Investigation number
199900673
Occurrence date
Location
Port Hedland, Aero.
Report release date
Report status
Final
Investigation type
Occurrence Investigation
Investigation status
Completed
Aviation occurrence type
Flight control systems
Occurrence category
Incident
Highest injury level
None

The pilot of the Cessna 441 reported that while checking the
aircraft's flight controls during a pre-flight inspection, a
rubbing sound was evident in the vicinity of the inboard section of
the left aileron. The ailerons were capable of full deflection in
the correct sense with no noticeable restriction of movement. After
an inspection by the operator's chief pilot and the check and
training pilot, the aircraft was deemed to be serviceable. A
precautionary note was made in the aircraft's Maintenance Release
for the aileron system to be inspected by the operator's
maintenance organisation. The pilot then continued operating the
aircraft. On return to the operator's main base at Jandakot, an
inspection by maintenance personnel revealed that the aileron
control cable was incorrectly rigged and fouling the airframe
structure.

The BASI investigation revealed the following deficiencies:

  1. a maintenance oversight and inadequate procedures for the
    release of an aircraft after undergoing maintenance to the flight
    controls;
  2. sixty flying hours had elapsed since maintenance was last
    performed on the aileron control system. The defect was apparently
    not recognised during that time; and
  3. the flight crew did not consult with company engineering
    personnel for technical advice prior to commencing the flight.

During the BASI onsite investigation, the details of this
occurrence, together with occurrences 9804343, 9900874 and 9900556,
which identified similar deficiencies, were discussed with the
operating company's management and staff. Concerns identified by
the BASI team were translated into company recommended safety
actions, which management undertook to implement. The company
immediately introduced changes to the duplicate inspection
procedures, and would introduce education and awareness safety
notices regarding effective communication between flight and
maintenance personnel. It would also emphasise the responsibilities
incumbent on the crew when carrying out the daily inspection
procedure. The implementation and effectiveness of these company
initiatives will be monitored by BASI.

Aircraft Details
Manufacturer
Cessna Aircraft Company
Model
441
Registration
VH-LFD
Serial number
4410164
Operation type
Aerial Work
Departure point
Port Hedland, WA
Departure time
1943 hours WST
Destination
Meekatharra, WA
Damage
Nil