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32 Flight Comment, no 1, 2000

Corporal Mike PelletierWhile conducting a normal twenty-five hourinspectionon a Griffon helicopter,Corporal Pelletiernoticed abnormal otational play n the crankassembly f the tail rotor control counterweight.Furtherinspection evealed hat play on the static stopwasalsoexcessive. orporal Pelletier mmediatelysuspectedhatthe retainernut had worked oose.

Corporal Pelletier ound that the retaining nut could beturned by hand. Technical rdersspecify hat the nutshould be tightened o nine hundred nch-pounds.Theonly thing restraining he assembly as ts lock-wire.CorporalPelletier's lertness nd professionalismesult-ed in the detectionof a significantsafety azard.Had thesituation remainedunnoticed and unresolved seriousaccidentwas ikely o occur. Welldone.

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Caporal-Chef Dave RainbirdLe caporal-chefRainbird, mecani-cien navigant ser-vant dans 'united'helicopteres duKosovo, ffectuaitl'inspection prevold'un helicoptereGriffon lorsqu'ila remarque que Ieniveau du liquidede transmissihn etait bas.Apres avoir refait Ie plein de liquide,Ie caporal-chefRainbird a decide d'effectuer une inspectionplus de1:aillee. tant donne Ie rythme rapide des operations,la chaleur ext.remeet a poussiereenvahissante,l avait deja

etabli quil seraitplus prudent d'effectuer une inspectionsupplementaire des composantscritiques.

Pendantcette nspection supplementaire, e caporal-chefRainbird a remarque line legerequantite de depot noir der-riere la conduite numero deux du circuit hydraulique. 11ensuite accedeau logement de la tran~!fiission et, en passantla main derriere la conduite, l a senti ine rainure. 11 alorsdecouvertque Ie c~ble du detecteurde imaille de la transmis-sion frottait sur a conduite et en provoquait l'usure. lnvisiblesa l'reil nu, eg dommagesdug a l'usure s'etendaientsur plusdes deux iers de a paroi de la conduite.l' effort supplementairedeplore par Ie caporal-chef Rainbirdainsi que son professionnalismeant permis l'identificationd'un element qui constituait une importante menacepourla securite aerienne.La rupture de cette conduite hydraUliqueaurait probablement necessiteun atterrissage orce dansune zone ou abondaient eg champs de mines non repertories.Bien oue. + ":

14 Propos de vol. n2. 2000

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Master Corporal Dave RainbirdMasterCorporalRainbird,a flightengineer ervingwith the KosovoRotaryWingAviation Unit, wasconductinga pre-flight inspectionofa Griffon helicopterwhenhe noticed'. .that the transmis-

sion luid wasJow.After topping up the fluid level MasterCorporal Rairibird elected o carry out a more in-depthinspectionof the area.He had earlierdecided hat giventhe high operational empo,extremeheat,and pervasivedust, hat an additional examinationof critical componentswould be prudent.

During his additional nspectionMasterCorporal Rainbirdnoticed a small amount of black esidueon the rearof thenumber wo hydraulic systemine. He then reacheddowninto the transmissionwell and running his hand alongthe rear of the ine he felt a groove.He determined hatthe transmission hip detectorwire rubbing against hehydraulic ine had causedhe erosion.The damage,whichwasundetectable y the nakedeye,amounted o wearthrough over wo thirds of the ine'swall.MasterCorporalRainbird's xtra effortand professionalismresulted n the identification of a significant light safetyhazard.The failure of the hydraulic ine would have ikelyresulted n a forced anding in an areawhereunchartedminefieldsabound.Welldone.

14 Flight Comment, no 2, 2000

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of the CRM concept, raining standards nd trainingprogram o ensure he operational equirements f allair force communitiesaremet.As an mmediate esultof this occurrencehe unit condued a reviewof the techniques pplicable o flight in obscuing phenomena.Squadronaircrewparticipated n a formaone day CRM lecture given he secondweekof Februar1999and recurrent raining wasconducted n February2000.The Commander Wing s implementinga programto ensure hat all 1 Wing aircreware givenadditionaltraining in CRM and Jisk management.During the courseof the investigationt wasdiscoveredhasomeof the crewhad self-medicatedwith common coldremedies. lthough difficult to quantify, he drugs hat werdetected n the crewcould have adversely ffected heirreactions n the cockpit. In addition, a non-flight surgeonqualifiedcivilian physicianon contract o the baseprescribone of the crewa drug that was not recommended oraircrewuse.

The unit Flight Surgeon nd BaFlight SafetyOfficer conductedreviewof the rules regardingsemedicationduring a flight safemeetingwith the whole squadroCAShas asked1 CAD to reviethe distribution and number ofqualified flight surgeonsnValcartieras well as review heprocedureswhich civilian doctofollow when reating aircrew.

This s not a new occurrence, imply new ndividuals epeing a previousevent.This was an expensive eminderof thneed o properly brief and demonstratehe sequenceso bexecutedn a planned raining flight.

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TYPE: CH146486 GriffonDATE: 7 December 1998LOCATION: Owen Sound ONA ircraft CH146486 departed the Owen Sound air-port at 23102 for a Night Vision Goggle (NVG)formation training sortie. Shortly after take-off theflying pilot (right seat) experienced a 'wash out' ofhis NVG and transferred control of the aircraft tothe non-flying pilot. Moments later, he #2 'ENGINEOUT' light illuminated and the #2 Inlet TurbineTemperature (ITT) climbed rapidly. The crew turnedback to the airport and then the #2 engine "FIRE"light illuminated on short final to the runway. Thecrew initiated the checklist procedure for an enginefire, executed a run-on landing and emergency shut-down and egressed he aircraft without incident.The aircraft sustained D Category damage dueto the overheat condition in the #2 engine.An engine overheat condition can occur if too muchfuel is metered to the combustion chamber. Excessfuel would most likely be traced to a failed FuelControl Unit (FCU) or improper selection of theFCU operating mode (Governor switch). Technicalanalysis of the powerplant and its components didnot reveal any electrical orh ' l 1 1 , -mec amca anoma y to exp am fig!the engine malfunction and fire. IIThe investigation su,b~e.quentl~f"'I:4~ilocused on the possIbilIty of ~ Iimproper selection of the FCU ;operating mode. In-flight selec-;ifJ\tion of the GOVERNOR switch I""from AUTOMATIC to MANU- ITaAL mode with the throttle inthe full open position will cause heFCUto meter 6 times the normal amount ofto the engine.The crew took-off with the HUMSUsage Monitoring System) PermanentTracker switch in 'Night' mode. When theHUMS system took an automatic samplingof the blade track, an infra-red beam wasprojected vertically into the blades from thesensor ocated on the nose of the aircraft in frontof the right seat pilot (flying pilot). This causedthe 'wash-out' of his NVG. Placing the mode switchin 'Day' prevents the projection of the IR beam.The HUMS 'mode' switch is located at the top rightside of the centre pedestal. The #2 engine Governor'mode' switch is located directly below it on the sameconsole.Analysis of the Cockpit Voice Recorder (CVR)tape indicates the right seatpilot's 'wash-out' prob-lem was rectified co-incident with the initiation ofthe engine emergency. Although the right seat pilot

Flight Comment, no 3, 2000

doesnot recall selecting 1,the HUMS mode switch [during the departure rom ithe airport, the possibility ~of an ncorrect switchselectionon the part ofthe crewwas nvestigated.If the right seatpilot moved he HUMS mode switchfrom Night' to 'Day' (aft movement),one would expectto get he resultheard on the CVR (wash-outproblemrectified). f he moved he.Governor witch o 'MANUAL'(aft movement), hen one wouldexpect he resultsseen.in the engine. .The Governorswitchwas ested o determine f it couldbe inadvertentlymoved during selectionof the HUMS modeswitch. It was mpossible o move he Governor switchwithout consciously ifting the switch first (overcentre ock). The Governor switch s also heonly switch in the cockpit hat hasa unique rian-gular op. Although t is possibleo make an ncor-rect switch selection rom a human factors per-

spective topographic misorientation), t wouldseemunlikely basedon the function and shapeofthe Governorswitch.The aircraftwas.configured in AUTOMATIC governoI for takeoff and the right seatpilotstated hat MANUAL governorwasnot selectedn-flight. The investiga-tion teamwas unable o determinewhetheror not the overheat onditionwascaused y an improper selectionof the FCU operatingmode (Governoswitch).The eventswhich precipitateIU the enginemalfunction and fire couldnot be determined.:Several eficiencies erediscovered uring the courseof theinvestigationwhich requiredcorrectiveaction. When he #2engine ailed, he #2 generator ell off line causing he non-essential us to de-energise.When he non-essential us de-energised,he co-pilots nstrument ighting extinguished ndthe #2 and #3 radioswere emporarilyunavailable. hese wodesign haracteristics rebeing nvestigated y the technicaland operationalauthorities o determine f there are anyproceduralor engineering hangesequired.

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Le commutateurGOVIRNOR du moteurnumero 2 se rouvedirectementSallS elui-cisur e m~mepylone.L'analyse e a bandede

l'enregistreur honique(CVR) ndique que eproblemed'eblouissement u pilote en placedroite s'estcorrige en m~me empsqu'a commencea situation d'ur-gence elativeau moteur. Bienque e pilote en placedroitene sesouvienne as d'avoir selectionnee commutateurdusystemeHUMS lors de departde 'aeroport, on s'estpenchesur e fait que 'equipageait pu commettreune erreurdeselection e commutateur.

Si e pilote en placedroite avaitdeplace e commu-, tateur de mode HUMS de a position Night' a aposition Day' (mouvement ers 'arriere), on s'at-tendrait a obtenir e resultatdont fait etat 'enreg-istreur phonique (problemed'eblouissement or-rige). S'il avaitdeplace e commutateurGOVER-NOR ser MANUAL (mouvement ers 'arriere),alors on s'attendraitaux resultats on-, states ans e moteur.

: On a fait l'essaidu commutateurdu: regulateurpour determiners'il pou-vait ~tredeplacepar nadvertance en-dant a selectiondu commutateurdudispositifpermanent.11etait mpossi-ble de deplacere commutateurduregulateur ansd'abord souleverenJ toute conscience e commutateur (Ie._.~ commutateur doit ~tre souleve pourchanger e position). Le commutateuIGOVERNORestaussi e seulcommutateurdu pastedepilotage dont Ie dessus st riangulaire.Bien qu'il soit possi-ble de selectionnere mauvaiscommutateurdu point devue des acteurshumains (desorientation opographique),ce seraitpeuprobablecompte enu ~ la fonction et de aforme du commutateurdu regulateur.Le regulateur el'helicoptereetait en positionAUTOMATIC pour Ie decol-lage et e pilote en placedroite a affirme que e regulateurn' avaitpasete selectionne ur MANUAL en vol. L'equiped'enqu~teurs 'a pasete en mesurede determinersi a sur-chauffeavaitete causee ar une erreurde selectiondumode de fonctionnementdu regulateur e carburant(commutateurGOVERNOR). escirconstances ui antcausee problemeavec e moteur #2 et Ie feu n'ont pu~tredeterminees.

TYPE: CH146486 GriffonDATE: 7 decembre 1998EN DROIT : Owen Sound ONL 'helicoptere CH146486 a quitte l'aeroport deOwen Sound it 2310Z pour tine sortie d'entraine-ment en formation avec unettes de vision nocturne.Feu apres Ie decollage, e pilote aux commandes por-tant des unettes de vision nocturne a ete victimed'un eblouissement et il a passe eg commandes del'appareil au pilote non aux commandes. Feu apres,Ie voyant 'ENGINE OUT' du moteur numero 2 s'estallume, 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 courtefinale sur la piste. L'equipage a execute a liste desverifications relative it un incendie moteur, a executeun atterrissage oblique et un arr~t complet d'urgencede l'helicoptere et a quitte l'appareil sans ncident.L'helicoptere a subi des dommages de categorie Dcauses par tine surchauffe du moteur #2.Une surchauffe de moteur petitse produire si trop de carburant -,est fourni it la chambre de com-bustion. Un excesde carburant Iserait probablement attribuable a 'Iun regulateur de carburant (FCU'"idefectueux ou it tine selection ~erronee du mode de fonction-Dement de ce regulateur(commutateur GOVERNOR).L'analyse technique du moteur etde sescomposantes n'a pu determiner aucunefaute electrique ou mechanique qui pourraitexpliquer leg defaillances du moteur et Ie feu.L'enqu~te s' est ensuite penchee sur laite d'avoir selectionne Ie mauvaisd'operation du FCU. La selection du commu-tateur GOVERNOR du mode AUTOMATICau mode MANUAL en vol alors que la com-mande des gaz est en position completementouverte amenera Ie regulateur de carburant itfournir six fois plus de carburant au moteur.L' equipage avait selectionne Ie commutateur du dis-positif permanent d'alignement de pales du HUMS(Health Usage Monitoring System) t la position'Night' avant Ie decollage. Lorsque Ie systeme HUMSa effectue un echantillonage automatique des pales,un faisceau nfra-rouge a ete projecte verticalementsur leg pales it partir du detecteur situe sur Ie nez del'helicoptere juste en avant du siege de droite (piloteaux commandes). Ceci a cause 'eblouissement de seslunettes de vision nocturne. Selectionner Ie commu-tateur dans la position 'Day' previent la projection dufaisceau R. Le commutateur du systeme HUMS setrouve dans Ie coin superieur droit du pylone central.

Propos de vol. n3. 20008

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Alors qu'il terminait son inspection du rotor dequeue et du baTtier d'engrenages a 90 degres, Iecaporal-chef Laporte a remarque que Ie bouchondu baTtier d'engrenages en question semblait setrouver en position plus elevee qu'a I'habitude surson support. Afin de proceder a une inspectionplus approfondie du baTtier d'engrenages, il apris Ie temps d'aller chercher un escabeaudans Iehangar. L'inspection detaillee a dairement demontreque Ie bouchon de remplissage d'huile du baTtierd'engrenage a 90 degres tenait a peine sur sonsupport.La perte d'huile de ce baTtier aurait pu avoir degraves consequencesallant meme jusqu'a la pertepossible de I'appareil et de son equipage. Le grandsaud du detail dont a fait preuve Ie caporal-chefLaporte, et ce, malgre de mauvaisesconditionsd'inspection pre-vol, merite d'etre souligne. .

Le Griffon portantIe numero CH-146426venait a peine de subirune inspection demaintenance planifieeet devait voler plustard dans la soiree.Le caporal-chef Laporteavait ete assigne a volerprecisement dans cetappareil au cours deson vol d'entralnementavec lunettes de visionnocturne (LVN).Le caporal-chef Laporte, a commence I'inspectionde I'exterieur ,del'appareil stationne sur la ligne devol.Le soleil etait deja couche et la faible lumiereambiante rendait I'inspection pre-vol difficile.

32 Propos de vol, nO 4, 2002

While completing his examination of the tailrotor and gO-degree gearbox assembly, MCplLaporte noticed that the gO-degree gearboxcap appeared to be sitting higher on its postthan usual. In order to complete a more detailedinspection of the gearbox, he took the extra timeto get an aircraft stand from the hangar. Uponcloser inspection, it became readily apparent thatthe gO-degree gearbox oil filler cap was merelyresting upon its post.The loss of oil from this gearbox could have hadcatastrophic effects, possibly resulting in the lossof the aircraft and crew. MCpl Laporte is to becommended for his superior attention to detailunder less than ideal pre-flight conditions. +

Griffon aircraft#CH-146426 had justbeen released frommaintenance after ascheduled inspectionand was scheduled tofly later in the evening.MCpl Laporte wasassigned to fly in thisparticular aircraft forhis night vision goggle(NVG) training trip.MCpl Laporte com-menced his walk-aroundwhile the aircraft was

parked on the flight line. The sun had alreadyset and ambient lighting was at a minimum,making conditions difficult for carrying out thepre-flight inspection.

32 Flight Comment, no 4, 2002