CAT File No. C-1378-41
MoT File No. RAP6504-C5051-028167
CIVIL AVIATION TRIBUNAL
Minister of Transport, Applicant
- and -
Northern Dene Airways Ltd., Respondent
Air Navigation Orders, VII, No. 3, s.12(3)
Air Regulations, C.R.C. 1978, c.2, s.826(1)
Journey Log Entries, Aircraft Maintenance
Gordon R. Mitchell
Decision: April 14, 1997
I confirm the Minister's decision of assessment of a monetary penalty. After consideration, I reduce the amount of Count #1 to $1,250.00 and reduce the amount of Count #2 to $1,250.00. Count #3 shall remain at $200.00. The total penalty amounting to $2,700.00 shall be made payable to the Receiver General for Canada and sent to the Civil Aviation Tribunal to be received within fifteen days of the receipt of this Determination.
A Review Hearing on the above matter was held Thursday, March 20, 1997 at 10:00 a.m. at the Prince Albert City Hall, Prince Albert, Saskatchewan.
At the outset Mr. Pratt on behalf of the Minister requested that an amendment be made to the Notice of Assessment of Monetary Penalty. The amendment would apply to similar wording in both Count #1 and in Count #2.
It was requested that the word "five" in the second sentence of both Counts be deleted. It was further requested that in the fourth sentence of both Counts that the words "landing light and" be deleted. The amendments requested were accepted.
The amended Notice of Assessment of Monetary Penalty follows:
Pursuant to section 7.7 of the Aeronautics Act, the Minister of Transport has decided to assess a monetary penalty on the grounds that you have contravened the following provision(s):
Air Navigation Order, Series VII, No. 3, 12(3), in that on or about May 1, 1996, at or near Stoney Rapids, Saskatchewan you did unlawfully operate a Piper PA-31-350 aeroplane, bearing Canadian registration marks C-GWUM on flights while it was not maintained and released in accordance with the approved maintenance manual, by reason of the fact that the said aircraft had the taxi light wired incorrectly and the right propellor spinner was cracked.
FURTHER, in that on or about May 2, 1996, at or near Uranium City, Saskatchewan you did unlawfully operate a Piper PA-31-350 aeroplane, bearing Canadian registration marks C-GWUM on flights while it was not maintained and released in accordance with the approved maintenance manual, by reason of the fact that the taxi light was wired incorrectly and the right propellor spinner was cracked.
A violation of Air Navigation Order, Series VII, No.3, 12(3).
FURTHER, in that on or about May 1, 1996 and May 2, 1996, at or near Uranium City, Saskatchewan you did fail to maintain the Aircraft Journey Log for a Piper PA-31-350 aeroplane, bearing Canadian registration marks C-GWUM by reason of the fact that the following defects to the equipment of the said aircraft were not entered:
- Right propellor spinner – patch is cracked;
- Left brake master cylinder leaking;
- Horizontal situation indicator is out at least 20 to 60 degrees;
- Co-pilot altimeter sticks at altitude;
- Landing and taxi light switches hot wired so both come on with one switch;
- Left firewall inboard rivets loose;
- Left main gear torque links loose;
- Fiber glass on both engine cowls need patching.
A violation of Air Regulation 826(1).
BREAKDOWN OF SANCTIONS:
COUNT #1 = $2,500.00
COUNT #2 = $2,500.00
COUNT #3 = $200.00
TOTAL : $5,200.00
A Piper PA-31-350, registered as C-GWUM and owned by Northern Dene Airways Ltd., was given a #3 inspection at YBE on April 19, 1996.
On May 1, 1996, it was sent to Elite Aero Ltd. in Prince Albert for maintenance. The air time since the #3 check on April 19, 1996 was 17.4 hours. During the flight to Prince Albert the Captain, co-pilot and apprentice engineer aboard completed a snag sheet (Exhibit M-4) covering items that required attention.
The crew members were to leave C-GWUM at Elite Aero Ltd. for the maintenance and were to return with another aircraft. The other aircraft was not available because of a serious maintenance requirement.
The maintenance items on C-GWUM were deferred, and the crew members flew the aircraft back north and put it back into service with no maintenance carried out.
On May 2, 1996 at Uranium City, Inspectors Hanson and Dittbrenner were in attendance when C-GWUM landed and was unloaded, and they did an inspection on the aircraft. While perusing the log books, Inspector Hanson found the snag sheet that had been made out the previous day enroute to Prince Albert. The defects were not entered in the log book. The sheet was between the pages. It was established that the aircraft was back in service, with none of the defects of concern having been remedied.
The allegations were made as a result of the inspection made by Inspectors Hanson and Dittbrenner.
The Following Exhibits were presented during the Review Hearing:
M-1 Log Book pages for PA-31-350, C-GWUM showing pertinent dates, particularly April 19, 1996, the date of #3 inspection and May 1, 1996, the date of flight to Prince Albert.
M-2 Snag sheet found between journey log book pages, C-GWUM.
M-3 Copy of pages from Airplane Parts Catalog for PA-31-350, note the patch drawn on the spinner at the approximate position seen.
M-4 Copy of Certificate of Airworthiness and Certificate of Registration of Aircraft C-GWUM, Piper PA-31-350, Serial No. 31-7405404.
M-5 Copy of Operating Certificate for Northern Dene Airways Ltd.
M-6 Copy of Inspection Program Approval, Reference No. C0482, for Northern Dene Airways Ltd. for Piper PA-31-350.
M-7 Copy of Service Manual pages applying to PA-31-350, wiring diagram for Landing, Taxi, and Wing Inspection Lights. The upper portion of the page is applicable to C-GWUM, Serial No. 31-7405404.
D-1 Right propeller spinner. This was identified, marked and left with Elite Aero Ltd., Ron Cochrane, Prince Albert for quarantine.
D-2 Copy of page from Northern Dene Airways Ltd. Maintenance Control Manual, section 3.6.
The Minister's first witness, Inspector Hanson, related that he and Inspector Dittbrenner did a ramp check on Piper PA-31-350, C-GWUM at Uranium City, Saskatchewan on May 2, 1996.
The aircraft had arrived, and after it was unloaded the inspection took place. When inspecting the log books Inspector Hanson found the snag sheet that had been made up the previous day during a flight to Prince Albert for maintenance. The crew members were to leave C-GWUM at Elite Aero Ltd. and return with another aircraft.
The replacement aircraft was not available, so the maintenance was deferred. C-GWUM was put back into service May 1, 1996, and was therefore inspected in Uranium City on May 2, 1996.
Inspector Hanson went through the list (Exhibit M-2) pointing out the defects that were also listed in Count #3.
The Minister's second witness, Inspector Dittbrenner, was sworn and further explained the defects listed. The term "hot wired" used in the list in reference to the taxi and landing lights received a lot of time and attention. The other defects were referred to, and there was some concern shown as to which if any were airworthiness items.
The third witness for the Minister, Co-pilot Robert Juravinski, relating to the trip to Prince Albert on May 1, 1996, referred to the making of the snag sheet during the trip which was to result in leaving C-GWUM for repairs and returning with a replacement aircraft. He went on to explain that the replacement aircraft was unavailable as it was not serviceable. The decision was that the defect items would be deferred, and aircraft C-GWUM was flown north again and put back in service.
The fourth witness for the Minister, David R. Johnson, Engineer with Northern Dene Airways Ltd., was sworn. He stated that on April 19, 1996 a #3 inspection had been carried out on C-GWUM.
When questioned regarding the landing and taxi light switches, he said that he had checked the wiring and that it was correct, but he had been unable to find the reason why the use of either switch turned on both lights. He replaced a short wire that was frayed, but stated that this was not part of the problem.
The aircraft was allowed to fly like this. He felt that the problem, though not rectified, was not an airworthiness concern.
Mr. I.B. Carson, representing Northern Dene Airways Ltd., called his first witness, Ron Cochrane, Engineer for Elite Aero Ltd., the AMO who was to do the repair on C-GWUM.
Engineer Cochrane gave testimony relating to the maintenance and operation of light circuits, landing and taxi lights, and the replacement of the landing light switch. He stated that the lights operated correctly after switch replacement.
He gave further testimony regarding the right propeller spinner and the repairs that were in place when he first saw the spinner. The repair was carried out in his shop, not by him personally.
Discussion regarding the items listed in the snag sheet and their relation to airworthiness were brought forward, and Engineer Cochrane gave his view as to their safety soundness.
Mr. Carson's second witness was Dave Webster, the owner of Northern Dene Airways Ltd. He related his concerns for a good maintenance program and the methods he used to accomplish this.
Mr. Webster sent aircraft C-GWUM to Elite Aero Ltd. at Prince Albert on May 2, 1996. He stated that all defects were to be corrected and that his company kept a close watch on all maintenance requirements.
He said that when C-GWUM was sent to Prince Albert the crew members were to return with another aircraft. The replacement aircraft was not available; therefore, the work required on C-GWUM was deferred, and the crew members flew C-GWUM back to be returned to service.
Dave Webster, owner of Northern Dene Airways Ltd., sent C-GWUM to Prince Albert on May 1, 1996 for maintenance requirements. He stated that his company policy regarding maintenance was very stringent. Some excerpts from his company manuals are as follows:
Paragraphs 3.6(a) and (b) of the Maintenance Control Manual:
(a) Following a flight all defects shall be entered in the aircraft Journey log.
(b) The aircraft shall not be returned to service until all the airworthiness related defects listed in the Journey log have been rectified.
Paragraph 3.2(c) of the Inspection Program Approval #C0482:
(c) The certificate of airworthiness of a company aircraft is not in force unless the aircraft has been maintained in accordance with its approved program.
During the flight to Prince Albert the crew members, Captain, Co-pilot Juravinski and an apprentice engineer completed a snag sheet for C-GWUM.
The defects on the snag sheet were not entered in the journey log, and the aircraft was returned to service without the listed items being taken care of.
The following day, May 2, 1996, at Uranium City, a ramp check was carried out on C-GWUM, with Robert Juravinski as Captain. After landing and unloading, Inspector Hanson and Inspector Dittbrenner carried out the inspection, and when checking the journey log Inspector Hanson found the snag sheet between the pages.
During the Review Hearing no one denied the existence of the defects listed on the snag sheet, but there was some controversy over which items related to airworthiness.
I found it hard to believe that anyone would not accept that all of the items are airworthiness related, the only difference being the time element. Obviously all had some sign of failure, and only the time factor, short or long, would decide complete failure on each.
I point out here that, although there was not an agreement in testimony given as to who knew of which defects existed, certainly the people named here knew of some, if not all, of the defects. Mr. Webster had to know; he sent the aircraft out for maintenance. Engineer Johnson knew; he had completed a #3 inspection just 17 hours earlier. Mr. Cochrane must have known of some; Engineer Johnson spoke to him every day on the phone. Co-pilot Juravinski on the flight to Prince Albert and the other two crew members knew because they made out the snag sheet on the flight.
The major focus was on two of the defective items listed at the Review Hearing. The first was the light system for taxi and landing lights. The system for these two lights is designed to operate with the landing gear down only. The landing light switch operates both the landing light and the taxi light together. The taxi light switch operates the taxi light alone.
Engineer Johnson who did a #3 inspection on C-GWUM on April 19, 1996 said that either switch turned on both lights together; only the landing light switch should do this, and he stated that this problem had existed as far back as he could remember.
He said that he checked the system, that the wiring was normal and that he was unable to find the problem. He replaced a short wire that was frayed, and it had no effect and was not part of this.
Later, when the aircraft was in Prince Albert, Engineer Cochrane stated that his firm had replaced the landing light switch, and then the lights functioned properly.
Engineer Cochrane said the switch was not opened or checked for condition.
The evidence given did not indicate that the landing light switch was unserviceable; no tests were done. If the switch had arced and welded the contacts as suggested by Engineer Cochrane, I believe this would have been noticed earlier.
When the landing light switch was replaced, the wires were most likely correctly attached and resulted in the system functioning correctly.
I believe that, at some time prior to or during the #3 inspection, someone working on the electrical system had inadvertently attached the short jumper lead from the positive post on the taxi light switch to the positive post on the landing light switch, when it actually belongs on the auxiliary post of the landing light switch.
This was incorrect and would operate both lights with either switch, as was the case, but would not likely be noticeable until viewing the lights while operating the switches on the ground.
The other defect that drew a lot of attention was the propeller spinner. Engineer Johnson stated that they had very few problems with cracks in the spinner and that the spinner was generally sound.
The spinner that is Exhibit D-1 has three patches on it. When Inspector Hanson checked the aircraft at Uranium City, he stated that a crack in the spinner had extended beyond the patch.
Engineer Johnson stated that one of the patches was cracked, and he had stop-drilled the crack in the patch.
I have a problem with stop-drilling a cracked patch. It should have been replaced.
The two engineers involved were questioned regarding the allowed standards for patching spinners, but they were not aware of them.
The patches were not uniform. The rivet spacing varied, and at least one patch was not properly trimmed at the edges.
The engineers said the patches were done to industry standards.
Engineer Johnson, in referring to the omission of entries in the log book, stated that he simply made an error in judgement. He said further that we realize we have a weakness in our system and will be addressing the matter immediately with upper level management.
Captain Juravinski was operating C-GWUM May 2, 1996 when the ramp check was carried out at Uranium City. He was assessed a monetary penalty at this time, and he paid the penalty.
I confirm the Minister's decision of assessment of a monetary penalty. After consideration, I do find the amount of the penalty excessive. I thereby reduce the amount on Count #1 from $2,500.00 to $1,250.00, and reduce the amount in Count #2 from $2,500.00 to $1,250.00. Count #3 shall remain at $200.00. The total penalty then amounts to $2,700.00.
Gordon R. Mitchell
Civil Aviation Tribunal
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