

break up a one-way lecture). Also:

It was not possible to determine the degree of standardization of online learning

principles. Similar problems occur when classroom HF training:

de nes competence as:

…a measurable skill or standard of performance, knowledge and understanding, taking