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THE PROBLEM

EXAMPLE 1

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THE FACTS

EXAMPLE 1

GROUND OCCURRENCE REPORT (96/33)

AIRCRAFT G-BTTP - EDINBURGH 16/11/9

LOCATION - Edinburgh Airport, Stand 9.

TIME OF INCIDENT -

1. Aircraft arrived on Stand 9 at approximately 18.35.

2. At approximately 20.00 hours Rip Van Winkle, an Avionics Engineer, approved to

carry out Line checks on the BAe 146, carried out a Daily Check which includes
inserting the ground locks to the aircraft. (Note Aircraft Tech Log sheet 243677
Item 1 indicates that the Daily inspection was signed at 23.00 hours. This is not a
true statement and may reflect a local practice of post dating inspections).

3. At approximately 20.10 a decision was taken to change No 1 Mainwheel by Omar

Sharif, Airframe Engineer, this led to the No 1 Brake unit being considered to have
reached a wear state that required the replacement of a spacer to extend the life of the
brake unit.

4. At approximately 20.20, while carrying out the functional check IAW BAe 146
Aircraft Maintenance Manual 32-42-24 which checks the operation of the auxiliary
cylinders, a check for the insertion of the undercarriage locking pins was carried out
by Omar Sharif, satisfied that the pins were in place, he selected undercarriage 'up'.
The nose undercarriage assembly started to retract slowly.

5. Approximately 20.30. The shift supervisor, Julius Caesar, was immediately notified,
he took charge of recovering the aircraft and notifying Maintrol of all actions taken.

6. The decision to Ferry the aircraft to Norwich for repair was taken by Maintrol on
17/11/96. A concession 9765/1302 was issued by QA. This concession was
supported by an Avro Technical/Operational Response which carries a CAA approval.

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Memorandum
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To: Mr I Sutcliffe
CC:
From: Julius Caesar
Date: 17 November 1996
Subject: G-BTTP. Incident on 16/11/96.

On starting shift on 16 November it was decided that RipVan Winkle would carry out the
daily inspection on "TP". This was carried out as per the Line Maintenance Manual. There
was a No 1. wheel change required, and as the No 1. Brake unit was near to needing a spacer
fit it was decided to do this at the same time. Omar Sharif was to carry out this task, with the
help of Fred Flintstone. In the meantime I was to carry out the daily inspection on "AC".
Midway through all this, there were two other A/C to handle, these were an Easyjet B737 that
needed chocks and a CPU, and a TNT B727 that needed a pushback. These tasks were
carried out by myself and Fred Flintstone. While we were away Rip Van Winkle was
rectifying some internal lighting faults, and Omar Sharif was progressing the No 1. wheel etc
(both on "TP").

On returning to the main ramp, Fred Flintstone continued to assist with the wheel and I
carried on with "AC", daily plus some minor defects. When I had finished all my work on
"AC" I returned to the portacabin to "sign up" for what I had done. While I was doing this a
Monarch engineer had come to thank us for our assistance with providing N2 for his A/C. At
this time Fred Flintstone came running to the door of the portacabin and said "come quick
something has happened to "TP" the nose leg has collapsed," I went to the scene to find "TP"
in a very nose down condition, the nose leg at first glance had in fact retracted forward, the
nose doors were open. My initial concern was that there were no injuries, and then for the
A/C. As everyone was alright I contacted the Airport Fire Service to help lift the A/C with
their compressed air bags. The A/C was eventually lifted back on to its nose wheel at about
4.00am.

The cause of this unfortunate incident was the nose u/c lock pin being in the wrong position.

The spacer fit, by procedure requires a test of the auxiliary braking system. To do this test it
is required to select u/c up with hydraulic pressure on, and of course u/c lock pins fitted.
During this test the nose u/c partially retracted. The position of the nose u/c lock pin in this
case is shown in the attached photo.

Contd....

All work was carried out IAW the A/C Maintenance Manual, Company Procedures, and
Health and Safety Regs.

The weather at the time of the incident was light showers which turned to heavy continuous
rain during the lift.

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The actual A/C lift was carried out by the Fire Service following procedures as close as
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possible with the resources at hand at the time, with safety a prime factor.

Regards.

Julius Caesar

YOUR CONCLUSIONS

AND

RECOMMENDATIONS

EXAMPLE 1
Conclusions

Recommendations

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THE PROBLEM

EXAMPLE 2

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THE FACTS

EXAMPLE 2

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Introduction

At approximately 06.15 on Friday 23 August 1996, F100 G-UKFE was involved in a ground
collision where the right-hand horizontal stabiliser impacted the right-hand corner of the front
hangar 3 door cut-out whilst the aircraft was being moved for operational service to the
Stansted Line.

Background

G-UKFE had been grounded for #1 engine defects on the 20 August 1996. Following
inspection and engine runs with Rolls Royce personnel. A decision was made in the evening
to change the engine. during the late evening the aircraft was repositioned into hangar 3 to
prepare for the engine change, during this exercise the right-hand stabiliser tip fairing was
damaged.

The engine change was progressed and the aircraft successfully completed engine runs at
approximately 21:00. Due to late arrivals of spares - a hydraulic pipe and the stabiliser
fairing, the aircraft was returned to the hangar for completion for morning service.

Meanwhile G-UKFF was positioned into hangar 3 to complete an MSI which involved
vertical stabiliser antenna checks and necessitated hangarage. This positioning took place at
22:00. At 23.00 G-UKFE was repositioned into the hangar, by push back, such that the
aircraft tail and engines were covered with the emergency exits just outside the protective
roof line. (See sketch). This operation was supervised by C Brown with a crew of 1
brakeman, 2 wing observers, 1 tailman and a Servisair tug driver. The operation was carried
out in accordance with the procedures, the staff utilising whistles.

The aircraft required the refitting of the prepared right-hand stabiliser tip and replacement of
the robbed hydraulic brake pipe and a PDI in preparation for service.

Personnel

Mr C Brown Shift Foreman

Mr H Black Technician
Mr B Green Tradesman
Mr I Blue Technician
C White Technician
Mr L Rust Tug driver (Gatwick Handling)

Mr Brown commenced duty at 18:43 having worked 19:00 - 08:00 hours the previous three
nights and a dayshift on the Monday.

Mr Black had commenced duty at 19:11 hours having worked on overtime shift the previous
night (19:07 - 07:34).

Mr Green had commenced duty at 19:24 not having worked the previous three nights. He has
been at Stansted since March 1996.
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The Incident HUMAN FACTORS

During the night both aircraft were worked by a number of staff with H Black having prime
responsibility for FE. I Blue for FF. At approximately 05:30 a call was made from the
hangar requesting the availability of a tug to reposition FE on stand and thereafter to
reposition FF for service. Servisair were requested to provide a tow, but advised within five
minutes that they could not provide a tug and had therefore subcontracted the aircraft
movement to Gatwick Handling.

Messrs Black and Green completed aircraft FE and prepared to return to the Ramp Line
Office with tools and documentation. They elected to utilise one of the ramp vehicles, shortly
after leaving the hangar they encountered the tug. Mr Black talked to the tug driver and as a
result Mr Green volunteered to return to the aircraft. Mr Black continues back to the Ramp
Line Office.

Mr Green returns with the tug driver to the hangar, they agree signals, the tow bar is fitted.
The tow bar is fitted to pull the aircraft straight ahead.

The aircraft was positioned as previously stated (ref B Green's sketch). By this time it had
been raining for some hours and a large puddle had formed flooding the access area in front
of the hangar. The aircraft position was such that the lead in lines would have been
underneath the aircraft and underwater. Although daylight, the prevailing light was poor
because of the overcast and there was heavy precipitation at the time.

Immediately prior to commencing the tow Mr Green radios to Ramp Line Office to advise
that he requires assistance to move FF from the hangar. He does not solicit assistance for FE.

He enters the aircraft, closes the door and the tow commences. The driver pulling directly
forward. Shortly after commencing the tow, Mr Green notes that the aircraft 'shakes' and
believes that this was where the wheels are rolling over the hangar door rails.

The aircraft continues to move forward turning to the right onto the taxiway. At this point,
Mr White attracted Mr Green's attention to stop the tow. Mr Green was advised that the
aircraft tail plane right-hand side had struck the hangar cut-out.

Mr Green advised Mr Brown that the incident had occurred at approximately 06:20. Mr 
Brown advised airfield operations, Maintrol and Mr Fullilove.

Damage

The right-hand tailplane struck the right-hand cut-out corner. The impact marks were such
that they were diagonally across the tailplane. The markings did not indicate that the aircraft
was turning at the time of the collision. They are consistent with a straight pull of the
aircraft, however, it does indicate that the aircraft was not square across the hangar opening.
I believe that when the aircraft was positioned in that the tail was effectively swung to the
right.

As this was not recognised, the straight pull forward led to the right-hand stabiliser tip
impacting the cut-out area.

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The stabiliser sustained damage to the outboard leading edge assembly which was torn over a
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six inch area. The tip assembly leading edge was rolled upwards and torn. The stabiliser
upper skin was punctured and had diagonal witness marks where the stabiliser had scraped
under the cut-out.

M EM ORANDUM

To: J Gibbons, Q A Manager

From: Mike Pardoe

Date: 10 September 1996

Subject: G-UKFE TOWING INCIDENT

On Thursday 5 September I interviewed Mr K Black in connection with the above incident

on the 23 August.

Mr Black advised that he had worked on the aircraft during the night of 22 August prior to
the incident. He had taken the aircraft over from U. Pink and completed the engine runs on
the compass base. The aircraft was removed from the base by AVE and positioned to the
Hangar. He went to the Line Office and then proceeded to the Hangar.

On his arrival he found that Mr Brown was in the process of supervising the parking
operation. Mr Brown was recalled to the Line and Mr Black took over. The aircraft was
positioned left of the centreline (looking into the Hangar).

Mr Black worked the engine change until Mr Green joined him at about 02:00 to perform
the Daily Check. He asked Mr Green to fit the stabiliser tip advising him of the
requirement to fit the static wicks and believes that he advised him that the replacement was
due to the previous damage.

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At about 05:30 Mr Green went off to phone for a tug, thereafter at ERROR INVESTIGATION
about 06:00 Mr Black EXERCISE
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decided to return to the Line to complete his documentation.

Shortly after leaving the Hangar they encountered the tug and Mr Black advised Mr 
Green that "you'd better go back over". Mr Black proceeds back to the Line Office.

He was not sure as to whether Mr Green had requested any assistance and did not give any
further thought as to how Mr Green was to extricate the aircraft.

Whilst completing the paperwork in the Line Office he was made aware that the aircraft had
been damaged.

The above only serves to re-inforce any observations and recommendations made in last
weeks report We will discuss this at our meeting on Wednesday.

At this time I have been unable to proceed with an interview with the driver due to litigation
questions.

Mike Pardoe
Head of Line Maintenance

cc: Robert Nunn - Managing Director

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YOUR CONCLUSIONS

AND RECOMMENDATIONS

EXAMPLE 2

Conclusions

Recommendations

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THE PROBLEM

EXAMPLE 3

THE FACTS

EXAMPLE 3

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YOUR CONCLUSIONS

AND

RECOMMENDATIONS

EXAMPLE 3

Conclusions

Recommendations

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