Dh,,-f-"rl'V/""IlY\h

r,..., I'II"'\+:"~

Corporal

Mike Pelletier
Pelletiernoticed abnormalrotational play in the crank assembly the tail rotor control counterweight.Further of inspectionrevealed that play on the static stopwasalso excessive. Corporal Pelletierimmediatelysuspected that the retainernut had workedloose. Corporal Pelletier found that the retaining nut could be turned by hand.Technical ordersspecifythat the nut shouldbe tightenedto nine hundred inch-pounds.The only thing restrainingthe assembly its lock-wire. was CorporalPelletier's alertness and professionalism resulted in the detectionof a significantsafety hazard.Had the situationremainedunnoticedand unresolved serious a accident was likely to occur. Welldone.

While conductinga normal twenty-five hour inspectionon a Griffon helicopter,Corporal

32

Flight Comment, no 1, 2000

Caporal-Chef

Dave Rainbird
Le caporal-chef Rainbird, mecanicien navigant servant dans l'unite d'helicopteres du Pendantcette inspection supplementaire, caporal-chef Ie Rainbird a remarque line legerequantite de depot noir derriere la conduite numero deux du circuit hydraulique. 11 a ensuite accedeau logementde la tran~!fiission et, en passant la main derriere la conduite, il a senti line rainure. 11 alors a decouvertque Ie c~ble du detecteurde limaille de la transmission frottait sur la conduite et en provoquait l'usure. lnvisibles a l'reil nu, leg dommagesdug a l'usure s'etendaientsur plus des deux tiers de la paroi de la conduite. l' effort supplementairedeplore par Ie caporal-chef Rainbird ainsi que son professionnalismeant permis l'identification d'un element qui constituait une importante menacepour la securiteaerienne.La rupture de cette conduite hydraUlique aurait probablementnecessite atterrissageforce dans un une zone ou abondaientlegchamps de mines non repertories. Bien joue. + ":

Kosovo, effectuait
l'inspection prevol d'un helicoptere Griffon lorsqu'il a remarque que Ie niveau du liquide de transmissihn etait bas.Apres avoir refait Ie plein de liquide, Ie caporal-chefRainbird a decide d'effectuer une inspection plus de1:aillee. Etant donne Ie rythme rapide des operations, la chaleur ext.remeet la poussiereenvahissante, avait deja il etabli quil seraitplus prudent d'effectuer une inspection supplementaire des composantscritiques.

14

Propos de vol. n 2. 2000

Master Corporal Dave Rainbird

MasterCorporal Rainbird,a flight engineer serving with the Kosovo RotaryWing Aviation Unit, was conductinga preflight inspectionof a Griffon helicopter whenhe noticed '. .that the transmission fluid wasJow.After topping up the fluid levelMaster Corporal Rairibird elected carry out a more in-depth to inspectionof the area.He had earlierdecidedthat given the high operationaltempo,extremeheat,and pervasive dust,that an additional examinationof critical components would be prudent. During his additional inspectionMasterCorporal Rainbird noticed a small amount of blackresidueon the rearof the numbertwo hydraulic system line. He then reacheddown into the transmission well and running his hand along the rear of the line he felt a groove.He determinedthat the transmissionchip detector wire rubbing against the hydraulicline had caused erosion.The damage, the which wasundetectable the nakedeye,amountedto wear by through overtwo thirds of the line'swall. Master CorporalRainbird's extra effortand professionalism resultedin the identificationof a significantflight safety hazard.The failure of the hydraulicline would havelikely resultedin a forcedlanding in an areawhereuncharted minefieldsabound.Welldone. .

14

Flight Comment,

no 2, 2000

of the CRM concept,training standards training and program to ensurethe operationalrequirements all of air forcecommunitiesaremet. As an immediateresultof this occurrence unit conductthe ed a reviewof the techniques applicable flight in obscurto ing phenomena. Squadronaircrewparticipatedin a formal one dayCRM lecture giventhe secondweekof February 1999and recurrenttraining wasconducted in February 2000.The Commander Wing is implementinga program 1 to ensurethat all 1 Wing aircreware givenadditional training in CRM and Jisk management. During the courseof the investigation wasdiscovered it that someof the crewhad self-medicated with common cold remedies. Although difficult to quantify,the drugsthat were detectedin the crewcould have adversely affectedtheir reactionsin the cockpit. In addition,a non-flight surgeon qualifiedcivilian physicianon contractto the baseprescribed one of the crewa drug that was not recommended for aircrewuse. The unit Flight Surgeon Base and Flight SafetyOfficer conducteda reviewof the rules regardingselfmedicationduring a flight safety meetingwith the whole squadron. CAShastasked1 CAD to revie.w the distribution and numberof qualified flight surgeons in Valcartieraswell as reviewthe procedures which civilian doctors follow whentreating aircrew. This is not a new occurrence, simply newindividualsrepeating a previousevent.This wasan expensive reminderof the needto properly brief and demonstrate sequences be the to executed a plannedtraining flight.. in

16

TYPE: DATE: LOCATION:

CH146486 Griffon 7 December 1998 Owen Sound ON

A ircraft CH146486 departed the Owen Sound airport at 23102 for a Night Vision Goggle (NVG) formation training sortie. Shortly after take-off the flying pilot (right seat) experienced a 'wash out' of his NVG and transferred control of the aircraft to the non-flying pilot. Moments later, the #2 'ENGINE OUT' light illuminated and the #2 Inlet Turbine Temperature (ITT) climbed rapidly. The crew turned back to the airport and then the #2 engine "FIRE" light illuminated on short final to the runway. The crew initiated the checklist procedure for an engine fire, executed a run-on landing and emergency shutdown and egressedthe aircraft without incident. The aircraft sustained D Category damage due to the overheat condition in the #2 engine. An engine overheat condition can occur if too much fuel is metered to the combustion chamber. Excess fuel would most likely be traced to a failed Fuel Control Unit (FCU) or improper selection of the FCU operating mode (Governor switch). Technical analysis of the powerplant and its components did not reveal any electrical or h ' l 1 1, mec amca anoma y to exp am fig! ., ':"110". the engine malfunction and fire. II ..~..~...,..,~,.., The investigation su,b~e.quentl~f"' focused on the possIbilIty of ~ I :4~il I improper selection of the FCU ; operating mode. In-flight selec-;ifJ\ tion of the GOVERNOR switch "" I from AUTOMATIC to MANU- ITa AL mode with the throttle in the full open position will causetheFCU to meter 6 times the normal amount of to the engine. The crew took-off with the HUMS UsageMonitoring System) Permanent Tracker switch in 'Night' mode. When the HUMS system took an automatic sampling of the blade track, an infra-red beam was projected vertically into the blades from the sensor located on the nose of the aircraft in front of the right seat pilot (flying pilot). This caused the 'wash-out' of his NVG. Placing the mode switch in 'Day' prevents the projection of the IR beam. The HUMS 'mode' switch is located at the top right side of the centre pedestal. The #2 engine Governor 'mode' switch is located directly below it on the same console.Analysis of the Cockpit Voice Recorder (CVR) tape indicates the right seatpilot's 'wash-out' problem was rectified co-incident with the initiation of the engine emergency. Although the right seat pilot
18 Flight Comment, no 3, 2000

doesnot recallselecting 1, the HUMS mode switch [ during the departurefrom i the airport, the possibility ~ of an incorrect switch selectionon the part of the crewwasinvestigated. If the right seatpilot movedthe HUMS mode switch from 'Night' to 'Day' (aft movement), would expect one to getthe resultheard on the CVR (wash-outproblem rectified).If he moved the.Governorswitchto 'MANUAL' (aft movement),then one :wouldexpect resultsseen. the in the engine. . The Governorswitchwastestedto determineif it could be inadvertently moved during selectionof the HUMS mode switch. It wasimpossibleto move the Governor switch without consciouslylifting the switch first (overcentre lock). The Governor switch is also the only switch in the cockpitthat hasa uniquetriangulartop. Although it is possible make an incorto rect switch selectionfrom a human factorsperspective(topographic misorientation),it would seemunlikelybasedon the function and shapeof the Governorswitch.The aircraftwas .configured in AUTOMATIC governor I for takeoff and the right seatpilot stated that MANUAL governorwas not selected in-flight. The investigation teamwas unable to determine whetheror not the overheat condition wascaused an improper selection by of the FCU operatingmode (Governor switch).The eventswhich precipitated IU the enginemalfunction and fire could not be determined.
:

Several deficiencies werediscovered during the courseof the investigation which requiredcorrectiveaction. Whenthe #2 enginefailed,the #2 generatorfell off line causingthe nonessential to de-energise. bus Whenthe non-essential debus energised, co-pilots instrumentlighting extinguished the and the #2 and #3 radioswere temporarilyunavailable. Thesetwo designcharacteristics being investigated the technical are by and operationalauthoritiesto determineif there are any proceduralor engineering changes required.

'9

TYPE: CH146486 Griffon DATE: 7 decembre 1998 EN DROIT : Owen Sound ON

L 'helicoptere CH146486 a quitte l'aeroport de Owen Sound it 2310Z pour tine sortie d'entrainement en formation avec lunettes de vision nocturne. Feu apres Ie decollage,Ie pilote aux commandes portant des lunettes de vision nocturne a ete victime d'un eblouissement et il a passeleg commandes de l'appareil au pilote non aux commandes. Feu apres, Ie voyant 'ENGINE OUT' du moteur numero 2 s'est allume, et la temperature d'entree de turbine (ITT) du moteur en question a augmente rapidement. L'equipage ~st retourne it l'aeroport et Ie voyant 'FIRE' du m6t~ur numero 2 s'est allume en courte finale sur la piste. L'equipage a execute la liste des verifications relative it un incendie moteur, a execute un atterrissage oblique et un arr~t complet d'urgence de l'helicoptere et a quitte l'appareil sans incident. L'helicoptere a subi des dommages de categorie D causes par tine surchauffe du moteur #2. Une surchauffe de moteur petit se produire si trop de carburant est fourni it la chambre de combustion. Un excesde carburant I serait probablement attribuable a 'I un regulateur de carburant (FCU'"i defectueux ou it tine selection ~ erronee du mode de fonctionDement de ce regulateur (commutateur GOVERNOR). L'analyse technique du moteur et de sescomposantes n'a pu determiner aucune faute electrique ou mechanique qui pourrait expliquer leg defaillances du moteur et Ie feu. L'enqu~te s' est ensuite penchee sur la ite d'avoir selectionne Ie mauvais d'operation du FCU. La selection du commutateur GOVERNOR du mode AUTOMATIC au mode MANUAL en vol alors que la commande des gaz est en position completement ouverte amenera Ie regulateur de carburant it fournir six fois plus de carburant au moteur. -,
..~

Le commutateurGOV ERNORdu moteur I numero 2 setrouve directementSallS celui-ci sur Ie m~mepylone. L'analyse la bandede de l'enregistreur phonique (CVR) indique que Ie problemed'eblouissement pilote enplacedroite s'est du corrige en m~metempsqu'a commence situationd'urla gence relativeau moteur. Bienque Ie pilote enplacedroite ne sesouvienne d'avoir selectionne commutateurdu pas Ie systeme HUMS lors de departde l'aeroport, on s'est penche sur Ie fait que l'equipageait pu commettreune erreurde selection commutateur. de SiIe pilote enplacedroite avaitdeplace commuIe , tateurde mode HUMS de la position 'Night' a la position 'Day' (mouvement versl'arriere), on s'attendrait a obtenir Ie resultatdont fait etatl'enregistreurphonique (problemed'eblouissement corrige). S'il avaitdeplace commutateurGOVERIe NOR ser MANUAL (mouvement versl'arriere), alors on s'attendraitaux resultatscon, states dansIe moteur. : On a fait l'essaidu commutateurdu : regulateurpour determiners'il pouvait ~tredeplacepar inadvertance pendant la selectiondu commutateurdu dispositifpermanent.11 etait impossible de deplacer commutateurdu Ie regulateur sansd'abord souleveren
J ._.~ toute conscience Ie commutateur (Ie commutateur doit ~tre souleve pour

:& ..';',,01,.

L'equipage avait selectionne Ie commutateur du dispositif permanent d'alignement de pales du HUMS (Health Usage Monitoring System) it la position 'Night' avant Ie decollage. Lorsque Ie systeme HUMS a effectue un echantillonage automatique des pales, un faisceau infra-rouge a ete projecte verticalement sur leg pales it partir du detecteur situe sur Ie nez de l'helicoptere juste en avant du siege de droite (pilote aux commandes). Ceci a cause l'eblouissement de ses lunettes de vision nocturne. Selectionner Ie commutateur dans la position 'Day' previent la projection du faisceau IR. Le commutateur du systeme HUMS se trouve dans Ie coin superieur droit du pylone central.
18

changer position). Le commutateuI de GOVERNORestaussi seulcommutateurdu pastede Ie pilotagedont Ie dessus triangulaire.Bien qu'il soit possiest ble de selectionner mauvaiscommutateurdu point de Ie vue desfacteurshumains (desorientation topographique), ce seraitpeuprobablecomptetenu ~ la fonction et de la forme du commutateurdu regulateur. regulateur 'Le de l'helicoptereetait en positionAUTOMATIC pour Ie decollageet Ie pilote enplacedroite a affirme que Ie regulateur n' avaitpasete selectionne MANUAL envol. L'equipe sur d'enqu~teurs pasete enmesurede determinersi la surn'a chauffeavaitetecausee une erreurde selectiondu par mode de fonctionnementdu regulateur carburant de (commutateurGOVERNOR). circonstances ant Les qui cause problemeavecIe moteur #2 et Ie feu n'ont pu Ie ~tredeterminees.

Propos de vol. n 3. 2000

Le Griffon portant Ie numero CH-146426 venait a peine de subir une inspection de maintenance planifiee et devait voler plus tard dans la soiree. Le caporal-chef Laporte avait ete assigne a voler precisement dans cet appareil au cours de son vol d'entralnement avec lunettes de vision nocturne (LVN). Le caporal-chef Laporte , a commence I'inspection de I'exterieur ,del'appareil stationne sur la ligne devol. Le soleil etait deja couche et la faible lumiere ambiante rendait I'inspection pre-vol difficile.

Alors qu'il terminait son inspection du rotor de queue et du baTtier d'engrenages a 90 degres, Ie caporal-chef Laporte a remarque que Ie bouchon du baTtier d'engrenages en question semblait se trouver en position plus elevee qu'a I'habitude sur son support. Afin de proceder a une inspection plus approfondie du baTtier d'engrenages, il a pris Ie temps d'aller chercher un escabeaudans Ie hangar. L'inspection detaillee a dairement demontre que Ie bouchon de remplissage d'huile du baTtier d'engrenage a 90 degres tenait a peine sur son support. La perte d'huile de ce baTtier aurait pu avoir de graves consequencesallant meme jusqu'a la perte possible de I'appareil et de son equipage. Le grand saud du detail dont a fait preuve Ie caporal-chef Laporte, et ce, malgre de mauvaisesconditions d'inspection pre-vol, merite d'etre souligne. .

32

Propos de vol, nO4, 2002

Griffon aircraft #CH-146426 had just been released from maintenance after a scheduled inspection and was scheduled to fly later in the evening. MCpl Laporte was assigned to fly in this particular aircraft for his night vision goggle (NVG) training trip. MCpl Laporte commenced his walk-around while the aircraft was parked on the flight line. The sun had already set and ambient lighting was at a minimum, making conditions difficult for carrying out the pre-flight inspection.

While completing his examination of the tail rotor and gO-degree gearbox assembly, MCpl Laporte noticed that the gO-degree gearbox cap appeared to be sitting higher on its post than usual. In order to complete a more detailed inspection of the gearbox, he took the extra time to get an aircraft stand from the hangar. Upon closer inspection, it became readily apparent that the gO-degree gearbox oil filler cap was merely resting upon its post. The loss of oil from this gearbox could have had catastrophic effects, possibly resulting in the loss of the aircraft and crew. MCpl Laporte is to be commended for his superior attention to detail under less than ideal pre-flight conditions. +

32

Flight Comment, no 4, 2002