Gimli Glider coming to a theatre near you - maybe

[J.O.]

https://www.ctvnews.ca/mobile/canada/gimli-glider-landing-getting-the-hollywood-treatment-1.3827653

[blues deville]

Barbara Gluck, president of the Gimli Glider Museum, says the story deserves to be a movie.............because the crew’s actions paved the way for another miraculous plane landing.........Gluck says the smooth landing would have never happened without the Gimli Glider.

Two completely separate but similar events handled as best as possible considering their situation. If either day, Gimli or Hudson, had been IMC conditions the two incidents would have had very different results.

[conehead]

Nobody talking about the Azores incident?

[blues deville]

1 hour ago, conehead said:

Nobody talking about the Azores incident?

A little news item referred to as 9-11 took care of their PR nightmare. 

[conehead]

Ahhh, yes. It was less than 3 weeks apart.

[DEFCON]

I've never understood how two individuals from the mtx department could willingly commit an act that placed several hundred peoples life at great risk and yet somehow avoid criminal or any other sanction; as far as I'm aware, their licences weren't even suspended by TC?

  

[boestar]

can you prove willful negligence?

 

[DEFCON]

As I recall, two personnel made a conscious decision to install a part that properly belonged on another aircraft type.

If you want to use the 'they didn't know any better' defense, you'd have to acknowledge the pair are too stupid to have ever held the licence that allowed them to place the travelling public & the corporation in jeopardy.

 

 

[boestar]

As I am not familiar with the particulars that led up to the issue I cannot comment on the qualifications of the individuals.

Lots of things take place in the process of a repair like that.  Did they know it was the incorrect part?  Were they handed the "required Part" and told to install it?  did it share similarities to the part or was it obviously wrong? (couldn't have been far off if it fit the hole).  Was the implied incompetence on the part of the mechanic or of the crew chief or supervisor overseeing the work?  Was the proper documentation used?  Was the part correctly identified?  ETC ETC ETC.

Aircraft maintenance is not cut and dry.  There are a thousand things that can cause an issue and only one can be fatal.  With all of that gross negligence would be pretty hard to prove.  No mechanic that I know after 30 years in the business would willfully install the wrong part, especially in a critical system.

 

[blues deville]

Same RR engine part but for different engine model. Not a criminal act but certainly human error. What’s interesting is this aircraft conducted one or more flights before the Azores trip and it wasn’t reported or investigated as a problem. 

 

[J.O.]

At the time, RR didn’t object to the substitution. 

[Maverick]

11 hours ago, J.O. said:

At the time, RR didn’t object to the substitution. 

It was a routine part replacement. RR would not have been queried most likely and if they had why would they agree? Two different engine models in two different airframes. 

[DEFCON]

Again, as I recall, there was pressure to get the aircraft on the flight line. The floor mechanic was directed by the manager to use the unit. I don't remember anything that ever came out suggesting RR approved the swap.

From Wikipedia: https://en.wikipedia.org/wiki/Air_Transat_Flight_236

"The investigation revealed the cause of the accident was a fuel leak in the #2 engine, caused by an incorrect part installed in the hydraulics system by Air Transat maintenance staff.^[2] Air Transat maintenance staff had replaced the engine as part of routine maintenance, using a spare engine, lent by Rolls-Royce, from an older model. This borrowed engine did not include a hydraulic pump. Despite the lead mechanic's concerns, Air Transat ordered the use of a part from a similar engine, an adaptation that did not maintain adequate clearance between the hydraulic lines and the fuel line. This lack of clearance — on the order of millimetres from the intended part ^[2] — allowed chafing between the lines to rupture the fuel line, causing the leak. Air Transat accepted responsibility for the accident and was fined 250,000 Canadian dollars by the Canadian government, which as of 2009 was the largest fine in Canadian history.^[2]" 

[boestar]

Defcon:

Many parts are interchangeable between engine types and airframe types.  These are generally identified in the IPC or some other approving documentation.  This would not be out off the ordinary.

Having said that, if the engineer in question had doubts about the fitment then it should have been questioned and validated to his satisfaction.  Now it is also not rare to install a line as a temporary measure (like installing a flex line in place of a rigid line) so long as you have supporting documentation.

Again I am not privy as to what, if any, supporting documentation was available to install the line on this engine.

Do not think that maintenance is cut and dry and only one part fits in one hole because this is rarely the case.

 

[DEFCON]

Thanks Boestar.

i do have a fairly good appreciation for the workings of a maintenance organization and know well how the best systems can run afoul as commercial / corporate concerns mount.

In this case, I clearly recall, the pressure was on, but to save a lot of back & forth, I'll just point to the fine, which was not an award for excellence.

 

 

[boestar]

Right and the fine was pointed at the organization and not the AME as it should have been.  This is how an AMO is set up to work.

 

[Airband]

Maintenance related issues contained in summary of Causes and Contributing Factors contained in Accident Investigation Final Report issued by Government of Portugal:

Quote

3.0 Conclusions

3.1 Findings as to Causes and Contributing Factors

1. The replacement engine was received in an unexpected pre-SB configuration to which the

operator had not previously been exposed.

2. Neither the engine-receipt nor the engine-change planning process identified the differences

in configuration between the engine being removed and the engine being installed,

leaving complete reliance for detecting the differences upon the technicians doing the engine

change.

3. The lead technician relied on verbal advice during the engine change procedure rather than

acquiring access to the relevant SB, which was necessary to properly complete the installation

of the post-mod hydraulic pump.

4. The installation of the post-mod hydraulic pump and the post-mod fuel tube with the premod

hydraulic tube assembly resulted in a mismatch between the fuel and hydraulic tubes.

5. The mismatched installation of the pre-mod hydraulic tube and the post-mod fuel tube resulted

in the tubes coming into contact with each other, which resulted in the fracture of the

fuel tube and the fuel leak, the initiating event that led to fuel exhaustion.

6. Although the existence of the optional Rolls-Royce SB RB.211-29-C625 became known

during the engine change, the SB was not reviewed during or following the installation of

the hydraulic pump, which negated a safety defence that should have prevented the mismatched

installation.

7. Although a clearance between the fuel tube and hydraulic tube was achieved during installation

by applying some force, the pressurization of the hydraulic line forced the hydraulic

tube back to its natural position and eliminated the clearance.

3.2 Findings as to Risk

1. The carry-forward items list that accompanied the replacement engine listed a postmodification

hydraulic pump model, whereas the fuel and hydraulic tubes installed on the

engine were pre-mod.

2. Time pressures, difficulties in accessing the SB and the apparent knowledge of the engine

specialist influenced the lead technician to curtail his search for the SB and to rely on verbal

advice.

3. The post-installation quality control checks following the engine change did not specifically

require checking the installation of the hydraulic pump, hydraulic tube and the fuel tube.

4. In the absence of a requirement to conduct a pre-installation, configuration (SB) parity

check, and of a commonly accepted method of carrying out this check, there is a risk that

incompatible components may be installed on aircraft and not be detected by existing maintenance

planning processes.

 

[DEFCON]

Thanks Airband, great information.

It would be useful to the discussion if someone knew how to find and acquire the actual 'charges' against AT? That document would tell the full and unsanitized story of the steps that led to the installation. For instance, and my memory may be faulty, but as I recall, 'the verbal advice the technician relied upon' was the product of a substantial disagreement between the line tech and his supervisor regarding the installation of the mismatched part; the supervisors position prevailed and the aircraft was returned to the flight line.

Blues ... do you have a source that confirms the aircraft was operated on a number of flights before the failure occured?

 

 

[boestar]

Regardless of the circumstances involved leading up to the incident.  In Canada the AME is protected under the AMO from any damages assessed unless Gross Negligence on the part of the AME can be proven.  In this case the airline bore the responsibility for the incident and payed the fines assessed.  This is the correct course.

 

[J.O.]

Transport Canada's database of corporate offenders only goes back to 2013. News articles from the time say the fine was for the improper maintenance of the aircraft.

[blues deville]

4 hours ago, DEFCON said:

Thanks Airband, great information.

It would be useful to the discussion if someone knew how to find and acquire the actual 'charges' against AT? That document would tell the full and unsanitized story of the steps that led to the installation. For instance, and my memory may be faulty, but as I recall, 'the verbal advice the technician relied upon' was the product of a substantial disagreement between the line tech and his supervisor regarding the installation of the mismatched part; the supervisors position prevailed and the aircraft was returned to the flight line.

Blues ... do you have a source that confirms the aircraft was operated on a number of flights before the failure occured?

 

 

No. I only recall the engine work was done prior to at least one other flight before the Azores departure. 

Initially it was thought the aircraft was a write off after the hard landing. However, further examination revealed their was no significant damage. We flew on the same aircraft last summer YYZ-BCN. All new interior recently installed and an excellent overhead cabin lighting system which in my opinion is better than the current Boeing design. 

[moeman]

Funny. I thought this thread was about the Gimli Glider...

[blues deville]

1 hour ago, moeman said:

Funny. I thought this thread was about the Gimli Glider...

Initially. The article made reference to Gimli and Sulley. We’ve somehow added our other glider event to the thread. Actually all three are connected. Both Canadian airline flights were self induced and Sulley’s was a result of Canada geese