On December 19, 2005, a Grumman Turbo Mallard amphibious airplane crashed into a shipping channel adjacent to
Question:
On December 19, 2005, a Grumman Turbo Mallard amphibious airplane crashed into a shipping channel adjacent to the Port of Miami, Florida. This occurred shortly after takeoff from the Miami Seaplane Base where Flight 101 regularly scheduled passenger flights to Bimini, Bahamas. This flight has 2 crewmembers and 18 passengers on board when the right wing separated during the flight, because of this all 20 people aboard were killed and the aircraft was completely destroyed. Flight 101 was operating under the provisions of the 14 Code of Federal Regulations Part 121 on a visual flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident (NTSB, 2005). According to the investigation done by the accident investigators, the maintenance crews for the aircraft had not properly accounted for the metal fatigue. What was even worse a mechanic has apparently discovered the crack on the right wing and used stop drill holes. This is a temporary method to stop a crack from growing, sadly, this did not work as it was found a mechanic has tried this method 3 separate times.
Statement 1
A post-crash analysis revealed that the skin crack had been stopping drilled 3 times prior to being covered up with a doubler. This indicates that the damage was observed at least 3 separate times, with the damage getting progressively worse each time. After the skin doubler was installed there were several instances of fuel leaks at the RH wing in that area. The doubler itself was deemed improper by the NTSB investigators, as well as the director of maintenance at Chalk's Ocean Airways. Per the NTSB, the improper repair on the RH wing was likely performed by Chalk's Ocean Airways, and there was no documentation of who performed the repair, or who inspected it.
In order to prevent an accident like this from happening, fatigue damage should be elevated to the FAA to determine possible fleet issues. The upper spar cap in the left wing of the accident aircraft was cracked and repaired, but the right side was never noticed. The G-73T aircraft had several instances of the rear spar upper and lower cap experiencing fatigue cracks near WS34. A stress crack at this location on more than one aircraft should have flagged a fleet-wide recurrent inspection requirement, or possibly a required doubler installation to reinforce that location to prevent further damage. The failure mode did exhibit exterior indicators that were overlooked, namely the skin crack and fuel leakage. Unfortunately, these issues were not taken seriously enough. They were documented, squawked, and brought up in the CASS meetings, to no avail.
To properly catch structural fatigue issues, the aircraft needed to comply with aging aircraft inspections. Unfortunately, the aging aircraft inspection that took place just 2 months prior to the accident was a review of documentation only. There was no note of the improper doubler on the RH wing. After its aging aircraft inspection, it was given the green light to continue operating. A supplemental inspection per 14 CFR 121.370a could have caught this damage, but this aircraft was not required to be subjected to supplemental inspections because it did not have a seating capacity of 30 or greater. The NTSB issued a Safety Recommendation regarding the exemptions from the supplemental inspections, noting that these inspections could have caught the structural damage before it escalated to catastrophic failure.
In summary, escalating fatigue damage to the FAA to allow for fleetwide communication of potential failure modes is critical to ensure fleet safety. Allowing for certain aircraft to be exempt from in-depth aging aircraft inspections due to size is an unsafe decision. The accident aircraft had over 39,000 flight cycles. If these aircraft were subject to the supplemental inspection requirements of 14 CFR 121.370a, the fatigue damage would have been caught and corrected prior to this incident.
Statement 2
After reviewing the NTSB's report there were so many failures and had one or more of the failures been addressed, the accident may not have happened. Since Chalk's was such a small airline, operating under 14 CFR Part 121, without adequate oversight of many program areas, the one thing I would suggest that could have prevented this accident was proper and adequate FAA oversight and surveillance. Proper FAA training for Inspectors coupled with programs like the current Data Collection Tool (DCT) to assess the maintenance program, reliability program, aging aircraft program, and safety program could have prevented this accident. There are many other avenues to approach how this accident could have been prevented such as a more attentive Continuing Analysis and Surveillance System (CASS) board, the FAA hotline or FAA whistleblower program, a more in-depth aging aircraft inspection, a more robust maintenance program, or adequate maintenance recording keeping. But one area that the company could have ensured they were in compliance with is 14 CFR Part 121 Subpart L: Maintenance, Preventive Maintenance, and Alterations where proper maintenance repairs were completed and documented for record keeping (Subpart L - Maintenance, Preventive Maintenance, and Alterations, 2023). The investigation found that this was an area of failure as there were missing maintenance logs, undocumented doubler repairs found in the area of failure, as well as other repairs that did not adhere to the maintenance repair instructions.
Statement 3
For this aircraft, because it is a seaplane and mostly operates on oceanic flights, an inspection panel AD would allow for easy inspection of the spars to look for corrosion. This accident could have been prevented however if the maintenance shop for the company had properly completed the structural repairs instead of covering up leaks with sealant and correctly placing rivets.
Statement 4
The attention to detail and to safety that the military has is not matchable. The first is applying documentation processes that ensure that aircraft are getting records reviews done during every applicable quality check. Documentation is a big deal in the aviation industry, you have to be able to track back any maintenance done to an aircraft. A monthly quality inspection should be added to the FAA requirements for every aircraft, when a mechanic knows his job is being inspected, they tend to follow all the rules. Ensuring that the inspections are actually being accomplished, and ensuring that all jobs are double-checked. A military example of this is having a 5 level and a 7 Lvl, one complies with the inspections following the instructions provided by the air force and the other one double-checks if every step was accomplished. This will ensure that a minimum of two sets of eyes look at the aircraft before certifying that the job was accomplished correctly.
Accounting Information Systems
ISBN: 9780132871938
11th Edition
Authors: George H. Bodnar, William S. Hopwood