Link Airways incident, Canberra 10/11/22

[Saab34]

Leave the ATSB for the finger pointing.

Depends on the operator really and how they deal with it. A smaller general aviation or turboprop operator might deal with such finger pointing a bit different vs say RPT carrier with big training/HR machines behind them. The finger pointing, blaming and bad handling stuff I’ve heard about is in smaller GA outfits.

 

[ausfox]

A number of individuals have responsibilities before an aircraft is clear to fly. These people have failed their task. I f the system is not sufficiently detailed and then implemented then it is the top level butts that need kicking.
This event is not a simple oh I missed that moment.

 

[Quickstatus]

Leave the ATSB for the finger pointing.

They are not into finger pointing either.

 

[Quickstatus]

This event is not a simple oh I missed that moment.

How do you know (either way)?. Airlines big and small are complex organisations which also do not operate in isolation outside of regulation.

These people have failed their task

In what way?, It is too simplistic to say they failed. Why? how?, what were the factors that caused that failure? What was the interplay between the individual and the system?.

 

[Ade]

And almost all rubbish.

Good to know ... one of my favourite dialogues in the movie "Goldfinger" pertains to a de-presurized cabin ...

cough, you know a lot more about planes than guns.

That's a Smith & Wesson . .

If you fire this close, the bullet will pass through me and the fuselage

like a blowtorch through butter.

The cabin will depressurise and we'll be sucked into outer space together.

If that's how you want to arrive, you're welcome.

Its not about finding fault, and more important to find the reason for the failure, and the reason is usually more complicated than just one person forgetting

Yea, that's right. There may have been a change to the way things are done and this was a gap, which was, so far, potentially filled by someone in the know and now someone else might have done the checks and this was missed, unawares. I tend to think of SOPs as a collective responsibility rather than being a single point of failure ... I mean, things are meant to be done a certain way by everyone involved to achieve the common cause ...

 

[Bolt]

Kinda reminds me of the flight departing Brisbane where the pitot tube covers weren't removed just earlier this year! https://www.atsb.gov.au/media/news-items/2022/pitot-probe-covers

Whatever is going on in Australia with pre-flight checks, clearly we're not learning the lesson.

- I mean, it's literally a red flag! Do we need to make these things bigger?

 

[Quickstatus]

I tend to think of SOPs as a collective responsibility

The “collective” extends beyond the organisation to the legislative and regulatory levels, as well as the Company board/executive

 

[ausfox]

Both the ground crew and flight crew are meant to have checked the aircraft. They missed a ratchet mechanism attached to a propellor. How is that not a failure.
I have worked on heavy and small aircraft for more than 50 years and am astounded that this could happen and then be apologised for.
I agree that the provision of serviceable, safe aircraft is a team responsibility and more than 2 sets of eyes are engaged in this. So it should not happen

 

[kangarooflyer88]

I'm not an aerospace engineer but would be curious whether the damage caused by this incident is repairable or if it's a write off? You reckon they could just putty the wall and buff it out, maybe?

-RooFlyer88

 

[Quickstatus]

How is that not a failure.

No one is saying that its not a failure. However a "failure" should not immediately equal retribution. Rather the reason for failure should be analysed and then improvements put in place. Systems where failure equal retribution generally are places where failures are under-reported. A system which invites failure reporting actually has a better change of making improvements.
Beware an organisation that says they have not had any failures.

So it should not happen

Hmm, that is a bit idealistic. A complex system involving machine and people, there will always be error and failure. That is not to say we should accept it but a recognition that it will occur despite best efforts and a continual safety focus.

apologised for.

No one is being an apologist (if that is what you mean). My point is merely that the recognition of failure and the remediation is much more complex than who the culprit is who forgot to remove the strap.

 

[jb747]

A number of individuals have responsibilities before an aircraft is clear to fly. These people have failed their task. I f the system is not sufficiently detailed and then implemented then it is the top level butts that need kicking.
This event is not a simple oh I missed that moment.

That applies to just about all events. Punitive exercises do nothing to improve safety. People make mistakes. Lines on checklists are missed. The aim is to reduce the incidence as much as possible. Nobody seriously believes it can be pushed to zero.

Both the ground crew and flight crew are meant to have checked the aircraft. They missed a ratchet mechanism attached to a propellor. How is that not a failure.
I have worked on heavy and small aircraft for more than 50 years and am astounded that this could happen and then be apologised for.
I agree that the provision of serviceable, safe aircraft is a team responsibility and more than 2 sets of eyes are engaged in this. So it should not happen

Nobody is apologising for anything. But, I think we are being realistic about what happened.

I'm not an aerospace engineer but would be curious whether the damage caused by this incident is repairable or if it's a write off? You reckon they could just putty the wall and buff it out, maybe?

It's a skin repair. Big deal.

 

[ausfox]

Seems like I am on another script here so I will leave it at that.

 

[eastwest101]

If these are the same straps that Rex use on their Saab 340s then it's on the left side and one end of the strap is on a prop blade and the other is tied to the top of the Saab 340 main cabin door stairs articulating hand rail. On Rex after boarding is completed a pilot will take the strap off the prop blade and take the strap into the flight deck while the flight attendant raises the stairs and then closes the main cabin door. This is also why on Rex Saab 340 flights on arrival, the very first person off the plane is always a pilot who straps the prop blade before any pax disembark. Rex ground crew never touch these straps, only pilots do that I have observed.

I wonder if Link SOP's are the same? Haven't flown Link myself.

Amazing that this strap stayed on for start up, taxiying and then came loose and hit the cabin wall without striking the ground or flying off away from the aircraft before takeoff.

 

[Quickstatus]

@ausfox , I used to think like you

One book by a fellow by the name of Sidney Dekker “drift into failure” and “just culture” fostered a different insight into the interaction between humans,machine, and the technical in the context of safety and failure

 

[dylarr]

I'm not an aerospace engineer but would be curious whether the damage caused by this incident is repairable or if it's a write off? You reckon they could just putty the wall and buff it out, maybe?

-RooFlyer88

The aircraft went back into service on the 5th December, so a little under a month to have it repaired.