Conducting investigations on similar incidents that occurred in - PowerPoint PPT Presentation

Conducting investigations on similar incidents that occurred in different countries A complex organization Arnaud TOUPET Senior Safety Investigator Capt. Nurcahyo ‘Ray’ UTOMO NTSC Senior Safety Investigator Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Investigating on similar incidents  A practical case : the investigation on several incidents involving propeller severe vibrations during flight  Organization of investigations according to ICAO Annex 13  Highlighted Solutions  Possible ways of improvement Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Practical case : propeller severe vibrations  On 18 th September 2013, in Indonesia, ATR 72-212A equipped with Hamilton Sundstrand Propellers 568F-1  Severe vibrations on engine #2 propeller during descent  Engine #2 was shut down after landing  Different blade angles observed on ground Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Practical case : propeller severe vibrations  Damages :  One blade was turning freely (blade trunnion pin broken)  Blade angle actuator forward plate found bent Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Practical case : propeller severe vibrations  Damages :  Two engine fittings found broken Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Serious Incident – full investigation  According to the Attachment C of the ICAO Annex 13, this occurrence was classified as serious incident.  NTSC conducted full investigation and sent notification to direct involve parties including France BEA as State of Manufacture.  Significant supports received from the BEA.  30 days after the occurrence NTSC issued safety recommendation to the aircraft operator. Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Practical case : propeller severe vibrations  On 4 th May 2014, in Trinidad and Tobago, ATR 72-212A equipped with Hamilton Sundstrand Propellers 568F-1  Severe vibrations on engine #2 propeller during descent  No findings from maintenance  On 5 th May 2015, vibrations after landing  Test runs leading to damages Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Practical case : propeller severe vibrations Propeller governing system description Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Practical case : propeller severe vibrations  Damages :  One blade was turning freely (blade trunnion pin broken)  Blade angle actuator forward plate found bent Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Practical case : propeller severe vibrations NOT A SERIOUS INCIDENT but SIMILAR INCIDENT INVESTIGATION proposed by BEA INVESTIGATION delegated to BEA Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Practical case : propeller severe vibrations  On 30 th November 2014, in Sweden, ATR 72-212A equipped with Hamilton Sundstrand Propellers 568F-1  Severe vibrations on engine #2 propeller during descent  Impossible to read instruments and to walk in cabin  Engine #1 fatheared then engine #2 Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Practical case : propeller severe vibrations  Damages :  One blade was turning freely (blade trunnion pin broken)  Blade angle actuator forward plate found bent Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Practical case : propeller severe vibrations  Damages :  A 180 ° crack Engine rear inlet case INCIDENT but SIMILAR INCIDENT INVESTIGATION by SHK Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Organization of investigations according to ICAO Annex 13 Serious incident Operator State of Registry State of occurence State of Operator or Type design Complete or partial organization delegation to another state State of Design Final assembly State of Manufacture organization IIC AccReps Advisers Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Organization of investigations according to ICAO Annex 13 Serious incident Accrep (Reg) Adviser (Ops) Accrep (Ops) IIC AccRep (Design ) Adviser (Design) Adviser (Assy) AccRep (Man) Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Organization of investigations according to ICAO Annex 13 Serious Indonesia Airline A Incident A EASA France (Man) ATR FAA USA (Man) Incident B T&T/France UTAS Canada (Man) P&W T&T (OPS) Airline B Incident C Sweden Airline C Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Highlighted Solutions Incident Notification Serious Airline A Indonesia Incident A France (Man) ATR T&T USA (Man) UTAS Canada (Man) Incident B Airline B Sweden Airline C Incident C Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Highlighted Solutions Information sharing between SIA Indonesia Airline A France (Man) EASA ATR T&T/France USA (Man) FAA UTAS Canada (Man) P&W Sweden Airline B Airline C Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Highlighted Solutions Examination requests and “to do list” Indonesia France (Man) ATR T&T/France USA (Man) UTAS P&W Canada (Man) Sweden Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Highlighted Solutions Update meetings March 2015 February 2015 Dec 2014 USA (Man) Indonesia Sweden ATR T&T UTAS France (Man) Indonesia France (Man) France ATR UTAS Sweden ATR FAA Airline C Oct 2014 France (Man) France/T&T EASA P&W May 2015 France (Man) France/T&T ATR UTAS France (Man) EASA UTAS ATR Sweden Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Highlighted Solutions Safety recommendations Indonesia 1st event (immediate) Airline A France (Man) 3rd event EASA ATR T&T/France FAA USA (Man) UTAS Canada (Man) P&W Airline B Sweden Airline C Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Highlighted Solutions What about the reports and final recos? Indonesia France (Man) T&T/France USA (Man) Canada (Man) Sweden Draft report Final recos Final reports comment process Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Possible ways of improvement  Improve SIA awareness of an on going investigation  Focal point (SIA or safety organization) Super IIC Investigating on similar incidents – Sri Lanka – 25-26 June 2015

Possible ways of improvement  Improve confidentiality principles for information sharing  Harmonization of reports and recommendations Similar investigations to be considered as a unique big one ? Investigating on similar incidents – Sri Lanka – 25-26 June 2015

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