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Cloncurry Mustering Crash, Screen Shot 2020-09-04 at 11.07.27 am - Coggle…
Cloncurry Mustering Crash
Event Sequence
The Helicopter's 2,200-hour service began on the 12 April 2017 in preparation for the upcoming mustering season
The 2,200 hour service was conducted under a tight timeline with minimally skilled staff
The Cloncurry Air Maintenance had to spread staff to work on 100-hour inspections as well as the 2,200-hour service
The LAME did a final maintenance check of the R22 however, did not inspect the Bell-crank assembly
The pilot completed pre-flight checks and left the Cloncurry Regional Airport on the morning of 2nd August 2017
After 3 minutes of flight time, the workers at Cloncurry Mustering Company witnessed an explosion in the general direction of the flight path
After multiple attempts to contact the pilot, another helicopter flew towards the smoke from the explosion and discovered the wreckage 7km from the airport
The pilot lost lateral control of the helicopter and the blades made contact with the rear tail chopping it off causing the helicopter to breakup in air
The pilot called the appropriate emergency services and deployed an emergency beacon to help locate the accident scene
System Parts
Mustering Helicopter
Robinson R22 Helicopter
Gearbox / Transmission
Engine
Controls
Airframe
Main Rotor System
This is where the bolt failed
Fuselage
Landing Gear
Tail Rotor System
Cloncurry Air Maintenance
Unclear roles and responsibilities
Training
Culture
Air Maintenance Traffic
Warehouse storage capabilities
Staff
Training
Roles and responsibilities
Tasks
Culture
System Lifecycle
Commissioning
Testing
Maintenance
First Flight
Maintenance
Parts
Service requirements
quality control
skills of employees
Decomissioning
After the lifetime of the helicopter for the Cloncurry Mustering Company, the R22 will be sold to a buyer
Operation
Contracting to farms to preform low level mustering of stock animals
Design
R 22 helicopter from Robinson helicopters
The R22 helicopter is the perfect arial mustering platform due to its extremely small size and light weight
People
Pilot
Began flying for Cloncurry Mustering Company in 2004
Had achieved over 10,000 flying hours
The Pilot was well rested the night before
The Pilots demeanour was normal the morning of the flight
The pilot had not exceeded the maximum flying requirements for the week
There were no drugs or alcohol found in post-mortem exam
Maintenance Team
2,200 hour service began on 12 April
Workforce = 2 LAME, 1 AME & 2 Apprentices
Minimally skilled workforce
Extremely busy work period
CASA Internal Audits show that CAM was a compliant organisation
Management
System Factors
Time Pressure
The R22 helicopter was due for the 2,200 hour service in the midst of cattle mustering season
In the month of July 2017, 21x 100-hour inspections were commenced and 20x were completed
Robinson Helicopters reported that a 100-hour inspection should take 24 labour-hours to complete
2,200 Routine
It was found that the company had either inadequately torqued or not reinstalled the fasteners on the bellcrank assembly on other aircraft prior to this accident
Job Design
All staff members of Cloncurry Air Maintenance worked full-time during the cattle mustering season
Minimisation of workforce and minimally skilled workers caused increased fatigue to the LAME's
Workers were often pulled away from the 2,200-hour service to assist with 100-hour inspections
Different workers would do different jobs each day meaning there was no clarity for progress
Lack of communication to complete tasks
Information Transfer
Time Restraints
No Clear Description of roles
Lack of communication between staff members of CAM
Workplace
Workplace Factors
The Cloncurry Air Maintenance building and staff structure was not designed for such a large work demand
Equipment Design
The Helicopter is designed with hard to reach bolts within the bell-crank assembly
The visibility of important components within the bell-crank are impeded from the outside
