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Maintenance Induced Failures

Commentary here by Mike Busch

YPJT, United Arab Emirates

I agree that distraction is the number one cause of maintenance errors, the usual reason for this slipping past the quality system is that the old fashioned chief engineer who once stalked the hangar floor keeping a watchful eye on the work is now confined to the office doing EASA paperwork.

A and C = couldn’t agree more. A written process is nothing like hands-on supervision and expertise! Work-packs used to be about 5/16in thick, now they’re nearly 3/4in because of the extra paperwork needed.

jxk
EGHI, United Kingdom

Planes maintained by third parties are often picked up from maintenance and immediately taken back to their normal routine, leaving no room for maintenance induced problems. At my field, it is customary to put a plane back into service very carefully, after having worked on it. For example after my prop bolt surgery – which isn’t completely through, but nearly – I find it only normal to tighten bolts, taxi up and down the field a couple of times, tighten bolts, do a fake take-off followed by an immediate landing, again, retighten bolts, only then to fly a tentative circuit – of course only if nothing unexpected showed up all the while.

One of the dangers of mandatory third-party maintenance is that it is all too easy to have blind confidence in the workshop – “they are certified, they are expensive, they have good reputation, this plane just has to be ok” – one who maintains the plane him/herself will leave more room for error. One more reason to go Annex II !

EBZH Kiewit, Belgium

There are virtually no maintenance induced accidents in European GA. Therefore I do not believe that there is a problem.

That there are no accidents does not mean there are no failures and shoddy work galore… I had deicing failures (kinked hose), a taped over static port, a complete engine instrumentation failure due to a botched software update, loose bolts, and some idiot who re-used some seals leading to massive oil loss and in-flight shutdown of one engine in a twin. And I ended up in a field once after my engine failed on the second flight after maintenance, an incident that remained unexplained…

And I don’t even own an aircraft!

And on the point of there being no accidents – modern safety management evaluates failures not on the severity of what did happen, but what reasonably could have happened, taking into account the mitigations in place. So for example an unsecured elevator attachment that could lead to a catastrophic accident is considered very severe even if it was caught in time to prevent it. And something being caught before quality control is less severe than after, because the quality control mitigates the risk.

Last Edited by Cobalt at 02 Aug 11:39
Biggin Hill

There are virtually no maintenance induced accidents in European GA.

That is a bold statement, Achimha. Surely the original article, written from a US’an point of view, states that there are many many. It almost looks like you are claiming maintenance in Europe is generally done to a higher standard than in the USA (which not everybody here would agree to, I’m sure) – or do you disagree with the original article’s author?

Actually, do you have any source for your statement? The original article claims 12% of accidents to be induced by maintenance, that seems a pretty high figure to me – but I am not sure of its sources.

[[ edit: perhaps we should differentiate carefully between incidents and accidents ? ]]

Last Edited by at 02 Aug 11:38
EBZH Kiewit, Belgium

There are virtually no maintenance induced accidents in European GA. Therefore I do not believe that there is a problem.

Only because one can deal with a frozen elevator trim in flight – caused by some idiot spraying some no-name motorbike lube in there.

If the resulting autopilot failure happened in IMC and at a bad moment, it might have been more interesting

It is difficult to make a fixed wing plane crash via bad maintenance but one gets close fairly often IME.

Last Edited by Peter at 02 Aug 11:39
Administrator
Shoreham EGKA, United Kingdom

One of the major findings of RCM researchers was that preventive maintenance often does more harm than good, and that safety and reliability can often be improved dramatically by reducing the amount of PM and using minimally invasive techniques.

Yes, and the logical extension of this is TBR, not TBO. When a piece of machinery has run for a certain amount of time, or starts breaking, it is considered trash. Repair or overhaul is a waste of time and money. Things are manufactured in very strict condition, the less hands that touch the stuff, the better. A lycoming is not designed nor manufactured around these more “modern” principles. But, there is nothing inherently wrong with “hand made” stuff that is meant to last “forever” either. It only requires more attention to detail and more dedication (in production and repair) and ends up costing 2-1000 times more than an equal quality “wasteable” unit depending on complexity and units produced.

There are no holy grail with these things, for the same reason that doing EASA paperwork around fancy maintenance routines is no replacement for a second pair of watchful eyes on the hangar floor. I remember learning about RCM ages ago. Today RCM means (if it is still called RCM that is) choosing the maintenance strategies (often several and on several levels) that ultimately minimizes a set of constraints, be it cost or risk or safety or whatever, in any combination. But RCM is certainly no excuse for sloppy maintenance, and an RCM analysis may very well result in scheduled maintenance being the best option.

A Lycoming is an old fashioned “hand made” piece of machinery. I would believe it works best if i is treated as such, but it must be treated properly. A BMW engine that is made to run for 200, 300, 500k? km without a single incident of any kind, and then thrown away is not even remotely related to a Lycoming engine.

As I am building my own experimental engine, from scratch, I also have to have some maintenance strategy. There is no TBO, not even “suggested” for homebuilt experimental engines. I have read several pieces of Mike Bush. They are interesting, but he is ultimately only pointing fingers at all and everything he feel is wrong, and this isn’t very helpful. With his experience and competence he could easily do a proper and thorough engineering RCM analysis that would serve as an example of an alternative (but practical) way to maintain aircraft engines (old “had made” ones).

The elephant is the circulation
ENVA ENOP ENMO, Norway

One has to consider that Mike Busch et al. not only are very knowldgeable engineers, they also happen to be very clever businessmen. Their articles, columns, webinars are all part of their business. Talk bad about the standards of maintenance = sell more seminar seats. Become famous doing so = be invited (for big $$) to speak at aviation conventions. Pledge for and against certain products = partner up with certain manufacturers = more $$.

American style marketing is more direct and blunt than marketing in Europe.

Last Edited by boscomantico at 02 Aug 12:01
Mainz (EDFZ) & Egelsbach (EDFE), Germany
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