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1 considerably, and I started working on taking on project
2 management for some of the engineering projects that were
3 going on, DPFMS installation, things of that nature. I
4 started running those as project manager and basically that
5 launched into the engineering department development.
6 Q Okay, thank you. Could you please describe your
7 professional qualifications for the position that you held
8 at the time of the accident, i.e., director of engineering?
9 A Yes, I've attended the University of Cincinnati
10 electronic course at the University of Cincinnati, and most
11 of my experience came from working with manufacturers, STC
12 holders, STC developers, engineering firms. At the time
13 Emery was dependent upon outside engineering firms to
14 develop STCs, and I can't recall how many projects I oversaw
15 as project manager -- that's basically the background for
16 that.
17 Q That's fine. Could you please identify any
18 special qualifications that were required by Emery at that
19 time?
20 A For?
21 Q For the position of director of engineering?
22 A I believe they were management -- prior
23 management experience, -- I can't really recall all of them.
24 Q Are you a current A&P?
25 A Yes, sir.
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1 Q What position, by title, did you report to while
2 acting as the director of engineering?
3 A Vice president of technical services.
4 Q And what positions, by title, reported to you as
5 the director of engineering?
6 A I had systems, structures, power plants and
7 avionics engineers reporting to me. The manager of
8 reliability, at the time it was Robert Peck, and the manager
9 of technical publications.
10 Q Okay, thank you. Could you please describe your
11 major duties and responsibilities as the director of
12 engineering?
13 A Major duties and responsibilities, mostly was
14 coordination of activities below me and then gaining
15 funding, analyzing the industry to see what was the next --
16 you know, the next big AD, not the smaller ADs, but larger
17 ADs -- aging aircraft things, when they shut down the Omega
18 system -- that was a -- you track those type of things and -
19 - around the world, to make sure that Emery was poised to
20 have the funding and the components, and have a project in
21 place to take care of those things, such as TCAS and things
22 like that. So it was kind of divided between managing the
23 processes and the people, and looking ahead to see what was
24 going to be required.
25 Q Alright. As the director of engineering, were
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1 you responsible for monitoring aircraft technical problems
2 in order to minimize their impact on operational performance
3 and maintenance?
4 A The reliability, yes.
5 Q As the director of engineering, were you
6 ultimately responsible for submitting changes to the
7 maintenance and inspection programs?
8 A The reliability -- the MRB, the maintenance
9 reliability board -- that's where the changes were
10 introduced. I'm not sure if I'm answering your question.
11 Q Were you ultimately responsible for submitting
12 changes to the maintenance inspection programs since the
13 manager of reliability reported directly to you? Were you
14 ultimately responsible for these functions?
15 A No, it was not a sole function to put those
16 changes into the maintenance program. It was a board
17 function.
18 Q Which would reside within the engineering
19 department?
20 A The maintenance reliability board consisted of
21 department heads. Any changes to the maintenance program,
22 there'd be a recommendation that would be -- you want me to
23 describe the process, real short?
24 Q That would be great.
25 A Okay. Reliability would analyze the incoming
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1 data. If there was a trend spotted for some sort of
2 negative impact, irregardless of what it was, a review of
3 the work decks, all the work cards, would be reviewed to see
4 where -- if that activity was taken -- if there was -- say
5 it was a seat lubrication. We were having problems with the
6 seats, the maintenance of the seats, jamming of the seats.
7 We found in some of the cards where the seats were being
8 lubricated, but we felt that either the lubrication was not
9 correct or we had a better lubricant out there, or that
10 maybe it wasn't frequent enough, reliability would propose a
11 change via a work card -- either an additional work card or
12 editing a work card. That card then would be presented
13 before the MRB to be voted upon, based on all the
14 information. And if it was adopted it would be then sent to
15 the FAA for approval.
16 Q Okay, thank you. Try to rephrase this a little
17 bit. What about changes to the maintenance program itself?
18 Maintenance manuals? Illustrated parts catalog, et cetera?
19 Wouldn't that reside within the tech ... group?
20 A Yes.
21 Q Which falls under engineering?
22 A Yes, sir, it did.
23 Q So there would be some type of cognizant
24 authority over the programs that were put forth?
25 A Yes.
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1 Q Alright, thank you. Would it be appropriate to
2 say that as the director of engineering, you were
3 responsible for initiating engineering changes as necessary,
4 to insure the continued airworthiness of Emery's fleet of
5 DC-8 aircraft?
6 A Yes.
7 Q Could you briefly describe your involvement with
8 this accident investigation?
9 A The night of the accident I was called at home at
10 around midnight. I --
11 Q Not quite that much detail, sorry. Which group
12 you were a member of and major functions you performed to
13 date?
14 A Member of the group's going to be a little
15 difficult. I started out with you, as you know, and I
16 believe that group was called the systems instructors group.
17 Q Air worthiness group.
18 A Okay, if it's all under the air worthiness group.
19 That's the group I've been with since the day of the
20 accident.
21 Q Okay, but initially you supported on scene
22 activities?
23 A Yes, I did.
24 Q And then approximately a year later, when we
25 reconvened the air worthiness group, you were present in ...
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1 A Yes, I was.
2 Q And follow up testing at Emery.
3 A I was not there for the follow up testing at
4 Emery.
5 Q Okay. My error there, thanks. Could you please
6 identify when you left Emery and why you decided to leave
7 the company?
8 A I left in June of 2000 to pursue an opportunity
9 to work and build a start up airline.
10 Q When were you rehired by Emery? And in what
11 capacity do you now serve the company?
12 A I serve the company -- I'm basically being
13 retained to help with different projects within Emery.
14 Throughout the course of this, because they wanted
15 continuity with the accident investigation, I was brought in
16 several times when there were events taking place regarding
17 the investigation, to assist and to maintain that sense of
18 continuity.
19 Q Okay, thank you. I'd like to shift my focus now
20 to the D-check that was performed at Tennessee Technical
21 Services, and in doing so discuss several of the issues
22 pertaining to the maintenance instructions provided by
23 Emery.
24 Mr. Robbins, was it standard practice at Emery
25 for engineering to write simple or generic work procedures
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1 that referred maintenance personnel to the applicable
2 maintenance manual for the detailed work scope?
3 A You're asking about the format of the work cards?
4 Q Yes, essentially.
5 A That was the -- that was the format -- that --
6 I'm not sure if I -- could you restate the question?
7 Q Was it essentially a standard practice at Emery
8 for engineering to write simpler, generic procedures that
9 would refer the mechanic or maintenance personnel to the
10 specific or appropriate maintenance manual?
11 A I don't think there was an effort to write
12 generic cards. I think there was an effort to give as much
13 detail on the cards as possible, given the diversity of the
14 fleet.
15 Q Okay, thank you. Can you describe how
16 maintenance personnel at Emery or its various repair
17 facilities were expected to determine the applicable or
18 effective maintenance manual or illustrated parts catalog
19 reference to be utilized when performing maintenance and/or
20 inspection tasks in accordance with Emery's maintenance
21 program?
22 A Sure. The process is very simple in practice.
23 There's two methods to begin with on identifying what
24 aircraft you have by serial number. Emery produced an
25 aircraft directory which showed the aircraft tail number,
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1 and all the associated other numbers -- fuselage number,
2 manufacture date, original operator, different codes for
3 IPC. That sheet was distributed widely and published --
4 updated whenever necessary, whenever an aircraft came on or
5 left certificate.
6 In that case, you could just pick up the serial
7 number off of that -- off of that directory. If that's not
8 available, say it was stuck out on the line somewhere, on
9 the aircraft cabin entry door there was a placard that would
10 give the serial number. That serial number -- you just need
11 that serial number, you go to the front of the maintenance
12 manual and in that introduction to the maintenance manual,
13 there is a list of the serial numbers. Adjacent to the
14 serial numbers is the applicable code -- this is a general
15 description of it -- I would have to walk through it -- but
16 that serial number is associated with a code in the case of
17 a maintenance manual, code 1, code 2.
18 Once you've established what the code is,
19 anywhere in the maintenance manual that you go, as long as
20 you stay within the confines of that manual, that code is
21 applicable for that aircraft.
22 Q In other words, if you did not have the proper
23 maintenance manual in hand at that time, in search of a
24 particular serial number that should be contained in that
25 manual, would you be able to -- you would not be able to
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1 find the applicable instruction for that aircraft, is that
2 correct?
3 A If the --
4 Q Let me try to rephrase that here. I think I
5 understood your response. What i'm saying is how would you
6 determine or how would maintenance personnel determine which
7 manual they need to refer to in order that they determine
8 the proper code effectivity, and therefore proper chapters?
9 A Well, in the course of this hearing there's been
10 a lot of talk about Emery's manuals, United's manuals,
11 Douglas manuals, and I'd like to, if I can, try to clear up
12 that premise first and maybe help people understand.
13 Q Sure.
14 A The Emery manuals are all the manuals that Emery
15 uses. Okay? Within that set of Emery manuals, there are
16 various manuals in there. One of the manuals that is in
17 there is the original -- I shouldn't say the original, but
18 the published Douglas maintenance manuals. That would be
19 one of the documents that you could go to, and in fact, if
20 you had virtually any of the aircraft, their tail numbers --
21 excuse me, their serial numbers would be listed in that
22 document. Does that answer your question?
23 Q So essentially you're saying a maintenance person
24 could refer to a -- the master maintenance manual for the
25 DC-8 fleet, and therefore determine within Emery's fleet,
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1 which particular maintenance manual they should refer to.
2 A As a starting point, yes, and depending on what
3 that maintenance activity or action was that you
4 specifically were looking for, that would be your starting
5 point. Yes.
6 Q Okay, thank you. In your opinion, as the former
7 director of engineering, when would it be appropriate for
8 maintenance personnel to refer to the master Douglas DC-8
9 maintenance manual or illustrated parts catalog, assuming
10 that the respective manual from the previous operator is
11 available and effective for that aircraft?
12 A It's a judgement call, but let me say this about
13 that comment. In the Douglas master maintenance manual, if
14 you follow the proper code and you get to a maintenance
15 activity, or let's say the maintenance action or activity
16 that you're looking for isn't in there, then you would have
17 to go to the previous operator's manual, and I'd like to
18 give you a brief description, or scenario if I could?
19 Q Sure.
20 A When Douglas built the aircraft, there is a post-
21 production or excuse me -- pre-production options are
22 installed in the aircraft. So as the airplane comes out of
23 Douglas, that aircraft has certain systems on it that may or
24 may not be relative to another aircraft. All those changes
25 are put into the Douglas maintenance manual, and there's a
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1 code assigned, and you find that code, just the way I
2 described before.
3 After the aircraft departs the factory, it goes
4 to the initial operator, they may or may not modify the
5 aircraft further. In most cases, these aircraft were
6 modified by the initial operator, and in that course, some
7 of the operators elected to update Douglas with the
8 information so that that manual was current. There was no
9 requirement to do that, but some of them elected to devise
10 and build their own in-house manual. Okay?
11 So once again -- I'll go back and answer your
12 question again, I go to the maintenance manual, I'm looking
13 for a specific maintenance activity, but I can't find one
14 that matches my aircraft in the master. Okay? I have no
15 option. I have to go to the previous operator. That's one
16 way of doing it. That's a fairly simple -- at least I hope
17 it's a fairly simple operation.
18 Q Let me try to rephrase my question. Maybe I
19 asked it incorrectly. Let's say you're working on a
20 particular aircraft, looking for a particular procedure.
21 Let's say you wanted to do some troubleshooting, say,
22 ailerons. And the particular chapter from that previous
23 operator -- it's a previous operator's aircraft -- did not
24 have a specific chapter related to that maintenance. Would
25 it be appropriate to go to a different -- the master
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1 maintenance manual? Or where else for technical data for
2 that troubleshooting?
3 A It's possible to do that, yes.
4 Q Would you be concerned if maintenance or
5 inspection personnel utilized the original equipment
6 manufacturer's maintenance manual in lieu of the maintenance
7 manual effective for that particular aircraft or system?
8 A No, if, in my opinion, in my experience with the
9 aircraft, if the -- most of the changes that I'm describing
10 are differences in aircraft or avionics related, there's
11 very, very few changes to the mechanical operation of the
12 aircraft. That's significant because in the avionics world,
13 I could go to a chapter in a maintenance manual and see that
14 the part doesn't even exist in the aircraft. My original
15 operator's manual will have that equipment. In a mechanical
16 sense, there's virtually no differences in these aircraft.
17 There may be some differences in the way you adjust certain
18 things, given -- I think we've talked about the United
19 versus the Douglas -- but to answer your question, would it
20 bother me? You'd have to give me a particular instance.
21 Q You just mentioned a moment ago that Emery
22 Worldwide Airlines operated a fairly diverse fleet with
23 aircraft, talking DC-8s dating back 40 years since
24 production, operated by not one or two, but probably several
25 various operators each. How do you know, as the director of
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1 engineering, or how do you expect maintenance or inspection
2 personnel to realize or recognize that a particular aircraft
3 may not have been modified in certain areas of maintenance
4 and therefore, that they are utilizing the proper
5 procedures? What if there had been maintenance that ...
6 reamed bushings for flight controls, et cetera, that might
7 have been improved or added to that maintenance manual? If
8 your maintenance personnel do not look into those manuals
9 and refer to a generic one not applicable to that aircraft,
10 wouldn't you be concerned for that?
11 A Well, if you were revising the manuals for
12 certain things like what you're talking about, the -- much
13 in the same way Tennessee Tech handled their revisions,
14 there's a circle around the chapter that's affected with a
15 revision. So there's -- it's a fairly straight forward
16 process, and maybe I'm not doing it justice, but the
17 possibilities of getting any wrong procedure, based on a
18 change in the case of these manuals, is very, very slim.l
19 Q I think the other point of my question would be
20 that in your response you indicated that you wouldn't be
21 concerned, at least outside the areas of avionics, because
22 you feel these aircraft are fairly similar.
23 A What I hope I left you with is that given the
24 specific topic, I'm ont overly concerned about it, but give
25 me a specific topic and I would like to address that
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1 individually, as to whether I would think that would be a
2 problem or not.
3 Q Okay, why don't we move on at this point here.
4 I'll try to keep that in the back of my mind while I'm
5 asking the questions here, and if I come upon a good
6 example, maybe I'll use it.
7 A Okay.
8 Q Could you explain how engineering was typically
9 informed of problems with existing work cards and/or their
10 associated maintenance procedures?
11 A You say how or?
12 Q Yes, how?
13 A Specifically, I'm not absolutely certain. I can
14 recall a couple of times when the manager of tech pubs was
15 approached by an individual, or maybe a phone call, and one
16 of the cards was questioned about its content or they wanted
17 to change to make it read better, something along those
18 lines. There was an official process which -- there was a
19 request for change document which should have been filled
20 out, and generally speaking, the people that wanted the
21 changes either didn't feel that they were -- it was that
22 necessary or didn't want to take the time to fill out the
23 form, but very few of those changes came through that
24 process. But that was the official way to bring about a
25 change in the maintenance work cards.
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1 Q If that process was utilized in accordance with
2 your maintenance policy and procedures manual, wouldn't the
3 engineering department be involved in the review of those
4 requests?
5 A Sure.
6 Q Prior to the time of the accident, were you aware
7 of any problems associated with the D-check work cards
8 identified within Exhibit 7-K, 7-Kilo, i.e., work card
9 number 3103, 3502, 3504, or 06?
10 A 3502?
11 Q Yes, all exhibits within Exhibit 7-K. 3103,
12 excuse me.
13 A No, I'm not aware with any problems with the
14 cards themselves.
15 Q Okay. According to the revision date block
16 identified on each of the work cards noted, these
17 maintenance procedures had not been revised since 1992,
18 therefore would it be fair to state that Emery was not aware
19 of any problems associated with these D-check procedures
20 since the time of the latest revision?
21 A The D-check cards are -- the D-checks are very --
22 very spaced out on these aircraft, and they don't get used
23 very often. That would be an indication of why the revision
24 date is from '92, which is a fairly long time ago.
25 Q Are you implying that for D-checks -- basically
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1 just let me ask a question. How often would you review the
2 work packages for, say, a D-check?
3 A If during the course of gathering reliability
4 data we felt that something needed to be addressed in the D-
5 check, it would be taken care of at that point or be
6 addressed or looked at in the D-check work cards or by
7 request for revision or request for change on the cards,
8 would be the times that we would look at it. Otherwise, and
9 as I said, the time frame between D-checks is fairly
10 lengthy, and therefore they don't get a lot of exercise.
11 And that same point, when an issue is brought before
12 reliability as a chronic problem, a D-check is not usually -
13 - at least in my experience, it's not really the best place
14 to attack a problem because it is so far out that it would
15 take you a long time to get the fleet changed or fixed or
16 modified or whatever would take place.
17 Q So what would be your philosophy on handling
18 problems that might arise when the aircraft comes in the D-
19 check? Are you suggesting that you would just wait until
20 the problem arises and deals with it as it comes up?
21 A I'm saying that the work cards were approved and
22 they were working documents. I was not aware, and I was not
23 informed of any problems or request for changes on these
24 cards by any party.
25 Q Okay, thank you. Could you please explain how
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1 engineering would track nonroutine maintenance items that
2 originated due to findings noted during the performance of
3 scheduled maintenance or inspection tasks?
4 A Reliability based its data off of pilot reports,
5 maintenance reports. In the case of nonroutines, there
6 would be maintenance items were tracked as a separate set
7 because there were -- a lot of the nonroutines are -- I'll
8 say cosmetic, or possibly cosmetic, or ball mat, trays --
9 roller trays, those type of problems are logged on
10 nonroutines. It's not something typically that would get
11 the attention of reliability to change a -- make a change in
12 a program to correct. So those items were tracked a little
13 bit differently than the pilot reports.
14 Q Okay, thank you. Could you explain why
15 nonroutine maintenance items identified during scheduled
16 maintenance were not recorded or entered on the applicable
17 work card that prompted the initial maintenance inspection
18 activity?
19 A Could you say that again, please?
20 Q Yes. Could you explain why nonroutine
21 maintenance items that would arise, or that identified
22 during scheduled maintenance were not recorded, i.e.,
23 entered - basically linked to the applicable work card that
24 prompted the initial maintenance or inspection task?
25 A Why they're not entered on the log page?
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1 Q Right. If you have a work card, for example, and
2 I'll just reference the same Exhibit since it should still
3 be out, Exhibit 7-K, the first card, doesn't matter, any
4 page, the work cards themselves have no block to enter any
5 nonroutine or any discrepancies noted during this
6 inspection, or maintenance activity. And I was just asking
7 why.
8 A Are you -- is this two questions? Are you asking
9 me why it's not put in the log book, or are you asking me
10 why the cards don't reflect a nonroutine?
11 Q No, I'm just asking if you can explain why the
12 nonroutines that are written during an inspection or
13 maintenance task, are not linked to the original work card
14 that led to that finding?
15 A Well, in the case of the C's and D checks, I
16 believe they are, by task. In the lower checks, the B-
17 checks, particularly, there's --
18 Q Please refer to Exhibit 7-K.
19 A Yes.
20 Q Page one, pick any page. Is there any block on
21 that particular work card that you're looking at -- I'm
22 looking at card 3103 -- for maintenance or inspection
23 personnel to enter any such nonroutines for any
24 discrepancies noted during this task?
25 A No, the nonroutine is linked to the card, not the
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1 card linked to the nonroutine.
2 Q Okay. Now, I'm asking, can you explain why?
3 A No, I cannot.
4 Q Do you think it would be beneficial, if you were
5 doing extensive maintenance and during a D-check, let's say
6 modifications to the nose structure, where you have cards or
7 procedures, work orders that engineering had put together --
8 A Those would be treated differently.
9 Q Okay.
10 A Those are generated off of routine inspections.
11 The nonroutines, specifically with regards to Exhibit 7-K,
12 would be corroded rivets, missing glare shield trim -- those
13 type of items -- paint missing -- those kinds of things
14 would be picked up -- I'm not specifically targeting these,
15 but those are the types of items that you would see coming
16 out of a nonroutine generated from a routine work card.
17 Modifications to the aircraft -- those are treated entirely
18 different. Those are documented. They're not even -- they
19 would never have a nonroutine -- to my knowledge, they
20 wouldn't have a nonroutine associated with them, unless it
21 was some side work or the facility that was doing the
22 modification required a nonroutine in order to do the job.
23 Q Is there a link between the nonroutines and the
24 work cards that originated that finding anywhere else, since
25 it's not on the work card?
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1 A It's -- it's on the nonroutine that goes back to
2 the work card.
3 Q So essentially you're stating on the nonroutine
4 there's a reference back to the particular inspection task,
5 i.e., work card?
6 A I believe so, yes.
7 Q Okay, thank you. Please refer once again to the
8 D-check work cards identified within Exhibit 7-K. Could you
9 explain the rationale behind the note found on each of the
10 work cards, i.e., "Use applicable DC-8 maintenance manual,
11 chapter 27, when performing this card."
12 A The rationale behind that?
13 Q Yes.
14 A As we were talking earlier about the coding
15 system in the Douglas maintenance manual, and once again
16 I'll refer to the diversity of the fleet, that Chapter 27 is
17 -- that's the ATA spec 27, main flight controls, will get
18 you to a section in the maintenance manual. Within that
19 section, given different codes -- Flying Tigers, United,
20 SAS, KLM -- those different effectivity codes -- this
21 particular task that's listed on this card may be 2730-7.
22 It might be 2730-4. Rather than try to -- and this gets to
23 the question I answered about the generic nature of the
24 statement -- in order to research the entire fleet -- and
25 remember the fleet changes -- these cards would be nearly
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1 impossible to maintain, and the main reason is because of
2 the lengthy approval process to get them through the FAA if
3 you make even an editorial change, that card goes through
4 the FAA for them to look at.
5 Q Therefore, in your opinion, would it be standard
6 practice for engineering to utilize this type of generic
7 reference?
8 A Again, I don't think there's a conscious effort
9 to be generic. It's --
10 Q Well, let me rephrase this. Let's say you have
11 an inspection card or work card, let's pick one of these out
12 of seven -- let's say work card, on page three, work card
13 number 3504.
14 A Okay.
15 Q Looks to be a total of 12 line items or tasks on
16 this specific procedure.
17 A I think there's ten, but go ahead.
18 Q It carries over onto page four.
19 A Oh. Okay.
20 Q The title of the card, "Install right elevator
21 assembly". Recorded check date, November 4, 1999 -- and
22 we're going to get into this a little bit further detail a
23 little bit later here, but in essence this card was opened
24 two, three weeks. A lot of different people could be
25 working on this -- personnel at different times, different
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1 shifts. Is it very effective, economically, for Emery to
2 require the maintenance personnel -- everybody who touches
3 this card, to do the research that you just identified?
4 Wouldn't it be better for engineering to specify the
5 appropriate procedures to be utilized?
6 A Now, as I said, when that aircraft would in this
7 case, go into heavy maintenance, the code that's used for
8 that aircraft would remain constant throughout the check.
9 And this work card is basically a work step card, and as the
10 mechanic, in this case, in the heavy check facility,
11 accomplished this task, the design of the card is to use, in
12 a kind of a broad sense, and use number two, "Hoist overhaul
13 elevator into position. Install eyeball -- and I can't make
14 out the rest of it, but that's a step that's defined maybe
15 in more detail in the maintenance manual. The reason why
16 this has got a step that is brought out to a signator or
17 signing block is so that Emery can be assured that the step
18 was accomplished as it's listed in this work card.
19 Q Let me try to be a little more specific here.
20 The question is not accounting for the various steps in any
21 given particular card. My concern, question, would be more
22 related to ensuring that maintenance inspection personnel,
23 when conducting a certain task or work card, are utilizing
24 the proper procedures that identify the correct installation
25 process for that particular effectivity, whether or not it's
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1 different from serial number 1, 2, 3, et cetera.
2 A You're asking -- if I get your question right,
3 you're asking whether or not this is an effective card in
4 order to insure that the maintenance facility is using the
5 proper effectivity?
6 Q No, sir, I'm not. I'm asking how engineering can
7 insure that maintenance or inspection personnel source the
8 appropriate maintenance manual, utilizing or referring to a
9 reference such as that listed on this work card or any of
10 these work cards. How can you be assured, in engineering,
11 that maintenance or inspection personnel go to the correct
12 manual?
13 A Well, based on my experience as a mechanic on
14 these aircraft, the process that you use to select the
15 proper manuals steers you in the right direction. It's a --
16 as I said, it's a fairly simple process. It's about the
17 same as going to the auto parts store and picking up
18 replacement headlight for your car. You could be in the
19 wrong aisle that sells fan belts, but you go to the aisle
20 where it says lights, and that's kind of chapter 27. What
21 type of light do you have is going to be given to you by a
22 number. That would be the code. I mean it's a fairly
23 straight forward process.
24 Q I would agree, and the question is not based upon
25 the lack of understanding from the Safety Board's
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1 perspective, but more based upon the assurance that the
2 maintenance or inspection personnel that are doing work in
3 association with this card, or any other card, actually
4 source and utilize the appropriate maintenance manual?
5 A I -- I'm going to have to say i don't know.
6 Q Was it standard practice for the engineering
7 department to include supplemental instructions on work
8 cards, i.e., the information that was important to the
9 maintenance or inspections to be performed, however, that
10 did not exist within the applicable maintenance manual
11 reference?
12 A Can you give me a specific instance?
13 Q Hold on one second. You want a specific one with
14 an Emery work card or --
15 A I need to understand and see what you're talking
16 about -- supplemental information --
17 Q Well, let's just say generally, you're in
18 engineering today, you're engineer, structural engineer
19 assembled a work card for an upcoming D check where you want
20 to inspect a ... elevator assembly. Let's say this is
21 related to the CPC program -- it doesn't really matter. And
22 in that card you identify, you know, in line with these
23 various work cards within Exhibit 7-K, a standard reference
24 to utilize the appropriate maintenance manual. And let's
25 say that for the purposes of this scenario that the
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1 inspection that you want is a very thorough inspection,
2 string D check, you actually want to require that
3 maintenance remove the elevator for example, let's say
4 disassemble the leading edge, look for corrosion.
5 On the work card itself you might have a generic
6 reference such as these in Exhibit 7-K, saying use the
7 applicable maintenance manual.
8 A Can I stop you at this point?
9 Q Sure.
10 A And can we use a different scenario than CPCP
11 because that -- you're getting into --
12 Q Forget I mentioned CPCP programs. We're going to
13 use the same example, your engineer is writing a card for
14 upcoming D check to pull off an elevator, to remove the
15 leading edge, to do an inspection for corrosion. The
16 applicable work card that's finally signed off by
17 engineering, by Emery, and issued for this particular work
18 to be performed includes a generic statement indicating
19 refer to the applicable maintenance manual, and therefore
20 there is no specific reference to a maintenance manual
21 reference, and generic work steps, essentially stating
22 remove elevator, disconnect leading edge, perform inspection
23 for corrosion. Reassemble. Reinstall. And that's
24 essentially the content on the work card itself.
25 Now, let's take this scenario to another step.
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1 Let's say the applicable maintenance manual is manual one.
2 Chapter 27 -- doesn't matter. For this applicable work --
3 and let's say this particular aircraft, in this particular
4 instance, we have a new mechanic, a new inspector that's
5 involved with this work card or this procedure that's
6 expected. They, for whatever reason, incorrectly identify
7 the manual that they feel they should be using, and in doing
8 so follow a procedure for removal, installation -- doesn't
9 matter, take your pick -- and they inadvertently cause
10 damage to the aircraft, injure somebody, miss an area of
11 vital inspection.
12 So once again, my question would be, not related
13 to the process of identifying what the applicable
14 maintenance manual would be for a particular serialized
15 aircraft while in D-check, C-check, B-check, doesn't
16 matter -- my question is, are you concerned from an
17 engineering standpoint that there might be individuals out
18 there that might be challenged due to work load issues,
19 might be newer personnel -- for whatever reason -- might
20 incorrectly identify the applicable maintenance procedures
21 and thereby miss something, inadvertently cause something
22 that might affect the safety of flight?
23 A The concern regarding the possible misuse or
24 incorrect use of the manual is mitigated because, in my
25 opinion, personally, that the facility that's using the
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1 maintenance manual has been certified by the FAA and has
2 been found to be competent and capable of identifying the
3 correct manuals and using the processes in those manuals to
4 perform maintenance on a given aircraft. And they are given
5 that capability, certified by the FAA to perform that
6 maintenance. I understand there may still be some gray area
7 about --
8 Q That's fine. Now let's continue the scenario
9 back to this question. We're in the same set of conditions
10 here. The initial question was, was it standard practice
11 for the engineering department to include supplemental
12 instructions on work cards, essentially for those cases
13 where the appropriate maintenance manual, let's say the
14 individual has it in hand, he's got the applicable
15 maintenance manual. But for whatever reason, this specific
16 reference is missing a vital step, or due to past
17 experience, whether it be an incident, economic reasons or
18 otherwise, engineering or that appropriate operator has to
19 determine that we need to supplement the information that's
20 in this maintenance manual, and for whatever reason they
21 have not already gone through the revision process for that
22 appropriate manual. Would engineering at Emery, include the
23 necessary supplemental information on that specific work
24 card? Is that a standard practice?
25 A In my experience, we had a form called a request
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1 for technical services for the engineering department. And
2 I hope I'm answering your question, but in that form,
3 anybody --
4 Q Let me -- I hate to interrupt but we're to stay
5 on topic here. We've already gone through that at this
6 point here.
7 A But this is a different process, this is just a -
8 - this is just identification of a problem, and I don't care
9 where it was -- a problem on a line, problem with heavy
10 check, problem with the type of information needed,
11 clarification from a technical standpoint -- that request
12 for technical services would come to engineering and we
13 would resolve it internally, and I'm not aware of that
14 process being used in this context. In other words, I'm
15 saying I've never seen, to my knowledge, I've never had that
16 happen to me.
17 Q Okay, so process aside, what I was really asking
18 about is if engineering had already made the determination -
19 - I didn't care about the process -- but had made the
20 determination, had recognized that a particular procedure
21 that the company knew was going to be an upcoming procedure
22 or maintenance task, inspection, and you had an existing
23 work card -- so in other words, somebody has made a request
24 at some point, now it's up to engineering at this point, and
25 now this aircraft is scheduled in for D-check next week.
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1 Would you ever include that type of supplemental information
2 on the work card itself, such that maintenance or inspection
3 personnel would be apprised of the additional cautionary
4 information they require?
5 A Given the specifics that you've given me, such as
6 what's going in the check next week, it would be impossible
7 to adapt that into a work card in that time frame, because
8 of the approval process. Now it may be part -- and I'm only
9 speculating based on what I'm understanding you to say, but
10 there's a work scope sheet that goes with the aircraft that
11 is in some cases it's revised as the check progresses and
12 possibly that avenue may be taken. I'm not -- and if you're
13 asking whether I knew or whether engineering knew if there
14 was a problem with the card would we address it before it
15 went out, the answer to that question is yes, given time and
16 authority and the MRB voted on that change, yes, absolutely.
17 Q Just keep in mind this example is just off the
18 top of my head, so a week time frame is --
19 A Well, -- okay, that's why I needed specifics.
20 Q Let me follow onto a comment to your response,
21 then. Let's say you are pressed for time and due to the
22 cumbersome revision process for your program at Emery, we
23 still have the same aircraft coming in, scheduled for a D-
24 check, and you recognized at the engineering level or the
25 maintenance level that there was a discrepancy in the
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1 program -- in a card -- in a reference, and wanted to get
2 out this additional necessary information to maintenance or
3 inspection personnel. How would you do that?
4 A If it was brought to my attention like that that
5 there was a deficiency in the cards, I knew there was a
6 problem or there would be a problem, I would expedite a
7 change to the card, hand walk it through the MRB and in the
8 case of -- when the certificate moved to Cincinnati, I would
9 if I had to, drive to Cincinnati, meet with the PMI, express
10 the concern about expediting the card and the approval
11 process and bring it back to prevent any damage or any
12 problems to the aircraft.
13 Q Alright, thank you. Let's refer back to Exhibit
14 7-K once again. Parties keep these out --
15 A I never left it.
16 Q And let's take a look at D-check work card number
17 3103, it should be page one, lower right hand corner. The
18 card is titled, "Remove the right hand elevator and tabs."
19 Could you please read the check date noted on the work card?
20 A Check date was September 7, 1999.
21 Q Would you expect the date entered on this work
22 card to accurately reflect when each of the work steps
23 associated with this work card were actually accomplished?
24 A I'm not sure. I'm not sure what prompts the date
25 to be put on the card, whether it's when it goes into work,
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1 out of work, some time in between. I really couldn't answer
2 on that.
3 Q I guess essentially what I'm asking is this
4 particular card only has three items, it's a pretty easy
5 card. We have a final check date -- I'm assuming this is
6 the date that this card is signed off as being completed in
7 its entirety. There's really no way to tell on this card if
8 item one was performed last month, item two last week and
9 item three today. Is that correct?
10 A That is correct.
11 Q Do you have any concerns regarding that from an
12 engineering standpoint? Not necessarily on this particular
13 card, but cards that might be more involved?
14 A From an engineering standpoint? Sure. The 145
15 maintenance facility is hired to basically manage the
16 process and to insure certain quality is built into the
17 product. In the management of that process, this is a tool
18 for Emery to use to insure that all steps were complied
19 with. The management of that process, whether step one was
20 done last week and step two was done this week -- as long as
21 the steps were accomplished, and they were accomplished in
22 accordance with the applicable maintenance manual, I don't
23 necessarily have a problem unless there's some expiration
24 dates, or there's some work conflict that happens with the
25 check. I don't specifically have a concern about the
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1 timing.
2 Q How can you be assured that there is no work
3 conflict with an extended card, say a procedure that's open
4 three, four weeks?
5 A I have had, in the course of some C-checks, prior
6 to the engineering department, the maintenance reps on site,
7 they would kind of initiate a process to say, you know,
8 these two things -- you shouldn't have these two together.
9 If there was a problem with the flow of the work via the
10 work cards, or if a facility was having a hard time
11 accomplishing the work cards because of the way that they
12 were ordered or written, or distributed -- anything of that
13 nature, that would come back through the maintenance reps.
14 We would try to identify -- and again, this did not happen
15 since I was he director of engineering, but I have been
16 witness to the process. They would come back, there would
17 be some dialogue between the heavy maintenance provider,
18 Emery's heavy maintenance group, and tech pubs to decide
19 what can be done about managing the process better, either
20 by changing the cards or by some other fashion.
21 Q Okay. During previous testimony, Mr. Hall
22 described steps that Tennessee Technical Services have taken
23 in the past to insure that their maintenance personnel
24 performed an adequate turnover of maintenance activities
25 that extend beyond one work shift. I think this pertains
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1 directly to this discussion here and the subject at hand.
2 Can you explain how Emery's maintenance program meets the
3 manual requirements of Federal Aviation Part 121.369?
4 A Is that an Exhibit?
5 Q Subpart B, step 9. Yes, that would be an Exhibit
6 7-T. I'll give you a couple minutes to find that.
7 A You say 7-Tango?
8 Q Yes, and I plan on reading the appropriate
9 section here. 7-Tango, pages six and seven.
10 A Okay, found it.
11 Q Six and seven.
12 A Pages six and seven?
13 Q Right. 121.369, subpart B, step 9. My question
14 being, can you explain how Emery's maintenance program meets
15 the manual requirements of this particular FAR, specifically
16 that the certificate holder's manual contain the procedures
17 to insure that required inspections, other maintenance,
18 preventive maintenance or alterations that are not completed
19 as a result of shift changes or similar work interruptions
20 are properly completed before the aircraft is returned to
21 service? In other words, once again we're referring to a
22 card that might be opened, detailed work package might be
23 open -- for two months if it's in D-check.
24 A Right. Prior to selecting any heavy maintenance
25 provider, there's an audit conducted on that facility. The
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1 audit is there to insure that they comply with all the
2 applicable regs -- and I'm stepping outside of my area of
3 expertise, but I know that I have seen -- I've seen the
4 audit paperwork. I know that some of these things in here
5 are addressed as to whether they're satisfactory or
6 unsatisfactory procedure at the facility. I'll have to
7 refer -- I don't have the document in front of me --
8 Q Well, I'm really more interested in just your
9 concern from an engineering standpoint, as the director of
10 engineering. Essentially Mr. Hall, yesterday, testified
11 that, if I recall correctly, TTS put in place a system, for
12 whatever reason, and keep in mind they are working to
13 Emery's Part 121 maintenance program, but for whatever
14 reason, felt it necessary to supplement that program with
15 in-house instructions whereby, for those types of cards in
16 this instance, where there would be shift changeovers, they
17 would attach maintenance manual procedures et cetera, and
18 stamp off each individual step, et cetera.
19 Obviously, that amount of detail is not in any of
20 these work cards that we're talking about that we're
21 concerned with today, and I'm just -- I'm just curious. The
22 question once again would be, how can Emery insure that a
23 repair station, TTS or otherwise, actually fulfills the
24 entire intent to the scope of a particular maintenance
25 action or inspection, especially one that is so drawn out
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1 that might be open two, three, four weeks?
2 A That's the job of the card, I would agree.
3 Q Let's move on.
4 A Okay.
5 Q Please refer to Exhibit 7-K again, pages three,
6 four and five. Once again we're talking about work cards
7 number 3504, top right hand corner on page three and four,
8 and work card number 3506 on the bottom of the page.
9 Wouldn't you agree that based upon the completion dates
10 recorded on these cards, and the fact that the cards are
11 worked in conjunction with one another, that work card 3504
12 remained open for more than two weeks?
13 A In conjunction -- you're saying that both these
14 cards were worked in conjunction with each other?
15 Q Yes, if you refer to page six --
16 A Yes, I see that.
17 Q Okay.
18 A And you're asking?
19 Q Essentially to confirm that the work that was
20 initiated on work card 3504 was initiated at some point on
21 or before November 4, 1999, but was not completed until
22 November 4, 1999. Excuse me, the first date should have
23 been October 14, '99, and was not completed until November
24 4, 1999.
25 A Again, I have to say that I don't know Tennessee
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1 Tech's procedures on what initiates someone to put a date in
2 that block, so I have no idea of the activity behind these
3 two cards marrying up.
4 Q Keep in mind, the questions I'm asking are from
5 an engineering standpoint, and I, myself, as an engineer,
6 I'm more interested in the procedure here, the mechanics of
7 the system here. What you're indicating here is, and I
8 realize that we haven't stopped, and if necessary we can so
9 you can read through these two cards and think about this
10 for a minute, but I'd have to say that I know myself,
11 Captain McGill, first couple times we went through these
12 cards, it is quite confusing to see when you first key in on
13 these approval dates, how, when you're performing work card
14 3504, which is installation of the right elevator assembly
15 procedures, and then refer to 3506, functionally check the
16 right elevator and tab, something which must happen after
17 the elevators are obviously installed, how then the
18 completion date on that work card can be at an earlier date?
19 And I know the answer at this point, so I'm not asking for
20 that.
21 A You're asking if it's a concern -- an engineering
22 concern?
23 Q Essentially that's where I was going, but
24 initially the question was, essentially by looking at these
25 two dates and realizing that they're worked in conjunction,
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1 realizing the work scope that a) you have to install these
2 elevators before you can do a functional check, check ... et
3 cetera, that yes, this work card 3504 had to have been open
4 for two and a half weeks or more. And then leading up to
5 your response, yes, would you as the director of
6 engineering, be concerned that you don't have an appropriate
7 turnover process or something in place?
8 A I would have to review Tennessee Tech's specific
9 turnover process to see if it was a concern. Engineering
10 typically does not get involved with the auditing process.
11 Once the cards are --
12 Q Excuse me. I'm not asking about an auditing
13 process. I'm talking from an engineering standpoint, now.
14 Engineering at Emery has developed these cards --
15 A Right.
16 Q -- but we're not talking about TTS or any other
17 vendor's turnover policy or in house procedures,
18 supplemental or otherwise, to the operator's 121 maintenance
19 program. I'm only discussing, and really only require
20 responses to the work cards from Emery, and Emery's
21 perspective pertaining to the content of these work cards.
22 Are you concerned, from an engineering standpoint, for those
23 maintenance items, inspection or otherwise, for which cards
24 are open for extended periods that that maintenance may or
25 may not -- essentially that maintenance might be missed due
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1 to the signoffs on these cards.
2 A If they follow the applicable maintenance manual
3 in its entirety, there should be no problems with these
4 cards.
5 Q Would you agree that would only be the case if
6 the work card itself is adequate --
7 A No --
8 Q Could you explain your reasons why?
9 A The work card is not meant to be the document
10 used to perform the maintenance. It's a direction to the
11 applicable maintenance manual. The work card is used to --
12 for Emery to document that the steps listed were performed.
13 Q Once again, this gets back a few minutes ago to
14 the discussion about supplemental instructions. I think you
15 would have to admit that any of us working in the aviation
16 have stumbled across, whether we specialize in avionics
17 systems, structures, power plants -- doesn't matter, the
18 maintenance manual is not infallible, neither is the
19 illustrated parts catalog. Member Goglia mentioned that
20 earlier. I don't think I've ever picked up an illustrated
21 parts catalog and not been able to find a mistake on the
22 page I'm looking at.
23 If the work cards merely refer to a maintenance
24 procedure, and as you previously indicated, there's a
25 lengthy period, still undefined, between the review of these
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1 D-check packages, which would include not only the scope of
2 the specific verbiage included within the work card itself,
3 but also that of the applicable maintenance manuals or other
4 technical data, how can you be assured that maintenance or
5 inspection personnel are going to perform the task properly?
6 Even if they have the appropriate manuals, how are you going
7 to be assured, when the cards are open this long, that
8 they've step by step completed the appropriate tasks, that
9 they haven't missed a bolt, or a safety, or a security?
10 A The only answer I can give you is to witness it
11 myself step by step, that's it. That's the only way I can
12 be absolutely certain that every step is accomplished is to
13 witness it myself. Outside of that, I -- I'm -- and maybe
14 I'm missing your point, but I don't understand -- these are
15 steps, this is what the cards are designed, straight out of
16 the parent document, which is the Douglas tech, that's used
17 to validate these steps were taken.
18 And I realize there are errors in the maintenance
19 manual and the IPC and the wiring diagrams and -- there's
20 errors, there are typos, there's issues with every
21 maintenance manual I've ever seen. They're human errors.
22 If I was to try to duplicate that process on this card, I'm
23 just as likely to introduce the same human errors or
24 different ones.
25 Q Wouldn't you agree that one of the roles of
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1 engineering would be to ... mitigate the number of human
2 errors that are out there --
3 A Yes.
4 Q -- and therefore being very specific? Alright,
5 thank you. I got a little bit off track here, but, could
6 you refer back to line item two on the same card?
7 A Card 3504, item two.
8 Q Actually, I'm not sure if I'm not a little bit
9 out of sequence here or not here. Let's just back up here.
10 Refer to card 3103, so it's page one. Could you please read
11 line item two?
12 A "Remove right hand elevator control tab. Bag and
13 attach all parts to tab."
14 Q Okay, thank you. Could you also confirm that the
15 two remaining steps on this work card, i.e., line items one
16 and three, include similar instructions regarding the
17 retention of hardware during the removal of the right hand
18 elevator and gear tab?
19 A Yes.
20 Q Okay, thank you. According to the records
21 associated with the accident aircraft on September 9, 1999,
22 Tennessee Technical Services performed a receipt inspection
23 of the right hand elevator that was ultimately installed on
24 November 8079 Uniform. For the record, this occurred two
25 days following the removal of the existing right hand
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1 elevator, in accordance with work card number 3103. Once
2 again, the check date assigned was 7 September 99 on work
3 card 3103. Therefore, is it safe to assume that in planning
4 for this particular D-check, Emery intended to replace the
5 elevator and tabs removed from the aircraft with overhaul
6 flight controls?
7 A I can't speak to what -- I didn't get involved
8 with the heavy maintenance planning process.
9 Q Do you happen to recall when the aircraft entered
10 the TTS facility for its D-check? Roughly?
11 A October -- I'm taking a guess, I don't know.
12 Q Can you refer back to card 3103 and look at the
13 accomplishment date for the --
14 A Okay, September, sorry.
15 Q Okay, so at least September, and departed D-check
16 November 19th. Was the engineering department aware that
17 the elevator assemblies on this aircraft were to be replaced
18 in lieu of overhaul?
19 A Specifically, no.
20 Q I guess this is essentially the same question I
21 just asked here. If not, can you explain why not? Why
22 wasn't engineering made aware of these plans so that you
23 could have included supplemental maintenance instructions on
24 the work card related to the retention of hardware and
25 disposition of the flight controls? So once again, we're
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1 referring to card 3103.
2 A And your question why the card stipulates to bag
3 all parts?
4 Q More or less. Well, essentially, to summarize
5 the trend of events, November 8079 Uniform entered TTS for
6 D-check. For whatever reason, existing elevator flight
7 controls, including tabs, both sides, would be removed and
8 would be replaced with overhaul units. Card number 3103,
9 within the Exhibit here, handles the directed maintenance
10 procedures for TTS to follow during that removal process.
11 It's fairly basic here. We've just gone through, really
12 only care about item two at this point, but all three steps
13 indicate bag and attach all parts to the elevator.
14 And therefore, my question is, since Emery, not
15 necessarily yourself, but somebody within Emery was
16 cognizant of the fact that these elevators would be
17 ultimately replaced with overhauled units, don't you think
18 it would have been appropriate to provide supplemental
19 instructions on this card or otherwise, such that TTS could
20 do something differently with these parts that had been
21 removed during the performance of card number 3103? For
22 whatever reason, the decision was that the overhauled flight
23 controls would --
24 A Well, the step tells you, "bag and attach all
25 parts to the tab" which is removed and sent out, so the
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1 parts don't exist at Tennessee Tech anymore, they would have
2 to use new parts.
3 Q Okay, thank you. We'll come back to this in a
4 minute. Please revert to the same Exhibit, page two. Work
5 card number 3502, titled "Install right elevator tabs". Can
6 you explain why there are five inspector stamps, including
7 what appears to be two stamps for step five, when the work
8 card merely requires inspections related to steps one and
9 five?
10 A No.
11 Q Based on the information recorded on this work
12 card, can you determine who was actually responsible for the
13 maintenance and inspection tasks identified? This question
14 goes beyond identifying inspector stamp or an A&P
15 certificate number, and refers specifically to those line
16 items where there are multiple stamps or signatures.
17 A No, not on this copy, no. I may be able to if I
18 really studied it, but it would be difficult.
19 Q Copy aside, assuming you had the original before
20 you now, would you be concerned from an engineering
21 standpoint if you had two inspector stamps in one block,
22 which are clearly distinct, two different individuals looked
23 at something. Why did that happen? What were the findings?
24 Did the first individual note something he was concerned
25 with that was ultimately resolved by the second?
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1 A In -- in my years as a mechanic, I have seen many
2 instances where people have used RII authority signatures
3 and inspector stamps outside the confines of what's required
4 by the procedures because they felt this was a critical
5 step, and I'll be honest with you, sometimes it's a matter
6 of just laziness that rather than go look at the proper
7 documents to see whether or not it's required, you put a
8 stamp. It's the safe thing to do. You put a stamp on
9 there. I can't tell you why this was like this. I can tell
10 you -- am I concerned about it? Does it make me concerned
11 that I had two inspectors instead of one looking at this? I
12 don't think so.
13 Q Aren't you really referring to a normal
14 maintenance task that possibly somebody has stamped off as
15 an inspector in addition to the requirement, the sole
16 requirement for the maintenance individual to sign off?
17 That's totally different than the question at hand.
18 The question would be referring to item number five, which
19 requires an inspector's stamp, and there are two inspectors
20 stamps. So my question once again would be, are you
21 concerned that there's not something else evident or that
22 transpired during the performance of this inspection,
23 "Inspector verify control and gear tab installation and
24 security."
25 A First all, this is a normal maintenance task, or
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1 whatever way you phrased it. This is a routine card, okay,
2 first. Second of all, I'm not that concerned that I had two
3 sets of eyes instead of one required. This would not cause
4 me concern except for divergence from procedures at the
5 facility, if you want to be honest about it.
6 Q That's exactly where I'm at. How can you be
7 assured, from a quality standpoint, from an engineering
8 standpoint, that we don't have a deviation here? That
9 something hasn't occurred that should have, or should have
10 that shouldn't have?
11 A Short of witnessing it myself, I cannot.
12 Q Do you not think that's part of engineering's
13 responsibility in putting together these programs?
14 A You're asking me if the result of two people
15 making a stamp on a card that clearly calls for one in the
16 development stage, if I'm concerned at the development
17 stage? I'm kind of confused, I think.
18 Q I think we all are here, but hold on. My next
19 question was going to be how do you prevent additional sign
20 offs such as these, but it doesn't appear that you're
21 concerned with that, so --
22 A I don't want to give the impression that I'm not
23 concerned. It's that I don't have any control over the
24 process unless I'm physically there. If you're going to ask
25 me if these cards are perfect, no, they're not. They are an
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1 evolution process, and I'm sure MSG-3 would provide better
2 cards. In fact, Emery was going in that direction.
3 Q Excuse me, a few minutes ago you said you didn't
4 want to get into MSG-3 and the CPCP program --
5 A Well, the reason I said that before is because
6 this MSG-2 type card does not include corrosion and SIDS
7 (ph) and things of that nature. MSG-3 does. That's why I -
8 - there's a significant change between the two, MSG-2 and
9 MSG-3, and that's -- and it wasn't that I didn't want to get
10 into it, it was that there was a -- from my perspective, it
11 was a difficult analogy to comment on.
12 Q Alright, as previously noted, work card number
13 3502, once again, page two of the same Exhibit, includes the
14 following note: "Use the applicable DC-8 maintenance manual,
15 Chapter 27". For the record, could you identify the
16 applicable maintenance manual that maintenance personnel
17 should have utilized when accomplishing this task?
18 A Can I?
19 Q Yes.
20 A Using the aircraft tail number, yes, I could.
21 Q No, today before you, here. It's one of the
22 Exhibits that's entered. You've indicated before that
23 you've been a party to the investigation. I know you've
24 been involved with the air worthiness group findings to
25 date. This is an area you should be intimately familiar
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1 with.
2 A Yes. I know which code it is, at least I'm
3 pretty sure, but --
4 Q Alright, please note for future reference for the
5 record, that DC-8 maintenance manual Chapter 27- 32-06 from
6 Exhibit 7-L is the appropriate maintenance manual procedure
7 for this tail number. Could you please refer to Exhibit 7-
8 L? Do you have the Exhibit before you now?
9 A Yes, I do.
10 Q Could you identify the revision date on the
11 bottom right corner of the applicable instructions?
12 A First page?
13 Q Yes.
14 A September 9, 1986.
15 Q Okay, thank you. Now referring back to work card
16 number 3502, could you please read step three for the
17 record?
18 A 3502?
19 Q Yes, found on page two.
20 A Card one --
21 Q There's only one card there. Card one of one.
22 It's five steps.
23 A Step two?
24 Q Please read step three.
25 A Three. "Install overhauled elevator control tab
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1 to elevator."
2 Q Okay, thank you. Can you explain how engineering
3 expected maintenance personnel to correctly identify and
4 source the parts, including hardware, required for this
5 installation, when as previously noted, work card number
6 3103 instructed maintenance personnel to bag and attach all
7 parts to those flight control surfaces that were previously
8 removed?
9 A You're asking how they were supposed to get the
10 hardware to do the installation?
11 Q That's correct.
12 A Go to the IPC.
13 Q Why would you -- or can you list off, from the
14 top of your head, what parts would be needed to -- what
15 we're talking about here -- install right elevator tabs. So
16 control tab, gear tab. Can you list -- are you familiar
17 with all the components, all the hardware that would be
18 necessary?
19 A To be quoted at it? No.
20 Q Generally?
21 A I mean there's --
22 Q Why would you expect maintenance personnel, once
23 again, for a card -- some of these cards have been opened,
24 are open for extended periods, it's not uncustomary for that
25 to be the case -- why would you expect -- why would you have
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1 an engineering department? Why would you expect maintenance
2 personnel for each individual that touches this card has to
3 work on this, has to go back to the maintenance manual, to
4 the IPC to identify what parts are necessary? What if there
5 was --
6 A It doesn't take two weeks to hang an elevator, or
7 a control tab. That process would require hardware to
8 attach it. You would have to go to the IPC to get the
9 hardware, attach the tab or the elevator at that point.
10 Now, after that happens, there could be a two week interval
11 where there's no activity because they're doing other cards.
12 That doesn't mean that every mechanic who walks by it or
13 looks at the card is going to the maintenance manual or the
14 IPC or the stores to get hardware. That's not the case.
15 Q Keep in mind, the reason we are here today, at
16 least one of the major reasons we are here today is to a
17 missing bolt. Now obviously, the Safety Board has not made
18 final determinations yet regarding probable cause for the
19 accident, however, I have to believe that everybody in this
20 room that's intimately familiar with the investigation
21 findings to date -- it's a matter of public record --
22 realize that we have a missing bolt on the right elevator
23 control tab, push rod attachment to the crank fitting for
24 elevator control tab. Wouldn't you agree that work card
25 3502 for this particular accident aircraft, which is titled
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1 "Install right elevator tabs", step three, "install
2 overhauled elevator control tab to elevator" has any bearing
3 on why we're here today? And isn't the hardware that's
4 required to install the control tabs the subject of
5 discussion? Isn't that why we're here? And therefore,
6 wouldn't the identification, proper identification of what
7 should or should not be installed, and whether or not it
8 should be safetied, be discussed here?
9 A Yes, it should.
10 Q You're essentially indicating that these parts
11 were removed, they were shipped out because the elevators
12 were shipped out. I guess I would contend, from an
13 engineering standpoint, that that would be a poor practice.
14 A Perhaps it's being shipped out so that they don't
15 use old hardware to reinstall the new elevator.
16 Q Alright, let's move on. Can you explain why the
17 work card does not indicate the required hardware to be
18 installed during this installation, and once again, I'm
19 referring specifically to work card 3502, step three,
20 "Install overhauled elevator control tabs to the elevator" -
21 - and if you know, this is for the right side only.
22 A The reason why it doesn't indicate it is because
23 this is formatted in accordance with the government's
24 original documents and MSG-2 processes.
25 Q And I'll finish your answer, based on previous
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1 testimony you've given a couple times, the work card refers
2 back to the appropriate maintenance manual procedures, is
3 that correct?
4 A Yes, it does.
5 Q Okay, thank you. I'm going to jump ahead here a
6 little bit here, and in the interest of trying to save some
7 time, but I would suggest you refer to Exhibit 7-L again,
8 and the question being since the applicable Emery
9 maintenance manual instructions, i.e., 27- 32-06, found in
10 Exhibit 7-L that was to be used during this installation did
11 not clearly identify the hardware to be utilized, can you
12 explain how the engineering department expected maintenance
13 personnel to correctly identify, install and secure the
14 necessary hardware?
15 A The lower side of that card, under C, referenced
16 procedures, it does list the illustrated parts catalog on
17 that front card.
18 Q Excuse me, can you say that again?
19 A Yes. Under two, special tools and materials,
20 there's reference procedures, C, 2a, is reference to the
21 illustrated parts catalog.
22 Q Which, if you refer to the last page of Exhibit
23 7-L is attached to this procedure?
24 A Okay.
25 Q Let me ask once again, -- let me back up I guess
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1 we're not going to save time here. Could you identify
2 anywhere within this specific Exhibit, maintenance manual
3 Chapter 27-3206, would you please identify the hardware
4 required to connect the right elevator control tab push rod
5 to control tab crank fitting attachment?
6 A All the parts?
7 Q Yes, please.
8 A I could -- you want me to analyze each part or do
9 you want me to just give you a general answer?
10 Q I thought I led this question enough. For the
11 life of me, I can't find dick in this manual.
12 A If pages six and seven don't show the required
13 parts, then it's not here.
14 Q Well, I think we need to establish this for the
15 record, so I'd ask you to take a few minutes reading with
16 you this maintenance manual procedure.
17 CHAIRMAN GOGLIA: Certainly. Why don't we take a
18 15 minute break while the witness, who doesn't get a break,
19 prepares.
20 MR. PUDWILL: Thank you, Mr. Chairman.
21 (Whereupon, a 15 minute recess off the record was
22 taken.)
23 CHAIRMAN GOGLIA: Continue.
24 MR. PUDWILL: Thank you, Mr. Chairman.
25 BY MR. PUDWILL:
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1 Q Once again, we were viewing Exhibit 7-L, which is
2 the applicable maintenance instructions that should have
3 been utilized, I'm assuming were utilized, to install the
4 right elevator control tab. Mr. Robbins, can you confirm
5 now whether or not this Exhibit, this maintenance manual
6 procedure identifies the required hardware at the pushrod
7 control tab crank fitting at the attachment?
8 A It's missing a part.
9 Q Can you be more specific?
10 A Yes, it's missing a cotter pin.
11 Q Walk me through your findings here.
12 A The nearest I can tell --
13 Q Please refer to the appropriate page.
14 A I'm on page six.
15 Q Okay, let me back and ask one question first.
16 Did you find any mention made of the hardware to be
17 installed at this location and the verbiage -- the work
18 steps leading up to the illustrated parts catalog?
19 A I wasn't asked to do that, I don't think. You
20 asked about the parts.
21 Q Well, the intent was to identify whether or not
22 the hardware required for this installation is identified
23 anywhere within this reference. The illustrated parts
24 catalog is part of this chapter, 27-3206. Let me walk you
25 through it. Let's go to page two. Specifically, step
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1 three, removal and installation. See this maintenance
2 procedure could be used for either.
3 Proceed to page three, subpart D near the bottom
4 of the page, step two. "Connect tab pushrod to tab crank
5 and secure." Do you have the same step before you?
6 A Yes, I'm there.
7 Q Do you see any mention made of hardware required
8 at this location in the verbiage on D-3?
9 A No.
10 Q At D-2, I'm sorry.
11 A D-2, no, I do not.
12 Q Okay --
13 A Except for the reference to secure, but that's
14 not a part.
15 Q Just for the record to speed this up, then, the
16 hardware required is not identified anywhere within this
17 chapter within the verbiage, the maintenance instructions
18 themselves. So therefore that leaves the illustrated parts
19 catalog. Can you walk us now through the findings that you
20 have referring to the figure on page 1001 or page six of
21 this Exhibit?
22 A Stand by one -- if you can give me just a second.
23 Q Sure.
24 A Okay, can you go to page six, you said.
25 Q Yes, sir.
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1 A Okay, I'm there.
2 Q You started to indicate that everything was
3 depicted other than the cotter pin. Can you explain what
4 you mean?
5 A Item 10 on page seven is a cotter pin. It's only
6 listed on the Exhibit page six in one place, and that's the
7 forward part of the control push rod.
8 Q Okay. But still, using this Exhibit, this
9 maintenance manual reference, this illustrated parts
10 catalog, once again, page 1001, which depicts figure 1001 of
11 this installation. Do you -- can you identify for the
12 record where the tab crank fitting is located?
13 A The lower right hand corner.
14 Q It's kind of hard to miss. It's labeled as such.
15 Can you see where the push rod attaches to this crank
16 fitting, just above that nomenclature?
17 A Yes, I can.
18 Q Can you confirm that is the bolt we are talking
19 about here today, correct?
20 A That is correct.
21 Q Is there a reference on this figure indicating
22 what hardware is required for this installation?
23 A Not on this figure, no. If I can interject a
24 bit?
25 Q The question is, can you identify anywhere on
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1 this Exhibit, on this figure or the associated parts list on
2 the next page, the hardware for this installation?
3 A If I knew what an AM 310-5 nut looked like, in
4 other words, was it castellated (ph), fiberlocked (ph), or
5 some other type of nut? If it was a castellated (ph) nut,
6 that would be a very good clue that a cotter pin was
7 required to safety, however it's not listed on figure six or
8 page six of this Exhibit.
9 Q Excuse me, can you please explain why you're
10 referring to item eight?
11 A Maybe I'm -- item eight is -- if you look on page
12 six, above where it says inboard hinge bolt --
13 Q Right.
14 A It lists items eight, seven and six.
15 Q Correct.
16 A Eight is a nut.
17 Q I would not disagree with you there.
18 A If it's a castellated (ph) nut, that would be --
19 the only reason you use a -- you only use a castellated (ph)
20 nut in conjunction with a cotter pin, but as I pointed out,
21 the figure on page six does not indicate an item 10 or
22 cotter pin to be installed.
23 Q Let's back up a little bit here. Emery's
24 engineering department issued a fleet campaign directive.
25 We have several Exhibits in here, I don't think it pays at
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1 this time to refer to the particular Exhibit, but we can if
2 necessary -- the one off the top of my head would be Exhibit
3 7-M, which is, I believe, A-27-8, "Perform a fleet-wide
4 campaign directive to inspect Emery's fleet of DC-8 aircraft
5 for proper hardware, proper installation, orientation, et
6 cetera at the -- at this installation at the control tab
7 crank fitting." Once again, we're talking about where the
8 push rod attaches to the crank fitting.
9 Item six, seven, and eight that you were
10 referring to, refer to the inboard hinge bolt, which
11 attaches -- this is the inboard hinge fitting for the
12 control tab. Item six, seven, and eight do not refer to --
13 A I see what you're saying, the push rod link.
14 Q Correct. This was identified previously through
15 the comments process, received by Emery in response to the
16 air worthiness factual report, essentially that hey, yes,
17 this procedure does identify the hardware for this location,
18 item six, seven and eight, and as pointed out at that time,
19 item six, seven, and eight, once again refer to the inboard
20 hinge bolt. So therefore, could you now confirm or would
21 you agree that this procedure, Chapter 27-3206, which is
22 referenced on work card 3502, as the applicable procedure,
23 nowhere within identifies the proper hardware to be
24 installed, orientation of that hardware, whether or not that
25 hardware should be secured, and if so, how, at this time.
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1 A The card refers you to the applicable manual. In
2 this case, this manual is deficient in those items.
3 Q Thank you. Isn't it also true that the Douglas
4 Aircraft Company DC-8 master maintenance manual and
5 illustrated parts catalog also lack this information?
6 A Do you have a reference?
7 Q I can produce one here. Hold on one second.
8 I'll refer to and say it's 7-A, it'll just take me a minute
9 to find the page -- page number. Alright, my memory is
10 partially here, it's been a while ago. There is a reference
11 in Exhibit 7-Alpha that I have in the back of my mind. It
12 does not identify the specific reference, however let me
13 read the paragraph. It's found on page 19.
14 It says, "A review of the DC-8 master maintenance
15 manual and illustrated parts catalog applicable to Chapter
16 27 revealed similar findings, i.e., no reference to the
17 hardware required to install the control tab push rod to the
18 tab crank fitting. However, as previously indicated, a
19 review of the DC-8 overhaul manual ..." -- I'll give you one
20 of my questions here -- "Chapter 27-16-1 did reveal the
21 hardware required at this location."
22 So, to answer your question, I do not have the
23 reference before me here, but it -- suffice it to say -- has
24 been established that the Douglas Company master maintenance
25 manual and illustrated parts catalog, at least at the time
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1 of the accident, also was lacking in the fact that it did
2 not depict this hardware, or describe this hardware.
3 Moving along here --
4 A Can I -- can I ask a question?
5 Q Yes.
6 A If I may? On Exhibit 7-L --
7 Q Yes, sir.
8 A -- page seven, item one, where it listed the tab
9 assemblies for the elevator, have those been researched to
10 see if the push rod and attaching hardware come as part of
11 that assembly?
12 Q I don't recall at this point after two years.
13 A Okay. That's the same with the Douglas master.
14 I'm assuming that it also references an assembly.
15 Q Once again, I don't recall at this time here.
16 A Okay.
17 Q But the bottom line would be that as just
18 established, neither the work card nor the applicable
19 maintenance manual, Chapter 27-3206 describe the hardware to
20 be required for this installation. Is that correct?
21 A I don't want to sound evasive, but without
22 looking at what those parts, those assemblies consist of,
23 I -- I can't answer that they don't. I can only say that
24 the items listed, in their individual -- the individual
25 parts don't show the hardware, but I don't know about the
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1 assembly.
2 Q Okay, that's fine. No problem. Why don't we
3 refer now to -- we'll come back to this now in a second --
4 why don't we refer to the fleet campaign directive found in
5 Exhibit 7-M. Come at this from a little bit different angle
6 here. Once again, for the record, this fleet campaign
7 directive was issued by Emery to perform an inspection of
8 the pushrod installation -- complete pushrod installation,
9 so both at the fore and aft end of the pushrod, based on the
10 best ... findings to date at that time.
11 CHAIRMAN GOGLIA: Mr. Pudwill, will you hold on
12 for one second.
13 MR. PUDWILL: Sure.
14 CHAIRMAN GOGLIA: Since you're going to go on to
15 the FCD. Would the witness please pull out 17-D, 7-M, I
16 believe you have in front of you, and 17-E.
17 THE WITNESS: 17-Delta and who?
18 CHAIRMAN GOGLIA: Echo.
19 THE WITNESS: All 17.
20 CHAIRMAN GOGLIA: We'll provide you with one.
21 THE WITNESS: I don't have 17 -- all's I've got
22 is seven.
23 CHAIRMAN GOGLIA: Mr. Pudwill, I planned on
24 getting into this area in a few minutes, whenever it came
25 back -- those three documents, so I would like to start -- I
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1 have some questions with them, and then I'll turn it back to
2 you.
3 MR. PUDWILL: Would you mind going ahead with
4 that? I need to review this fleet campaign directive,
5 anyway.
6 CHAIRMAN GOGLIA: Okay, thank you. You have 17-D
7 and E?
8 THE WITNESS: Yes.
9 CHAIRMAN GOGLIA: And 7-M?
10 THE WITNESS: Yes, I have all three.
11 CHAIRMAN GOGLIA: Okay. Would you take 17-D
12 first.
13 THE WITNESS: I have it.
14 CHAIRMAN GOGLIA: Okay. Are these documents
15 prepared by the engineering department? Are they originated
16 in the engineering?
17 THE WITNESS: I wasn't there at the time of the
18 distribution of this, but typically they would be. They
19 would come out of the engineering department.
20 CHAIRMAN GOGLIA: Okay, and they're numbered from
21 the top right hand side, in this particular case, 7-M -- I
22 mean 17-D is A-27-7, is that correct?
23 THE WITNESS: That's correct.
24 CHAIRMAN GOGLIA: And it was issued when?
25 THE WITNESS: 2/16/01.
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1 CHAIRMAN GOGLIA: Okay. And if you would
2 continue on the pages two, three, and four. The following
3 three pages. And in the introduction, would you read that?
4 I'll read it aloud for everybody.
5 "Due to the possibility of incorrectly installed
6 parts on the elevator push-pull rod assembly, an inspection
7 of the rod assembly is called for. This FCD inspects the
8 rod ends for proper installation of the bolt, washer, nut,
9 and cotter pin."
10 I have a question for you. Do you know that this
11 was done? It says all -- the whole fleet?
12 THE WITNESS: Do I know that it was complied with
13 on the entire fleet?
14 CHAIRMAN GOGLIA: Yes. Yes or no?
15 THE WITNESS: Well, I believe -- I wasn't there
16 at the time. I believe I saw a list with all the aircraft
17 complied with, but I can't be certain.
18 CHAIRMAN GOGLIA: And do you recall ever seeing
19 what the outcome of that was?
20 THE WITNESS: I only saw the document.
21 CHAIRMAN GOGLIA: Okay. Now, if you would take
22 7-M. And again flip to the cover page. And it's A-27-8.
23 And it's essentially a month later by the date, is that
24 correct?
25 THE WITNESS: That is correct.
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1 CHAIRMAN GOGLIA: And now in this campaign, it's
2 expanded.
3 THE WITNESS: Yes, it is.
4 CHAIRMAN GOGLIA: What kind of -- to your mind,
5 as the head of engineering, an engineering person, what
6 would drive the engineering department or the maintenance
7 department to expand this inspection?
8 THE WITNESS: Sometimes when you -- and I kind of
9 know the history of the origin of 27-7 -- okay, I was
10 involved somewhat with the investigation at Tennessee Tech
11 when we saw some items that we didn't like. And I'll give
12 you the real world scenario. There's times when you get a
13 lot of -- if you publish something, and this has happened to
14 me countless times, you publish something, the instant it
15 hits the street, mechanics call from all over pointing out
16 discrepancies and punctuation, spelling of words,
17 information missing. There's lots of reasons why it may be
18 expanded or reissued to facilitate everybody's questions.
19 And I'm speaking in a general term. I don't know that
20 that's what happened here.
21 CHAIRMAN GOGLIA: And you don't know why they
22 would include the opposite end of the push-pull rod?
23 THE WITNESS: I have -- I don't know.
24 CHAIRMAN GOGLIA: Okay. And then if you would
25 look at 17-E. And this one is 27-8, r... and it is a --
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1 one week later, 3/22/01. And now we add a clearance check.
2 So inside of 30 days, we have a fleet campaign directive
3 issued, reissued, reissued again, expanded and expanded
4 twice. I have concerns that things were being found that
5 drove maintenance and engineering departments to expand the
6 look.
7 THE WITNESS: I don't know that that's the case,
8 however, in similar situations I can -- as I said, I have
9 some familiarity with the first original 27-7 -- because of
10 the seriousness of the nature of the topic, there was a rush
11 to get this out so that at least people were out there
12 looking at the general area to see if there was a problem.
13 Thirty days later, there's a reissue that's expanded from
14 four pages to 11, and I'm assuming this is to -- in my
15 experience -- this is done in response to feedback from line
16 mechanics, maintenance control people who look at these and
17 research them, find other documents or -- possibly finding,
18 not necessarily problems in the field, but conflicts between
19 the content of the FCD and what they're actually seeing on
20 the aircraft. And by conflicts I mean that because of the
21 speed or the urgency to get the initial one out, there's a
22 possibility that it wasn't researched as thoroughly as it
23 could have been, given -- you know, if it wasn't such a
24 serious and wanted to get some immediacy out of it.
25 CHAIRMAN GOGLIA: Can I draw your attention back
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1 to 17-D?
2 THE WITNESS: 17-D?
3 CHAIRMAN GOGLIA: Dog. Correct. The first FCD
4 that was issued on February 17, 1991 -- I mean 2001 -- and
5 on the left hand side of the page, in the second line down,
6 "Complete the entire fleet no later than February 26th". So
7 this campaign was done or nearly done before this next one
8 was issued. But you have no recollection, or no direct
9 knowledge of the findings?
10 THE WITNESS: As I saw -- I saw the document
11 briefly. I didn't analyze the document, no.
12 CHAIRMAN GOGLIA: Okay, Mr. Pudwill, are you
13 ready to continue?
14 MR. PUDWILL: Yes, I am, Mr. Chairman.
15 BY MR. PUDWILL:
16 Q While we're on the subject matter, I am referring
17 of the three, to Exhibit 17-Echo.
18 A Which version is that?
19 Q That's eight. 27-8, revision one.
20 A Okay.
21 Q One little quick general question. Can you
22 identify the signature in the approved by space on page 1 of
23 11?
24 A It looks like Edward Jones.
25 Q Can you identify who that would be?
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1 A At the time, he might have been the director of
2 quality control or the manager of quality control.
3 Q Wouldn't this document originate within the
4 engineering department?
5 A Origination, yes. An FCD is -- in the Emery
6 context, an FCD is treated different than say an EO.
7 Q Wouldn't you have reviewed this document at that
8 time, after whoever had prepared it?
9 A As I said, I wasn't there at the time, but I
10 would assume that it was reviewed by engineering.
11 Q I'm sorry, I might be missing something here.
12 This was -- oh, essentially can you -- I'll just ask, was
13 this before or after you left the company?
14 A After.
15 Q Okay, thanks. Please refer to page 2 of 11. And
16 right in the middle of the page, it's materials.
17 A Yes.
18 Q It identifies the hardware here. So I'm not
19 asking for you know, those numbers -- I can't expect anybody
20 to remember that, but essentially would you agree that we
21 have a bolt, a washer, nut, and cotter pin required at this
22 installation?
23 A Yes.
24 Q Two each. Okay, now I'm referring specifically
25 to the control tab attachment at this point right now?
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1 A Are we in the FCD document?
2 Q Yes, we are.
3 A Okay.
4 Q And just for confirmation of that, flip forward
5 to page nine of 11, and it shows a figure, depicting both
6 the fore and aft ends of this push rod. And once again, I
7 recognize that this can be corrective ... check both ends,
8 but I'm really just trying to confine comments to the
9 accident location at this point, so the attachment at the
10 rear of the push rod to the control tab push rod, and would
11 you agree that you have a bolt, nut, washer and cotter pin
12 depicted in the upper right hand corner, which would be at
13 the tab crank fitting?
14 A Beginning with item 24, is that what that arrow -
15 - is that the area we're talking about?
16 Q Yes, item 24.
17 A Yes, it appears to be a bolt, washer, nut and a
18 cotter pin.
19 Q Okay, thank you. Now, please refer back to
20 Exhibit 7-L, keep that Exhibit 17-Echo available. Compare
21 that figure, if you will, to figure 1001 on page six of the
22 Exhibit, which is page 1001 of maintenance manual Chapter
23 27-3206. Do you see now that item six, seven, and eight,
24 which refer once again to the inboard hinge bolt are in a
25 different location?
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1 A Yes, I agreed before.
2 Q Okay, and therefore now, can we make the
3 assertion that this maintenance manual reference, which is
4 applicable for the accident aircraft, and once again that
5 TTS was expected to utilize during the performance of work
6 card 3502 found in Exhibit 7-K, would essentially be
7 inadequate in that it did not define the hardware at this
8 location?
9 A This particular maintenance manual does not
10 depict the hardware.
11 Q Alright, thank you. Next question was going to
12 be identify source of technical data available to Emery
13 personnel and their contract providers that clearly depicts
14 this hardware by part number, to be installed when
15 connecting the control tab and push rod --
16 A Which document are we on right now?
17 Q I was just going off my notes here.
18 A I'm sorry.
19 Q This -- if you paid attention, you heard ... we
20 already answered this when we referred back to Exhibit 7-
21 Alpha, but essentially, the question was if you could
22 identify a source of technical data that would have been
23 available to TTS at the time, and of course the answer has
24 already been revealed, the ... factual report and the answer
25 that I was looking for was the overhaul manual, chapter 27-
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1 16-1, figure two. And once again, that's Exhibit 7-Alpha,
2 Section 8.2, page 16.
3 To my knowledge, that's the only location that
4 the Safety Board was able to identify the hardware for this
5 installation other than for the drawings provided by
6 Douglas, which I'm assuming TTS did not have available.
7 A On those, I'll take your word, but again, I have
8 to state without knowing what parts consist of -- what's
9 consisting in the parts of an assembly that's listed in the
10 IPC, I'm -- you know, that -- there's a spot there that may
11 be -- there may be something in the assembly listing on the
12 IPC that includes these parts.
13 Q Okay, but --
14 A By far what I'm saying is there's exploded views,
15 and then there's things that come as a set, such as, you
16 know, black boxes and things of that nature. The box itself
17 has a part number, which is an assembled bunch of
18 transistors and what not. The IPC wouldn't necessarily list
19 the transistors. The overhaul manual might, but the IPC
20 would not. So again, I'm interjecting, and it's only a
21 question that I have looking at what you've provided, that
22 the assemblies would have to be reviewed to see what they
23 contain.
24 Q Wouldn't the illustrated parts catalog that's
25 found on pages 1001 and 1002 of maintenance manual Chapter
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1 27-3206 be the applicable illustrated parts catalog for this
2 installation, and therefore shouldn't this procedure, this
3 illustrated parts catalog, include this information?
4 A Include what? I'm sorry, I didn't hear that.
5 Q Identification of the hardware to be installed.
6 A Once again, there's many components on the
7 aircraft, Kevin, that are made up of multiple parts. The
8 higher assembly gets the part number.
9 Q Okay, in the case of -- you know, a lot of these
10 mechanical components, all kinds of components, there's --
11 those are assemblies of multiple parts, sometimes thousands
12 of parts, with the parent part number is what you get out of
13 the IPC. The components that comprise that part number are
14 only listed in the overhaul manual for that particular part,
15 and I'm only caution because I've been working with these
16 aircraft for many years, and sometimes these assemblies --
17 sometimes are where the supposed or the apparent missing
18 parts exist in the assembly itself.
19 MR. PUDWILL: Mr. Chairman, do you mind if I take
20 a minute to confer with my colleagues here?
21 CHAIRMAN GOGLIA: No, in fact I have a couple
22 questions that I can ask right now.
23 MR. PUDWILL: I appreciate that, thank you.
24 CHAIRMAN GOGLIA: Mr. Robbins, when did you leave
25 Emery? What was the date?
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1 THE WITNESS: June -- the end of June 2000.
2 CHAIRMAN GOGLIA: Okay, and where were you in
3 1999 in the organization?
4 THE WITNESS: I was director of engineering. The
5 spring of '99, April, May, something like that.
6 CHAIRMAN GOGLIA: And what were you doing before
7 that?
8 THE WITNESS: Manager of maintenance training.
9 CHAIRMAN GOGLIA: And about how long?
10 THE WITNESS: Six years.
11 CHAIRMAN GOGLIA: There is a number of concerns
12 been voiced by the pilot group about problems with Emery and
13 concerns -- concerns they have about Emery's maintenance in
14 that period of time. Have you heard those?
15 THE WITNESS: I've seen some report in the
16 newspaper, in the local paper.
17 CHAIRMAN GOGLIA: Okay, and did you, as part of
18 your normal duties and especially in the spring of '99, did
19 you ever have access to somebody from the flight ops side
20 bring to you any of the debriefs that the Captain fills out?
21 THE WITNESS: Yes, I saw a couple, a few.
22 CHAIRMAN GOGLIA: And did any of those raise
23 concerns to you about the allegations or concerns that the
24 flight crews were having about the performance of the
25 maintenance department?
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1 THE WITNESS: Yes, in fact, I can recall taking
2 an initiative and doing some research by myself to see if
3 they were founded, and I'll be very honest with you, in each
4 case that I tried to track down evidence of somebody --
5 whatever the allegation was, I can't recall off the top of
6 my head -- but in each case, I could not find substantiation
7 to support the claim.
8 In a lot of cases what I saw was disagreements
9 over -- in some cases, disagreements over the use of the
10 MEL. There's a phrase in the MEL that says something to the
11 effect that you can defer it if the time and material
12 doesn't -- it's going to interfere with the schedule or
13 something along those lines, I can't be sure. That's a
14 point of contention. I mean my -- the mechanic in me says I
15 want to fix the airplane, but sometimes I just literally
16 can't because I don't have the parts available, possibly the
17 tooling, or the time to get the airplane out to make the
18 scheduled departure.
19 The flight ops people, obviously want to fly the
20 aircraft. That's their job. That's what they do. There's
21 almost an inherent conflict whenever you have an aircraft
22 that's got a component broken. And those sometimes depend
23 on people's -- the tempers get a little short when they've
24 been up for -- away from home for a few days. Mechanics
25 don't always have the most gifted way of explaining things
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1 to air crew. There's lots of reasons why there may be a rub
2 in the cockpit which manifests itself into an alleged report
3 of something else. And as I said, in the instances that I
4 took the initiative and tracked these things down, when it
5 got down to the end game, there was -- there was really
6 nothing there but a disagreement that maybe got out of hand
7 a little bit.
8 I'm not saying that there's never a chance of any
9 of this stuff happening. I'm saying in my personal
10 experience, that's what I came to.
11 CHAIRMAN GOGLIA: And I am familiar with the
12 phraseology in the MEL that you're talking about that allows
13 that difference of opinion to exist, and in the course of
14 your duties, did you ever feel any obligation that company
15 policy should be clear in that area and try to initiate some
16 action?
17 THE WITNESS: I think it's very clear, the
18 verbiage. It's the application. You know, the line gets
19 crossed when the air crew wants to leave -- or I should say
20 the air crew wants everything to work on the airplane, and I
21 don't blame them. You know, everybody would like to fly an
22 aircraft with 100 percent of the components working.
23 Maintenance would like to provide that in almost all cases.
24 It's when those two oppose each other, that's where the
25 conflict comes.
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1 Sometimes there's an appearance -- it could be if
2 I'm stuck in Phoenix and I need a bleeder valve or something
3 along those lines, some of these places are difficult to get
4 parts to in a hurry. If the part doesn't arrive at the
5 aircraft in time for the maintenance to be performed and for
6 it to be properly tested, you know, what do you do? And in
7 some cases, incorrect troubleshooting or a system that's
8 troubleshot gives you indications that it could be one of
9 several items that are broke. You order what you think it
10 is, based on your experience, and it winds up not being that
11 part. Now your block time -- you ordered the part, and the
12 airplane's still broke.
13 So I mean there's many different reasons to have
14 a conflict in the cockpit. I've been involved in several.
15 It's just the nature of the business, unfortunately, I think
16 in some cases.
17 CHAIRMAN GOGLIA: I may have you beat in numbers
18 with those conflicts.
19 THE WITNESS: I'm being conservative.
20 CHAIRMAN GOGLIA: In the course of your job as
21 director of engineering, did you ever get concerned over the
22 use of repeat MELs?
23 THE WITNESS: There's been some concern raised
24 about three particular systems that I know of -- four.
25 Autopilot, pressurization, weather radar, and fuel. Those
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1 have been heavy hitters for a long time. I'll address the
2 first three - autopilot, weather radar and pressurization in
3 one swat. The airplane is a dynamic machine. It flies in
4 the air and that's where the pilots want everything to
5 operate. Weather radar picks up storm cells, supposed to.
6 Pressurization is supposed to keep the cabin pressurized at
7 7-8 psi, whatever the particular number is. Autopilot is
8 supposed to maintain that airplane in flight in a steady
9 state, or a stabilized flight.
10 When the airplane lands I can no longer produce a
11 storm cloud to see if the weather radar's working. I can't
12 pressurize the airplane to those pressures, and I certainly
13 can't get the autopilot to hold the airplane stable enough
14 for me to check it out. In the case of the DC-8 -- a lot of
15 the newer aircraft have built-in tests, buttons on the boxes
16 that are a 30 percent chance that whatever it says is bad
17 might be bad. The DC-8 doesn't have that. It's left up to
18 troubleshooting, intuition, and in some cases, best guess.
19 There's no way around it. It's an older aircraft and it is
20 a very difficult and sometimes cantankerous aircraft.
21 But an airplane that's got problems in a dynamic
22 situation and you place it in the hands of the mechanics in
23 a static situation, some of those things are difficult to
24 find. In the case of the fuel --
25 CHAIRMAN GOGLIA: Excuse me. Nobody ever said
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1 our job was going to be easy.
2 THE WITNESS: Well, I got in it because I liked
3 airplanes, not because they love me.
4 In the case of the fuel, there's almost a
5 standard joke in the industry -- and I'm not talking Emery,
6 I'm speaking DC-8, worldwide. The only time a DC-8 doesn't
7 leak is when it doesn't have any fuel. That's -- you know,
8 it's not that bad, but it's -- the aircraft was not built
9 with integral tanks. There's years worth of work in those
10 tanks. It's very difficult aircraft to keep moving
11 economically. It's one of the reasons why it's probably
12 going to be phased out.
13 Speaking from my own personal experience, first
14 of all, I'm very proud of the fact that I worked at Emery
15 even though there seems to be a -- this hearing is not a
16 really good forum for me to say that, but i know that the
17 people there did a good job and they -- almost every case,
18 did as good a job as they could. And I think it was a very
19 concentrated effort to do the right thing. I could just go
20 on forever, I know you've got other witnesses, but -- any
21 company -- I've been attached to several airlines. Any
22 airline -- any one, any repair facility put under the
23 scrutiny and the magnifying glass that Emery has gone
24 through in the past two years, you're going to find warts.
25 Doesn't make it a bad --
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1 CHAIRMAN GOGLIA: I think we found cancer.
2 THE WITNESS: Well, you might have. You may
3 have, but believe me, and you've got enough experience you
4 know there are problems in the industry and I can't deny
5 that. Like I said, I think that for the most part, from my
6 experience with Emery, they tried very hard to do the right
7 thing.
8 CHAIRMAN GOGLIA: Okay, Mr. Pudwill, are you
9 ready?
10 MR. PUDWILL: Yes, sir, I am.
11 BY MR. PUDWILL:
12 Q I'll try to briefly refer back to Exhibit 7-L.
13 And specifically, page seven, which is the parts listing for
14 the illustrated parts catalog. And I'll just state for the
15 record, nowhere in here does this parts catalog, which is
16 titled "Elevator control tab removal and installation"
17 identify the hardware required at this location. No
18 question there.
19 A Oh.
20 Q Can you explain why the engineering department
21 failed to revise the maintenance instructions related to
22 this work card, work card 3502 in Exhibit 7-K to include
23 supplemental instructions or information regarding the
24 hardware utilized?
25 A No, I can't.
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1 Q Thank you. Please refer once again to Chapter
2 27-3206, Exhibit 7-L, page 203, and note the line near the
3 bottom of the page just immediately before Section E, which
4 states, "Inspector. Check control tab installation security
5 and safeties." Could you provide your own interpretation of
6 this inspection task since no further details are provided?
7 A As I stated about a castellated (ph) nut, the
8 security piece for that is a cotter pin, and in this context
9 obviously the hardware, as you've indicated, is deficient on
10 the drawings provided in this Exhibit.
11 Q Excuse me, drop back from the lacking hardware at
12 this point, just please comment on this task itself, which
13 states "Inspector check the tab installation for security
14 and safeties." What does that mean?
15 A That means to check for the hardware, that it's
16 installed, and that the securities -- the safeties part of
17 it is the safety wires to be applied, the fact that it is
18 applied correctly, and in the case, like I said, of a
19 castellated (ph) nut, that a cotter pin is installed in that
20 castellated (ph) nut through the bolt.
21 Q Okay, so to summarize then, if you would refer to
22 figure on page six again, in looking at this installation,
23 obviously you would attach or inspected if the tab hinge
24 eyebolts, for which there are three, the inboard hinge
25 bolts, which is at the base of the crank fitting, and the
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1 push rod attachments at both ends of the push rod for the
2 control tab during this step?
3 A I hate to do this, but could you repeat -- just
4 the contents of the question?
5 Q Essentially I'm asking you to summarize what --
6 you said generically what this inspection step -- the types
7 of things you would look for. I guess I'm now asking in
8 what areas would you look for these types of installation,
9 security and safeties, if you were doing this inspection
10 today? Please refer to page six, if necessary.
11 A If you install both ends of the push rod --
12 basically anywhere there's an attachment that you've made in
13 the process of installing this tab.
14 Q Okay, thank you. As the director of engineering,
15 would you be concerned that inspection personnel may or may
16 not be familiar with this installation? Once again, we've
17 already established that this Chapter here does not identify
18 the hardware, so would you be concerned that maintenance
19 personnel not as familiar with the system might not realize
20 that the installation even requires a castellated (ph) nut?
21 In other words, possibly installed and --
22 A I am concerned now that I see that the card does
23 not show hardware.
24 Q Go ahead, thank you. Obviously, not knowing that
25 you had left in June of 2000 kind of limits the scope, but
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1 since you are still involved with Emery and directly
2 pertaining to this accident investigation, can you explain
3 why Emery or Emery's engineering department has never issued
4 any revisions to these maintenance instructions? Either on
5 the applicable work card or Chapter 27-3206?
6 A To my knowledge, this item has never been brought
7 up to engineering or Emery's attention for that matter, that
8 there are missing components on these figures.
9 Q Let's drop back. I won't refer to the figure,
10 but just visualize in your mind the various fleet campaign
11 directives. Those three campaign directives were self-
12 contained in that they didn't refer to any other figures. I
13 mean there was an IPC reference on the first page, granted,
14 however, there are figures attached to those fleet campaign
15 directives that clearly depict the maintenance task at hand,
16 the instruction for this fleet campaign directive, and
17 clearly identify the hardware.
18 A That's correct.
19 Q If -- if this hardware was identified elsewhere,
20 in the procedure for the installation or otherwise, wouldn't
21 you expect a reference on the fleet campaign directive to
22 verify the installation in accordance with whatever that
23 manual might be?
24 A In the development of the FCD, it was already
25 known that the only place that the correct or the preferred
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1 direction of the bolt installation was in the overhaul
2 manual. The pictures, I believe, reflect the overhaul
3 manual, if I'm not mistaken, and there would be no reason
4 for anyone to go to look at these first because it was
5 already clear that they did not show the preferred direction
6 of the installation.
7 Q I'll accept that, but it also could be a
8 possibility, wouldn't you agree, that maybe somebody in the
9 engineering department -- once again, this is after you had
10 already left -- had attempted to source this information via
11 the maintenance manual, was unable to obtain it information
12 or identify that information, and therefore utilized the
13 overhaul manual or otherwise?
14 A If the engineers got a hold of it, much like
15 yourself, it would not get through, if that's -- if they had
16 been in the IPC and it did not show those parts, they would
17 not have let it pass without some sort of notification that
18 the parts were not listed.
19 Q I want to jump off script here, since it appears
20 that Emery until this time has been unaware that the
21 applicable maintenance manual instructions that TTS, once
22 again, would have utilized during the installation of this
23 control tab, were inadequate in the fact that they did not
24 identify this hardware, and I guess simply state or ask
25 Emery, yourself, to confirm whether or not -- when you were
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1 first made aware that this bolt was missing, and after that
2 point in time, whether or not or why not, that you did not
3 go back into the applicable procedures to try to identify
4 when this bolt might have been left out or not safetied.
5 A Is that multiple questions or am I --
6 Q I guess it is and I apologize for that.
7 Essentially, can you identify when Emery became first aware
8 of that -- that we had a missing bolt, or that a missing
9 bolt might have played a factor in this accident?
10 A In or around February, 2001.
11 Q Okay, thank you. Knowing what you know now,
12 regarding these procedures and the lacking information, can
13 you explain how this particular reference 27-3206, obviously
14 as written, meets Federal Aviation Regulations part 25.1529,
15 which once again, Exhibit 7-Tango, pages two to three,
16 specifically instructions for continued airworthiness,
17 subpart B, maintenance instructions, item three. And I'll
18 read the line item: "Information describing the order and
19 method of removing and replacing the products and parts with
20 any necessary precautions to be taken."
21 A You're asking does it meet that ?
22 Q How does this manual, as written, meet that FAR
23 requirement?
24 A I didn't produce the manual, I --
25 Q Can you identify -- that's fine, thank you. Can
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1 you explain, knowing now what you know, that -- how the
2 maintenance instructions, included in this Chapter meet the
3 requirements of FAR Part 121.367, same Exhibit, subpart C,
4 which once again, I'll read, states the following:
5 "Each certificate holder shall have an inspection
6 program and a program covering other maintenance, preventive
7 maintenance and alterations that insures that each aircraft
8 released to service is air worthy and has been properly
9 maintained for operation under this Part."
10 A May I ask, you want me to say whether or not it
11 complies with it?
12 Q Yes. Can you explain how this maintenance manual
13 referenced as it currently exists, meets that FAR
14 requirement?
15 A No, I cannot.
16 Q Alright, thank you. I'd like to leave the D-
17 check area now and jump ahead in time, a short period of
18 time, a week out of D-check, in reference to the flight crew
19 discrepancy and the troubleshooting that Emery performed on
20 November 25, 1999. Give me just one moment, please.
21 Please refer to Exhibit 7-O, which is the
22 maintenance log page, number 8086-11 dated November 25,
23 1999. Mr. Robbins, are you familiar with this writeup?
24 A Yes, I am.
25 Q Alright. Are you also familiar with the evidence
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1 collected to date and documented within the maintenance
2 group chairman's factual report which is Exhibit 11-Alpha?
3 Specifically, pages 10 through 11 pertaining to this event?
4 It essentially describes, from the maintenance group
5 chairman's perspective, the events that transpired during
6 this troubleshooting?
7 A I don't have that Exhibit. Which one was it?
8 11?
9 Q 11-Alpha. Pages 10 through 11. I think we can
10 jump ahead without it here. Since you are rather familiar
11 with this. Referring back to Exhibit 7-O, for the record,
12 would you please read the discrepancy as entered by the
13 flight crew?
14 A "Elevator required more back pressure than normal
15 to flare the aircraft. Also, during elevator check" -- I
16 don't know what that word is -- "CG to 25.4 percent 2F, 23.3
17 percent."
18 Q Okay, thank you. Could you also please read the
19 maintenance entry in the corrective action block on the
20 right hand side?
21 A "Found left and right hand elevator dampers
22 reversed. Moved left to right side, right to left side.
23 Ops check good. No defects noted." And there's ...
24 Q Alright, thank you. Can you describe how you
25 first became aware of this discrepancy? In other words, do
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1 you recall whether or not engineering was contacted to
2 assist in troubleshooting?
3 A No, we were not, to my knowledge.
4 Q Do you have any first hand knowledge of the
5 actual troubleshooting that was performed on that date?
6 A Through reading the documents and talking to the
7 individuals involved, yes.
8 Q Any first hand knowledge? You were not present
9 during this troubleshooting?
10 A No.
11 Q Alright, thank you. Can you briefly describe any
12 relevant information you might have learned since that time
13 that would help clarify the actual configuration of the
14 elevator dampers and their associated linkages prior to any
15 corrective action by any Emery maintenance personnel?
16 A Can you state that again?
17 Q Sure. Could you briefly describe any information
18 you might have obtained since then, that would help you
19 clarify for us here today, the actual installation,
20 including the associated linkages to the dampers -- either
21 side, prior to any corrective action by Emery? In other
22 words, prior to reversing the dampers?
23 A Information that was available to the mechanics
24 prior to --
25 Q No, I'm asking if you are aware of -- just asking
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1 you to describe any information that you learned since then
2 regarding what transpired that night. Do you know what
3 the configuration was as the aircraft came in? I'm trying
4 to determine what the configuration of the damper assemblies
5 were as the aircraft departed TTS.
6 A As I understand it, the dampers being reversed,
7 left to right, right to left, placed the link arm and crank
8 arm toward the top part of the elevator. In a normal
9 configuration, the link arm and the crank arm would be
10 located towards the lower part of the elevator.
11 Q Okay. Would the -- would Exhibit 7-Q be
12 beneficial to you --
13 A Is that the drawings?
14 Q Yes. What I think you're referring to is
15 probably Exhibit 7-Q, drawings shown on page five and six.
16 Can you confirm whether or not this is what you're trying to
17 describe?
18 A Yes, this is the reverse position.
19 Q And just for the record, this is just a drawing
20 produced by the Safety Board, based upon the actual drawings
21 provided by Douglas. These drawings were put together, they
22 are to scale and they omit unnecessary detail, but
23 essentially page five depicts a DC-8 71 Foxtrot, with the
24 elevator deflected full throttle, 27 degrees trailing edge
25 up. The damper is reversed, and the linkage assembly that
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1 connects the horizontal stabilizer to the damper, i.e., a
2 link and a crank arm, are essentially mirror imaged to what
3 they should have been. Is that correct?
4 A Roughly.
5 Q Okay, and can you confirm that sheets one and two
6 of that same Exhibit would indeed identify the correct
7 installation for comparison?
8 A Yes.
9 Q Alright, thank you. Could you please identify
10 the troubleshooting performed by maintenance that you are
11 aware of that night?
12 A The troubleshooting performed by maintenance
13 consisted of walking to the back of the aircraft, looking up
14 and seeing that the link arms were not exposed on the lower
15 side of the elevator. And they had run into this once
16 before, twice before in the past, and it became apparent
17 that the elevator dampers were reversed.
18 Q Do you feel that would be an easy task to discern
19 these linkages from a distance of -- I'm guessing here, I
20 might be wrong -- 15 feet below at night?
21 A Yes.
22 Q Okay, thank you. In your opinion, what types of
23 problems could possibly cause the elevators to require more
24 back pressure than normal to flare the aircraft?
25 A Air speed, weight, use of the horizontal
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1 stabilizer trim on approach, flap settings, something stuck
2 in a cable, bearings that were worn. There's a litany of
3 things that could be --
4 Q Okay, --
5 A -- particularly with the statement -- if I can
6 quote -- "requires more back pressure than normal" -- that's
7 a very arbitrary description.
8 Q Fairly subjective?
9 A Fairly subjective.
10 Q Okay, would you consider elevator icing to be a
11 possibility? Possibly an obstruction between the leading
12 edge and the horizontal stabilizer?
13 A I'm not -- you could speculate that that -- I
14 mean that could, in certain cases, possibly -- you know,
15 it's just too hard to tell.
16 Q Okay. You mentioned one of these, but would you
17 consider excessive friction, binding, or obstructions in the
18 travel of the cables or control tab linkages to be a
19 possibility?
20 A That's a possibility.
21 Q What about improper cable tension? Or a mismatch
22 between the left and right control tabs or gear tabs?
23 A I would -- based upon the writeup, I would rule
24 out rigging issues, strictly because rigging doesn't come in
25 and out of rig. Once it's rigged, it's done. In this case,
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1 the aircraft had taken several flights -- I believe it was
2 eight days or nine days worth of flights with no reported
3 problems. I would, based on my experience, not go to
4 rigging first.
5 Q Is there any way to know that you might not have
6 had excessive force applied to the cables for whatever
7 reason, during flight or on the ground -- maintenance
8 personnel or flight crew that might not have stretched the
9 cables or something?
10 A In my experience with the DC-8, basically I go
11 back to my statement, once it's in rig, it's in rig, and
12 they don't come out unless something happens or somebody
13 does something to it.
14 Q Well, once again, it hasn't been -- I don't think
15 anybody here can completely identify the exact configuration
16 of this aircraft when it left TTS. I mean I think generally
17 everybody has a good idea, I'm only really concerned with
18 flight controls, specifically, the elevators, but still to
19 date there is no clear proof one way or another of the
20 configuration of the dampers.
21 A I think the writeup and the subsequent signoff is
22 a very clear indication --
23 Q But as you indicated, you're not absolutely
24 confident that the dampers were installed as such.
25 A I am absolutely confident that the dampers were
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1 reversed.
2 Q But what about the linkages?
3 A The linkages necessarily had to be -- would have
4 to be reversed, otherwise you'd have restricted areas as you
5 pointed out on your drawings three and four.
6 Q The point I was trying to make is, and I don't
7 disagree with that comment there, is that an aircraft that
8 has just undergone heavy maintenance, i.e., a D-check, over
9 a period of time of several months, has had a lot of
10 different work cards and procedures applied throughout the
11 check, just as an example, or a comparison, in the case of
12 the dampers. I'm not doubting that the dampers were
13 reversed, but I'm just saying that's one anomaly coming out
14 of a D-check. There could be other anomalies, wouldn't you
15 agree? Such as mismatched control tabs, gear tabs?
16 A Yes.
17 Q What about checking the control tab torque tube
18 bearings inside the elevator inboard ... that are reportedly
19 susceptible to binding in rough operation? Would you
20 consider that a possibility?
21 A In this scenario that I described, and one in
22 which I know the mechanics have already given a statement to
23 what they had actually done, the mechanic that finds a
24 fairly subjective writeup, in this case, more pressure than
25 normal, it's not a real descriptive analysis of what the
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1 condition was. If I was to walk back there and find
2 something very obvious and quite evidently attached to the
3 surface that the pilot is giving me some indication that he
4 felt something different, I would swap those dampers, do
5 exactly as the mechanics did, and let the aircraft fly
6 again, knowing that the aircraft had flown for some period
7 of time -- a short period of time -- regardless of -- I
8 wouldn't stop - these are line mechanics. They are not out
9 there to analyze things to death. They find something, they
10 fix it, and they move on. And in this case, that's what
11 they did. They're not out there looking for continual
12 problems. I know that they actuated the control column
13 several times and didn't feel any stiffness, and -- I mean I
14 would not -- I would not expect any line mechanic to go any
15 further once they found these dampers, based upon knowledge
16 at the time.
17 Q I'm sorry, I don't mean to cut you off, but we
18 will get there. Really all I was asking was trying to
19 establish areas that you feel, as a licensed A&P and
20 familiar with the DC-8 aircraft, and certainly the flight
21 controllers that possibly could have caused such a writeup,
22 and once again, don't you think a restriction in bearings,
23 obstructions, or the other things that we've listed could
24 possibly have caused this type of writeup?
25 A Yes, that's possible.
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1 Q Alright, thank you. Now, you had mentioned a
2 moment ago about troubleshooting steps that or expectations
3 that you would have, as far as maintenance as far as what
4 they would look at, et cetera, and I believe the comment
5 essentially was that you wouldn't expect maintenance
6 personnel to dissect the installation, if you will, but in
7 identifying -- let me ask this, don't you think it is a
8 necessary task to try to at least attempt to identify
9 possible causes for a known discrepancy before you can ever
10 hope to effectively correct that? And once again, let's
11 assume you have no direct troubleshooting procedures in
12 hand.
13 A And the mechanics did that. I mean the very
14 first step you should do -- one of the very first steps is
15 to go take a look at the area. Is there anything obvious?
16 You know, could be anything -- a piece of FOD stuck in the
17 control surface. The very first thing I would do, after I
18 checked the control column to see if I could physically tell
19 if there was a difference, I would inspect the control
20 surfaces, and upon that inspection is when they found the
21 dampers.
22 Q Okay, that's fine. During your previous
23 testimony you indicated you had several years experience as
24 a manager of maintenance training at Emery. Therefore,
25 could you identify a DC-8 Chapter 27 maintenance manual
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1 reference with troubleshooting guidance related to the
2 elevators and applicable to this aircraft?
3 A You're asking me if I would sit in front of the
4 tapes could I find one?
5 Q Can you identify a maintenance manual chapter
6 that would be effective for the accident aircraft that would
7 provide troubleshooting instructions to maintenance
8 personnel, that you, in the engineering department, would
9 expect maintenance personnel to refer to during such
10 troubleshooting?
11 A Chapter 27.
12 Q Alright. In your opinion, does maintenance
13 manual chapter 27-00-37, which is found in Exhibit 7-R --
14 take a few moments to locate that --
15 A Okay.
16 Q In your opinion, does this maintenance manual
17 reference provide guidance that could have been utilized by
18 maintenance personnel during the troubleshooting of this
19 flight crew discrepancy?
20 A Could have been.
21 Q Okay, thank you. Would you not also agree that
22 the troubleshooting procedures identified in this chapter,
23 i.e., parts one through three -- there's only three parts
24 within this reference, for the audience, referring to pages
25 one and two -- provide a thorough check of the elevator
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1 flight control system?
2 A I don't know if it's a thorough check. It's a
3 check.
4 Q Please take a moment to --
5 A I mean I would have to have some other documents
6 to reference that's a specific control check to see if this
7 is a thorough one.
8 Q Well, in your opinion -- and please, if
9 necessary, take a minute or two, review through parts one,
10 two and three, to, in your own mind, identify the scope of
11 the areas that are covered here in context to those problem
12 areas that you identified previously and therefore, in your
13 opinion, do you think this would do a pretty good job in
14 troubleshooting the elevator system.
15 A Okay. Yes, I'd say it's a fair troubleshooting
16 process.
17 Q Okay, thank you. To your knowledge, and based
18 upon your previous experience as the manager of maintenance
19 training, were maintenance personnel instructed to utilize
20 this maintenance manual reference when troubleshooting?
21 Chapter 27 flight controls?
22 A Specifically?
23 Q Sure.
24 A I don't think there was any words --
25 Q I mean was maintenance personnel made aware of
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1 the fact that there was troubleshooting procedures, or that
2 troubleshooting procedures did exist in the various
3 maintenance manuals chapter 27?
4 A Yes.
5 Q Okay. If Emery maintenance personnel did utilize
6 this chapter to troubleshoot during this discrepancy, isn't
7 it possible that they performed part two, step two, i.e.,
8 checks of the control tab push rods for adequate clearance?
9 A If they used this, they would be using this.
10 Q Can you think of any reason why maintenance
11 personnel might not have utilized the troubleshooting
12 guidance provided in this chapter?
13 A Yes, I can.
14 Q Could you expound upon that?
15 A Yes, they found the dampers reversed.
16 Q Alright, thank you. Do you find any reference in
17 27-00-37 regarding the elevator dampers?
18 A No.
19 Q I realize that you already indicated or testified
20 that essentially that night, maintenance personnel -- this
21 is obviously word of mouth --
22 A It's not word of mouth, it's in the records.
23 Q But essentially from your perspective, you were
24 not there first hand, so from my perspective, your testimony
25 is via word of mouth. Talking to the maintenance personnel
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1 there, it doesn't really matter, but essentially what you
2 stated prior is that via walk around, linkages were noted
3 abnormal on the elevator dampers.
4 A Not via walkaround. During a mechanic --
5 Q I'm talking maintenance personnel, I'm not
6 talking flight crew.
7 A Okay.
8 Q Do you think that it's odd that maintenance
9 personnel on duty that night, and based on the knowledge
10 that the Board has, there's at least four individuals
11 troubleshooting this flight crew discrepancy, that they
12 wouldn't have referred to the maintenance manual and
13 wouldn't have checked some of these things identified in the
14 maintenance manual reference?
15 A Do I find it odd?
16 Q Yes.
17 A Not in the least.
18 Q Could you explain what prompted this
19 maintenance -- excuse me. Are you familiar with the TTS
20 maintenance inspection where it related to this installation
21 of the elevator dampers that's dated November 30, 1999.
22 Please refer to Exhibit 7-P, or 7-Papa, page four if
23 necessary.
24 A I have it.
25 Q Okay. Could you explain what prompted this
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1 maintenance inspection remark?
2 A This particular aircraft, these particular
3 dampers.
4 Q Okay. I want to refer now back to Exhibit 7-Q,
5 once again, the damper drawings for the installation. Could
6 you refer to pages one and two of the Exhibit and just in
7 your own words, describe the approximate rotation of the
8 damper rotor, i.e., the crank arm on the damper, throughout
9 the full range of the elevator travel when the dampers are
10 configured normally?
11 A It appears to be about 120 degrees, maybe a
12 little more.
13 Q My estimate would be closer to 170 degrees. I
14 know it's pretty hard to tell on these drawings since
15 they're running off scale here, but that's fine. Could you
16 refer to pages five and six of the Exhibit? And describe
17 the approximate rotation of the damper rotor throughout the
18 full range of the elevator travel when, as you had indicated
19 previously, the dampers are reversed and are hooked up to
20 accommodate this reversal?
21 A It appears to be about a half an inch of travel.
22 Q Probably five, ten degrees?
23 A That may be close.
24 Q Alright, thank you. Based upon this information,
25 would you expect the elevator dampers to offer more or less
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1 resistance to elevator movement when the dampers are
2 reversed as described above?
3 A Less.
4 Q Alright, thank you. In fact, probably much less.
5 Would you be concerned about an aircraft in service if its
6 elevator dampers reversed as depicted within Exhibit 7-Q,
7 pages five and six, i.e., reverse dampers?
8 A From my understanding, in some cases, these
9 dampers are removed from the aircraft altogether. The
10 safety of flight concern -- I'd be concerned because they're
11 not correct.
12 Q Isn't -- aren't you actually referring to the
13 outboard damper installations on the DC-8 elevator which
14 have been removed or deactivated, not the inboard?
15 A I may be. I mean it would concern me. I would
16 be concerned that these would be installed incorrectly. Any
17 part incorrectly installed.
18 Q And why would you be concerned?
19 A Because it's not correct.
20 Q Beyond that? >From an engineering standpoint,
21 from a licensed A&P standpoint?
22 A You're asking me to evaluate this part in this
23 configuration, and I can assure you that the mechanics did
24 not analyze, much like you did, in a CAD program and
25 animated to find out what the effect would be of a reversed
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1 damper on the overall system. They found something
2 incorrectly installed and fixed it, and that's basically
3 what I would have done based upon my concern that a part was
4 incorrect.
5 CHAIRMAN GOGLIA: Mr. Pudwill, hold on. Now, if
6 I agree with what you just said, how do they assure
7 themselves that they corrected the deficiency as noted?
8 THE WITNESS: If they went to the cockpit, pulled
9 the control column back and forth, didn't feel anything;
10 went outside, gave a general inspection, saw the dampers
11 were reversed; reversed those dampers back to where they're
12 properly aligned or proper positions; go back up and do
13 another check on the control column. The only option at
14 that point is to let the aircraft fly again. There's no
15 safety of flight item.
16 CHAIRMAN GOGLIA: Wait a minute. The only
17 option.
18 THE WITNESS: Well, I shouldn't say the only
19 option, but an option is to --
20 CHAIRMAN GOGLIA: Man oh man, I've got some --
21 THE WITNESS: It's not the only option.
22 CHAIRMAN GOGLIA: You sat through the hearing on
23 the EPI indicator, didn't you?
24 THE WITNESS: Yes, I did.
25 CHAIRMAN GOGLIA: You saw the video, didn't you?
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1 THE WITNESS: Yes, I did.
2 CHAIRMAN GOGLIA: When you pull the yoke back and
3 push it forward, you don't move the flight control full
4 range, do you?
5 THE WITNESS: No, you do not. But that's --
6 CHAIRMAN GOGLIA: Think about what you're saying,
7 right, because you're making yourself look stupid.
8 THE WITNESS: But that's the test the mechanics
9 are to do is to do a pull test on the control column.
10 MR. PUDWILL: Mr. Chairman, do you mind if I
11 proceed here?
12 CHAIRMAN GOGLIA: No, please proceed.
13 MR. PUDWILL: Alright, thank you. I would just
14 like to state for the record that keep in mind here that
15 this is still an open accident investigation. Some of what
16 has been entered in the Exhibits for this public hearing
17 might become more important when the Board finally convenes
18 and makes their final determination regarding probable
19 cause, and of more interest, from my perspective, issues any
20 safety recommendations. And this just happens to be one
21 area, it's a late find, and I was, like you, unaware of this
22 until recently when I produced these drawings. We --
23 obviously somewhat handicapped in the obvious there, don't
24 always have access to the aircraft, the drawings necessary,
25 but yes, I would agree that this is relatively new
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1 information, but I'm just asking you, as the former director
2 of engineering for your engineering perspective and/or at
3 times your perspective as a former maintenance supervisor,
4 or manager of maintenance training. So I'm merely asking
5 your opinion on these matters.
6 BY MR. PUDWILL:
7 Q Essentially, would you agree that the elevator
8 dampers configured in this matter, i.e., when the dampers
9 are reversed as you had pointed out in the drawings, page
10 five and six, if configured in this manner would be
11 effective in opposing flutter?
12 A They would be limited in their ability.
13 Q Thank you. Realizing that the elevator travel is
14 unrestricted when the elevator dampers are reversed and
15 connected as depicted on pages five and six of Exhibit 7-Q,
16 and that the dampers offer much less resistance to any
17 elevator movement in this reversed configuration, could you
18 now comment on the corrective actions, once again from an
19 engineering perspective, using hindsight, could you comment
20 on the corrective actions taken by maintenance personnel
21 related to the flight crew discrepancy noted? I'm asking
22 you to be critical, to critique the troubleshooting, and
23 specifically what Mr. Chairman just mentioned, the ultimate
24 corrective action for this flight crew discrepancy.
25 A The ultimate corrective action --
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1 Q Let me rephrase that last part --
2 A I understand what you're saying. You're asking
3 whether or not the dampers being reversed and then put back
4 in their normal position would have cleared the pilot
5 report.
6 Q True.
7 A Okay. In this case, no, but if I can just make a
8 comment. There was a list of things that were possibilities
9 or potentials that could give the feel of a heavier than
10 normal flare, and a lot of those dealt with aerodynamics,
11 use of trim, things of that nature. There were no
12 subsequent writeups. Based upon the evidence, and my
13 engineering background, I would have to say it was more than
14 likely an aerodynamic problem. It could have possibly been
15 ice, I don't know, but --
16 Q Okay. I'm just about finished in this area here.
17 Let me first share with you, from the Safety Board's
18 perspective, or at least at the staff level here, the
19 reasons behind asking many of these questions really stems
20 from the way Emery's program is put together. And really
21 what I'm referring to is -- specifically is, you know,
22 whether or not nonroutines are issued for this type of work.
23 In this particular case, we have no evidence that a
24 nonroutine was written against this flight crew discrepancy.
25 I recognize that's not required per Emery's maintenance
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1 policy and procedures manual, however, you'd have to admit
2 that from the perspective of the Board and the staff
3 investigators involved with this investigation, once again,
4 looking from hindsight -- it's easier to be critical from
5 our end -- looking back and to critique these events,
6 however, in looking for the first time at a discrepancy such
7 as that written up by the flight crew on November 25th,
8 based on the information alone in the log page -- because
9 that's all we have -- there are questions. It seems
10 suspect, it seems odd and the reason being is that there's
11 no trail of the actual inspection methods that were
12 utilized, the manual references that were utilized.
13 Can you explain why -- I realize you're not in
14 maintenance, but in accordance with your MP&P -- policy and
15 procedures manual -- maintenance personnel should have
16 entered the specific maintenance manual chapter they
17 utilized during this work. In this case, they indicate that
18 they found the dampers reversed. They reversed the dampers.
19 Through later testimony indicate that was done in accordance
20 with maintenance manual chapter 27-70-09. Why is that not
21 reflected on this card?
22 A I can't answer that.
23 Q Right. Just trying to share with you some of the
24 perspective on our end on why we have to ask these types of
25 questions. One final question in this area. As the
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1 director of engineering, would you be concerned, once again,
2 looking back, that maintenance issued an air worthiness
3 release and returned this aircraft to service without truly
4 identifying the cause of the noted discrepancy?
5 A If I was to analyze this at that time, would I
6 have wanted the aircraft to continue in service? I think
7 the prudent thing to do would be no, knowing what I know
8 now.
9 Q Thank you. I'd like to move now to the last main
10 area in my line of questioning, which would be the B-2
11 check. The inspection program which was accomplished on
12 January 22, 2000, approximately one month prior to the
13 accident.
14 A Do you have an Exhibit?
15 Q Yes, specifically, inspection work card B-009,
16 please refer to Exhibit 11-I for a copy of the inspection
17 card -- and this is the unsigned copy.
18 (Pause.)
19 Q Mr. Robbins, do you have the Exhibit before you?
20 A Yes, I do.
21 Q Alright. Could you please read the first
22 sentence of the inspection instructions found beneath the
23 title, "Right hand and left hand elevator and tab
24 inspection"?
25 A Yes. "Visually inspect elevators and tabs for
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1 general condition, corrosion, leakage and security of
2 attachment. Inspect static discharges for general condition
3 and security."
4 Q That's fine. Excuse me -- could you describe
5 Emery's interpretation of this inspection, specifically
6 related to the phrase "security of attachment"? i.e., please
7 identify the work scope required to satisfy the intent of
8 this work card.
9 A Emery's interpretation is that this is a arms
10 length visual inspection that does not constitute removal of
11 panels.
12 Q Would this be consistent with your interpretation
13 of this?
14 A From what I know of these B-checks, yes it would
15 be consistent with what I've been told.
16 Q Okay. Therefore you're saying you would not
17 expect maintenance personnel to inspect the security of the
18 control tab hinges during this inspection?
19 A I'm saying in the context of what the description
20 of the inspection is, it's not expected to open the panel
21 and go in anywhere -- any panel.
22 Q Well, just to refresh your memory, if that's the
23 hindrance here, yes, if you were to inspect the inboard
24 hinge fitting or control tab, the push rod attachment you
25 would have to remove the faring on the upper surface.
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1 That's not my question. My question was based on Emery's
2 interpretation of this card, really requested whether or not
3 you could affirm that you would expect maintenance to
4 inspect the security of the control tab hinges, and, in
5 effect you have answered that by saying you would not expect
6 them to open up the panels, and therefore there's no way
7 they could inspect this fitting.
8 A Based upon what I know of what the interpretation
9 of what the visual inspection is.
10 Q Therefore, for the record, you would not expect
11 maintenance to inspect either control tab push rod
12 attachment for security at the dry crank assembly, or the
13 control tab crank fitting. Is that correct?
14 A In my -- to what I understand it to be, no.
15 Q Once again, I'm asking you, as the former
16 director of engineering, for Emery's interpretation, so you
17 are speaking for Emery. I am asking for Emery's
18 interpretation.
19 A The interpretation is as I indicated.
20 Q Okay, thank you. What about the elevator hinges?
21 Would you inspect those?
22 A The ones that are visible -- anything in the --
23 anything that's visible and basically arm's length, it's --
24 Q Well, can you explain what the intent of this
25 card is? I mean dropping back from the explanation, if --
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1 you're indicating you would inspect the hinges but only
2 those that are readily accessible?
3 A I do a visual inspection, what I can see.
4 Q Would that include the hinges for the control
5 tab?
6 A What I can see, yes, without removal of the
7 panel. That's been -- and I'm not -- I'm not an expert on
8 this. I mean probably not the right party to talk to on
9 this, but as I am -- as I understand it, that's how it was
10 presented to me.
11 Q To recap then. Just for the record, there are
12 four hinge fittings that attach the control tab to the
13 elevators, three that are external to the control tab
14 faring. The fourth, the inboard hinge fitting, we've looked
15 at earlier, as the source of confusion for the hardware,
16 i.e., at the base of the crank fitting, can you explain why,
17 if you were doing an inspection -- I'm asking for your
18 opinion right now -- why, if you were doing an inspection
19 for security of attachment, you would even bother to look at
20 the three hinges that didn't require access if you weren't
21 going to look at the hinge fitting and securities for the
22 other one that did require access?
23 A The card tells me to do a visual inspection.
24 Q For security of attachment. Thank you.
25 A Yes.
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1 Q Do you think that more experienced DC-8
2 maintenance personnel at Emery would agree with your
3 interpretation of this inspection?
4 A I have no idea.
5 Q Seems like there's quite a bit of confusion about
6 this card. This card has come up several different times
7 from everybody's perspective, it must have some significance
8 here. Once again, you, as the former director of
9 engineering -- would not engineering, by the very nature of
10 generating the maintenance instructions for which
11 maintenance personnel within Emery or other repair stations
12 or providers rely upon, be responsible for the content and
13 therefore cognizant of -- or the repository, if you will,
14 for the interpretations of these various work cards?
15 A The interpretation of the statement or the
16 inspection?
17 Q Essentially engineering writes these cards,
18 correct?
19 A There was no engineering at the time this card
20 was written. But yes, they would revise them and --
21 Q An engineering function within Emery prior to the
22 growth of the organization as you came to know it --
23 A That's correct.
24 Q -- would have been responsible for the initiation
25 of this card, correct?
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1 A Yes.
2 Q Thanks. Do you care to comment on testimony
3 provided by Mr. Hall from TTS yesterday, or that of Mr.
4 Hoffstetter earlier today, related to the inspection or to
5 this inspection, i.e., that maintenance personnel would not
6 be able to inspect the security of the control tab
7 installation without first removing the associated
8 inspection panels and farings?
9 A You want my comment on that?
10 Q Yes.
11 A I would agree.
12 Q Let me rephrase it a little bit differently
13 because I admit the question isn't phrased too well. My
14 take on their testimony these past two days is that yes,
15 they would inspect this based on the content of the verbiage
16 on the B-009 card for the B-2 check package.
17 A That they would -- it's a difference of
18 interpretation, I guess.
19 Q Okay, thank you. Can you explain why this
20 procedure is written so vaguely? Why do you leave this
21 interpretation up to the maintenance personnel?
22 A I cannot tell you that. I can tell you that it
23 was derived from the Douglas OM, but I haven't looked at
24 this specific card in the OM to see if it's written this
25 way.
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1 Q In your opinion, is it a good engineering
2 practice to issue maintenance instructions that are so
3 general?
4 A With this particular card, without having a
5 maintenance manual to back up the process, I would have
6 written it different.
7 Q Give me one minute here to refer to the
8 reference.
9 (Pause.)
10 CHAIRMAN GOGLIA: Mr. Pudwill, would you like to
11 take a few minute break? I think everybody would like to
12 stretch a little bit, it seems.
13 MR. PUDWILL: I just need a couple minutes, but
14 that would be great. Sure, thanks.
15 CHAIRMAN GOGLIA: Okay, why don't we take a 15
16 minute break, and we'll do it promptly in 17 minutes. 6:40,
17 6:55.
18 (Whereupon, a 17 minute recess off the record was
19 taken.)
20 CHAIRMAN GOGLIA: On the record, please. Please
21 proceed.
22 BY MR. PUDWILL:
23 Q Alright, thank you. As the director of
24 engineering, wouldn't you prefer to issue specific
25 instructions that are clearly defined in lieu of procedures
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1 that require interpretation by maintenance? This is just a
2 general question.
3 A Yes, that would be preferred.
4 Q Can you explain why this work card, once again,
5 B-009, found on Exhibit 11-I, does not specify step by step,
6 the locations, access requirements, and detailed inspections
7 to be performed during the performance of this work card?
8 A This is not a detailed inspection -- there's two
9 types of inspections, visual and detailed. In this case,
10 since it does not call for removal of the panel, the only
11 thing I can say is if it's written correctly, that it does
12 not require panel removal.
13 Q Okay, thank you. Could you briefly describe your
14 structural engineering background or experience?
15 A I have very little.
16 Q Can you describe your background as an A&P
17 mechanic doing sheet metal repairs on aluminum structure,
18 let's say, flight controls?
19 A Very little sheet metal work.
20 Q Can you describe your first hand experience as an
21 A&P mechanic performing repairs on any metallic structures,
22 aluminum preferably, related to the removal of corrosion and
23 subsequent repairs?
24 A Yes, you want me to relate what I've done or --
25 Q Just in general. What type of experience do you
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1 have?
2 A Basic repairs and corrosion repairs, things of
3 that nature. Clean corrosion, things of that nature.
4 Q I'm curious. How long has it been since you have
5 worked as an A&P?
6 A Exercised my A&P license and worked on an
7 aircraft?
8 Q Worked as a mechanic.
9 A Ten years.
10 Q You came to Emery in '89 as a maintenance
11 supervisor, is that correct -- or, excuse me, as an avionics
12 supervisor?
13 A Yes, I do some work with general aviation, is
14 that applicable?
15 Q Yes, that's fine. Could you describe your
16 responsibilities at Emery throughout your various positions,
17 associated with the corrosion prevention and control
18 program? What's your knowledge of the program? What is
19 your knowledge of how findings are addressed, et cetera?
20 Instructors training and inspections?
21 A I have limited knowledge on that. I know that
22 there's different levels of corrosion findings, and there's
23 different definitions of what a level one, level two
24 findings are.
25 Q Could you describe your knowledge of the intent
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1 of that program? As far as recurring inspections and
2 inspection intervals?
3 A My opinion of the -- my interpretation of what
4 the purpose of the --
5 Q Essentially the purpose or the goal of the
6 program.
7 A It's to identify components that are corroded or
8 structures that are corroded in an interval that, in the
9 reporting process, in the data collecting process, the
10 entire fleet of DC-8s, having all operators communicate
11 their findings would produce possibly special inspections or
12 alternative methods to treat specific areas -- things of
13 that nature, to make the overall fleet a better fleet.
14 Q Isn't the overall goal to maintain corrosion
15 within the existing program to an acceptable level such that
16 your set inspection intervals are adequate -- essentially,
17 you go out, you make an assessment, you have findings. You
18 classify those findings. If they're acceptable, your
19 inspection program is fine. If -- if corrosion is more
20 widespread than inspected, therefore a higher
21 classification, you would make changes to your maintenance
22 program. Would you say that would be a fair assessment of
23 the overall goal?
24 A Yes.
25 Q Okay, thank you. I'd like you to please refer
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1 now to the overhaul records found in Exhibits 7-S, that's 7-
2 Sierra. These are related to the right elevator assembly
3 that was installed on the accident airplane during the
4 latest D-check in November 1999.
5 A I have it.
6 Q Okay. Please refer to -- let's see, starting on
7 page five -- this entire Exhibit kind of addresses the
8 lineage of these controls, et cetera, as the 8130-3 air
9 worthiness approval tag on page two, going backwards here.
10 Page one is the serviceable part information tag, part
11 number, serial number, et cetera. Pages three and four
12 indicate that this assembly came from FAA-FAR -- FAA
13 approved repair station Complete Controls Inc., and starting
14 on page five, we essentially have a summary of the type of
15 work that was performed on these elevators, or in this case,
16 the right elevator.
17 I'd like to refer you to the main body of this
18 section, "Primary/hidden damage" starting about the middle
19 of the page. And specifically, pages six through eight,
20 line items one through -- well, starting on five -- one
21 through 149 different discrepancies that were initially
22 noted. Keep in mind that this is during the overhaul of the
23 elevators.
24 Now I'd like to read a few of the findings
25 listed, just for your future reference. I refer to line
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1 item 73 on page seven. I want you to understand this is
2 just identifying the discrepancies noted during overhaul.
3 "Frozen rod end bearing on rod assembly." I haven't
4 bothered to take this to the next step and source these IPC
5 reference numbers here, but I'm assuming this is the push
6 rod for the control tab installation.
7 Item -- take the next one -- 74, "Rod and bearing
8 on rod assembly frozen, corroded." 76, "Corrosion on yoke
9 end of rod assembly." I'm assuming that's the drive crank
10 assembly for the push rod. 77, "Corrosion on shaft of rod
11 assembly". Item 79, "Rod eye bearing unknown, adjustable
12 end of the rod end" i.e., the end that attaches to the crank
13 fitting. "Rough in operation". 80, "Corrosion." 81,
14 "Corrosion on push rod". 85, "Corrosion on hardware
15 fitting." 86, "Exfoliation of fitting". 88, "Frozen
16 bearings". 92, "Corrosion on all eyeball bearings", i.e.,
17 the hinges. 93, "Rough or frozen bearings on eye bolt".
18 Then to page eight, item 136, "Gear tab hinge
19 fitting is double drilled with holes elongated." 138,
20 "Control tab -- three hinge fittings cracked". 139,
21 "Control tab hinge fitting number four, cracked". Item 142,
22 "Gear tab hinge fitting, number seven, has corrosion."
23 Based upon your experience at Emery, and as an
24 A&P licensed mechanic, wouldn't you agree that these types
25 of findings are expected on flight controls as old as these?
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1 A Expected?
2 Q Anticipated, expected? Wouldn't you expect to
3 see these types of findings during an overhaul, especially
4 if the periodicity on that overhaul is at D-check intervals
5 or greater?
6 A I -- to be honest with you, I have nothing to
7 gauge this by. This was the first detailed overhaul flight
8 control or elevator that I had really gone through, so I --
9 Q As the director of engineering, is that just
10 because of you're not as familiar with structures as
11 avionics, or --
12 A It's basically -- you don't go through a lot of
13 these. I mean I -- you don't see a lot of these flight
14 control surfaces go through a --
15 Q Would you, as the director of engineering,
16 require or ask your subordinate, i.e., the structural
17 engineer to review ... records for critical items installed
18 on your fleet of aircraft, such as flight controls?
19 A Not as a general practice, no.
20 Q Would you not look at items during overhaul or
21 otherwise for possible clues towards improvements in the
22 reliability program or maintenance programs?
23 A You mean look at this flight control and see the
24 damage on it and whether we can improve on the CPCP program?
25 Q CPCP program or maintenance program in general?
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1 A This flight control did not come from Emery. I
2 mean it wasn't a --
3 Q I realize that. It's from third party
4 maintenance, Complete Controls, Inc., but the set of
5 elevators was ultimately installed on the accident aircraft
6 and it appears that this is a fairly common practice, to
7 source -- certainly it's a common practice within industry
8 to source flight controls and other line replaceable units.
9 Can you describe how you would track repairs that had been
10 done to an installation such as this when it does not stay
11 with one particular aircraft? In other words, essentially
12 the elevators in this particular case, are being treated as
13 a line replaceable unit.
14 A As the component is serialized, the -- the
15 serialized unit would be tracked so you would always know
16 where it was.
17 Q Would you agree that the types of problems that I
18 just listed from the overhaul records could ultimately
19 affect the safety of flight if -- and once again -- if not
20 caught by an effective maintenance and inspection program --
21 during overhaul or otherwise?
22 A Yes.
23 Q Okay. Then can you explain why, in knowing the
24 types of damage that you'd expect to see, and -- this might
25 be beyond the scope -- based on your structural experience,
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1 but in my mind, based on expecting these types of findings -
2 - and happen on all structures, all aircraft, more on older
3 aircraft, obviously, if you're talking corrosion et cetera -
4 - but we in engineering have to expect these types of
5 problems when we write our maintenance programs, in my
6 opinion anyway -- basically, would you not or could you
7 explain why Emery has not defined a more thorough inspection
8 program in this area? And once again, I'm referring back to
9 this B-009 card, to insure the continued airworthiness of
10 the airplanes based on the knowledge of these types of
11 findings?
12 A You're asking me if I can explain the 009 based
13 upon these findings?
14 Q No, essentially I'm asking you whether or not you
15 feel it would be appropriate to further specify additional
16 work steps on a card such as this inspection, this B-009,
17 which is intended to inspect for security and attachment.
18 When you do these B-checks, at whatever periodicity, you
19 might accomplish this particular inspection, whatever the
20 interval is, things can happen. Degradation, corrosion,
21 loss of safeties, hangar rash, forklift, you name it. In
22 your opinion, is that not the purpose of the B inspections,
23 or intermediate inspections in general, to look for the
24 overall condition of the aircraft? And if you have an
25 inspection related to security and attachment, or an
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1 installation of a critical flight control component that you
2 would not want to look at a little bit closer than just the
3 general visual inspection?
4 A There are more detailed inspections in the C-
5 checks, and those are every two years. I don't know how
6 much corrosion is -- migrates or builds up between the two
7 year C-check interval, but your question is whether or not
8 the B-checks should be expanded to include a more detailed
9 corrosion inspection? Is that --
10 Q Let me back up just a minute here, it's easy to
11 lose your train of thought here. Take you back to this
12 Exhibit, 7-S, with all the findings related to corrosion.
13 If you require a minute or two, that's fine, but of all the
14 areas of corrosion that I listed, and I really only listed
15 corrosion for one reason, and that is, I don't find any
16 corrosion external to the flight controls. And I would
17 expect that. Surfaces are painted. Moisture doesn't
18 accumulate there. Where corrosion occurs, as you're well
19 aware in engineering, is internal structure.
20 If you refer back to yesterday's flight
21 presentation that you gave, you presented several photos
22 depicting various angles, views of the control tabs and
23 elevators, and clearly on those photos or in that
24 presentation there were several shots depicting drainage
25 holes, one of them being right in the center of this inboard
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1 end of the elevator immediately above the faring for the
2 control tab attachment. Can you explain why that drain hole
3 would be there? Obviously to drain moisture out of that
4 area.
5 All these items that are listed -- corrosion on
6 torque tubes, frozen bearings, et cetera -- don't you think
7 it would be prudent to inspect for corrosion at intervals?
8 A I think that it should definitely be looked at to
9 be included in the CPCP documents, so that once again, the
10 fleet can improve. If it's not already. I'm not sure if it
11 is.
12 Q Well, essentially, would card B-009 be effective,
13 if you were indeed looking for corrosion as it states --
14 "Visually inspect elevators and tabs for general condition,
15 corrosion" et cetera, et cetera -- when we know the
16 corrosion is going to be internal to the structure,
17 predominantly, and we're not even looking? Or is this
18 simply a case Emery didn't want to look?
19 A I certainly don't think it was a case that they
20 didn't want to look. I don't -- again, I think it's an
21 issue that would be best addressed in the CPCP program.
22 Q Alright, nothing further on that. Before I close
23 out this line of questioning, I'd like to refer once again
24 to the installation procedure for the control tabs,
25 specifically maintenance manual Chapter 27-3206.
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1 A Is this 7-L?
2 Q Yes, it is.
3 A I got it.
4 Q Alright, if you recall, it's probably been an
5 hour ago already, but we went to page 203, which is page
6 three of the Exhibit, and I had asked you for your
7 definition of the line immediately above Section E,
8 operational check. And I'll read the line once again.
9 "Inspector, check control tab installation security and
10 safeties." Do you recall this discussion?
11 A Yes, I do.
12 Q Do you recall your response to my question
13 regarding what areas you would inspect and what you would be
14 looking for during this inspection --
15 A Yes, I do.
16 Q -- since the steps are not clearly defined within
17 this procedure?
18 A Yes.
19 Q Okay, thank you. Could you then please explain
20 why this instruction and the installation procedure,
21 inspector to check control tab installation security and
22 safeties means something totally different from that defined
23 by Emery, using similar verbiage on inspection card B009,
24 which once again states in part, "Visually inspect elevators
25 and tabs for general condition, corrosion, leakage and
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1 security of attachment."
2 A This inspection listed here at Exhibit 7-L is an
3 installation, not just a general visual inspection.
4 Q I don't think anybody here is contesting the
5 meaning of the words general visual inspection. What we are
6 questioning is the intent of a card that says inspect for
7 security of attachment.
8 A I've already indicated that the card could use
9 improvement. I don't know -- I'd have to go back to the ...
10 to see what the origin of the card was to discern what they
11 were driving at.
12 Q Thank you. I have nothing further in this area.
13 I have one remaining area, Mr. Chairman. And this area
14 pertains to instructions for continued air worthiness and
15 the surveillance program at Emery.
16 Mr. Robbins, could you please describe how Emery
17 revised those DC-8 manuals, i.e., the maintenance manual,
18 the illustrated parts catalog, et cetera, that originated
19 with previous operators?
20 A How they were revised?
21 Q Yes.
22 A By supplemental manuals.
23 Q Can you explain how that would be available to
24 maintenance personnel, such as for the particular aircraft
25 during the D-check for these types of procedures?
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1 A There's a complete set of manuals, including
2 supplemental manuals available at all stations, including
3 the vendor maintenance facilities.
4 Q Are you aware of any supplemental information in
5 this manual that would help shed some light on these
6 procedures where we're missing hardware identification
7 information?
8 A No.
9 Q As previously established, Emery issued a fleet
10 campaign directive to inspect the condition of DC-8 elevator
11 control tab push rod attachments. Can you explain why
12 engineering never issued any associated changes to the
13 applicable Emery maintenance manuals or illustrated parts
14 catalogs, based upon the findings of this investigation?
15 A I don't know if they did or did not. I'm not
16 aware of what happened afterwards.
17 Q As previously established, Tennessee Technical
18 Services issued a maintenance inspection alert to clarify
19 the installation of the elevator dampers based upon the
20 troubleshooting that we discussed a little while ago that
21 occurred on November 25, 1999 in reference to the flight
22 crew discrepancy "excessive aft pressure to flare the
23 aircraft". Can you explain why Emery never issued any
24 maintenance changes related to these findings?
25 A I -- once again, I don't know that they -- if it
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1 was or was not done.
2 MR. PUDWILL: Mr. Chairman, I'd like to ask that
3 at least some consideration be given to some type of follow
4 up in these two areas such that before we meet for the final
5 Board meeting, the Board can ascertain whether or not Emery
6 is taking any steps to correct the deficiencies that have
7 been noted to date in the maintenance program.
8 CHAIRMAN GOGLIA: Rest assured we will have
9 plenty of opportunity.
10 MR. PUDWILL: Alright, thank you.
11 BY MR. PUDWILL:
12 Q In light of the discrepancies that we've been
13 talking about here, primarily chapter 27-3206, the
14 associated work card, installation procedures that TTS is
15 required to use as part of Emery's Part 121 maintenance
16 program, and the deficiencies regarding specific
17 installation instructions that clearly identify the
18 hardware, method of attachment, orientation, type of safety,
19 et cetera, and the lack of details regarding inspection
20 requirements, do you believe that Emery has fulfilled the
21 requirements established by Federal Aviation Regulation Part
22 121.373, once again, this is Exhibit 7-Tango, subpart A, and
23 I'll read, "Each certificate holder shall establish and
24 maintain a system for the continuing analysis and
25 surveillance of the performance and effectiveness of its
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1 inspection program, and the program covering other
2 maintenance, preventive maintenance and alterations, and for
3 the correction of any deficiency in those programs,
4 regardless of whether those programs are carried out by the
5 certificate holder or another person"?
6 A You're asking me for a legal interpretation or a
7 legal --
8 Q I'm asking you for -- I'm asking you whether or
9 not you, as the former director of engineering, feel that in
10 light of the discrepancies previously noted, i.e.,
11 installation and inspection requirements associated with the
12 control tab at the missing bolt location that's been
13 previously identified, in light of those discrepancies, do
14 you feel, or in your opinion, is the maintenance program as
15 is meet the requirements established by the FAR 121.373
16 subpart A.
17 A Based upon what's before me, I would say probably
18 not.
19 MR. PUDWILL: I have no further questions, thank
20 you, Mr. Robbins.
21 CHAIRMAN GOGLIA: Okay, the remainder of the
22 technical panel, are there any additional questions?
23 HEARING OFFICER HILLDRUP: Yes, sir, just a
24 couple of questions.
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1 DIRECT EXAMINATION
2 BY HEARING OFFICER HILLDRUP:
3 Q Mr. Robbins, obviously Emery felt it was
4 important during the B-check, B-2 check, that is, to check
5 for the security of attachments on the elevators and control
6 tabs as established in the B-9 card. And you may have said,
7 and I apologize if so, could you comment on why that would
8 be important? Why would you be checking security of
9 attachments?
10 A Why -- on the B-2?
11 Q Yes, why would you -- why is that important?
12 A It's important, while you're up there working
13 on -- doing other maintenance activities, it's a good idea
14 to go look around to see if there's anything obvious that
15 should be corrected.
16 Q Okay, let me rephrase it another way. What would
17 be the consequences, for instance, if you were to have a
18 loose attachment, or a missing bolt, if that were the case,
19 at one of the attachments. What might the consequences be?
20 Just your opinion.
21 A I mean it could go up to an including loss of the
22 control surface, I would assume.
23 Q Flutter, perhaps, actual physical damage. Okay.
24 Is there any reason to believe that an attachment that is
25 covered by a faring is any less important than one that is
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1 not covered by a faring? From that perspective?
2 A No.
3 Q And is there anything in the B-009 card itself
4 that specifies that that certain attachments are not to be
5 looked at?
6 A Not that I know of.
7 Q Thank you. Just one more question. I think you
8 had mentioned during earlier testimony about the mechanics
9 that had detected the damper reversal had indicated -- I
10 believe you had indicated that they had come across this
11 before. I believe you had said it, is that correct?
12 A Yes, at some point in the past, that's what was
13 relayed to me, that --
14 Q Do you know if that was while they were with
15 Emery?
16 A I have no idea.
17 Q Okay, yes, that was news to me, but thank you
18 very much. That's all I had.
19 CHAIRMAN GOGLIA: Okay, we will now go to the
20 parties and the Airline Pilots Association.
21 DIRECT EXAMINATION
22 BY MR. GUNTHER:
23 Q Mr. Robbins, when was the MRB established?
24 A The MRB established -- I don't know the exact
25 time.
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1 Q Was it before or after the accident, the
2 maintenance reliability board?
3 A Oh, it was well before.
4 Q You talked about before the damper reversals, and
5 the crew and the actions that they took, and your
6 familiarity with it. Being a licensed mechanic, knowing
7 what you know now, would you have released that aircraft to
8 service after they had been swamped without a test flight?
9 A I probably would have gone through some
10 additional troubleshooting -- not troubleshooting, but
11 additional functional checks, and then I would have
12 consulted somebody else -- maintenance control or somebody
13 else, if I was the line mechanic. I may have -- knowing
14 what I know now.
15 Q You also talked about problems with complaints
16 from pilots with regard to debriefs for things like
17 pressurization, radar, problems that they've had occur. Did
18 Emery, at the time they were in operation, run an all-
19 weather worldwide operation at that time?
20 A Yes, they did.
21 Q They did. Would it bother you, if you were a
22 pilot, to be dispatched with an inoperative radar?
23 A If -- yes, it would, if I knew I was being
24 dispatched without a radar, I'd be upset.
25 Q And your background's in avionics, am I correct?
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1 A That's correct.
2 Q What procedures do you have for testing things
3 like that?
4 A There's limited troubleshooting or testing
5 procedures in the maintenance manuals. There's a self-test,
6 basically, and then you can paint the ground and paint other
7 objects, but it's not a storm cell of adequate density to
8 accurately put on the scope. It's a difficult process.
9 Q What about pressurization problems. You said
10 that the -- you can't duplicate on the ground the type of
11 situations you would get airborne.
12 A Yes, in some cases, because the aircraft moves up
13 and down in the atmosphere, the outside pressurization --
14 the outside pressure changes. In a lot of cases your
15 pressurization reported problems are due to fluctuations
16 while the airplane's climbing or descending. Those are
17 difficult to produce -- reproduce on the ground because you
18 can't change the outside air pressure.
19 Q Did you ever have an aircraft that was damaged
20 due to hail with inoperative radars?
21 A With inoperative radars? I don't know of any
22 specifics, sir.
23 Q When you were the director of engineering, you
24 were responsible for both maintenance programs and
25 publications?
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1 A That's correct.
2 Q You have anything to do with turnover logs?
3 A No.
4 Q Do you know what a turnover log is?
5 A Yes.
6 Q Could you describe what one is for me?
7 A The turnover log is when there's a shift change
8 or a personnel change on a particular task that's not
9 completed, there should be a written description of the work
10 that's been accomplished, and the status of the work at the
11 time of the turnover of personnel.
12 Q Mr. Wood described some of the paperwork that was
13 so-called "locked down" at the Emery facility after the
14 accident with 79 Uniform. Were those turnover logs -- would
15 you consider that they may have been locked down?
16 A It's hard to say if the -- if the sweep through
17 to gather up the paper that is relevant, if that would have
18 been picked up, I can't really say on that.
19 Q Is there a possibility that they could be in the
20 long term storage also?
21 A A turnover log?
22 Q Yes.
23 A I -- I don't know. I don't know.
24 Q Approximately how far into the FCD did you leave?
25 A Into the FCD?
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1 Q Yes, the fleet campaign directive.
2 A Did I leave?
3 Q Uh-huh.
4 A Can I look at the date on the 27 --
5 Q Sure.
6 A I was already gone.
7 Q Who was the director of engineering during the
8 FCD after you left?
9 A Dan Kirkpatrick.
10 Q Do you have any first hand knowledge, or
11 knowledge of the results of that FCD?
12 A No, as I said, I saw the list of the results
13 briefly, but I didn't take a very good look.
14 Q If you, in your previous position as director of
15 engineering, had run a fleet campaign direction for
16 instance, security of push pull rods, anything to do with
17 flight controls, other safety of flight items like that,
18 after the FCD was complete, would you have made the results
19 available to any of your vendors?
20 A I don't think I would have. If there was a
21 procedure that had been born out of the results, I would
22 share that procedure, but the results of the FCD itself, not
23 as a standard rule, no.
24 Q Why not?
25 A Because -- basically because -- if you will, it's
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1 uncooked, it's raw data that really should be -- before you
2 go in and distribute information to -- there should be an
3 analysis process that determines -- there should be an end
4 result, okay. If I found something, if I got a finding on
5 one of these things, what caused it? How did it get to be
6 in the shape or condition it's in? And see if there's a
7 root cause. That would be preferable to send to a vendor
8 and to inform your line and your maintenance staff as to
9 what the root cause is, rather than a result. That way you
10 can -- basically, in an educational process, you can prevent
11 the end result rather than just give them an end result.
12 Q Well, not to disagree with you, but isn't that
13 censoring safety information that they might need?
14 A Of the maintenance people?
15 Q Yes, Part 145 or one of your vendors that may
16 have supplied a part or an assembly that you may have found
17 in a fleet campaign that may have a problem.
18 A It would all depend upon the results of the
19 tests. I mean this is subject to lots of different factors.
20 I would not -- if there was a safety issue, I would not --
21 certainly would not withhold the information. I would
22 inform them if I felt it was an important point or a safety
23 issue at stake.
24 Q You talked about work cards and supplemental
25 information. During the time that you were the director of
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1 engineering, was there any attempt made to change the work
2 cards at all?
3 A There were ongoing processes to revise the work
4 cards to make them better, yes.
5 Q And what was the result of those?
6 A They -- we revised cards. I mean they went
7 through the MRB for various reasons, to boost reliability,
8 to correct deficiencies in the cards, various reasons. But
9 there was an ongoing -- actually it was a continual effort
10 to look and revise the cards and take care of necessary
11 issues with them.
12 Q Knowing what you know now, would it have been a
13 good idea, or do you think it would be a good practice, to
14 place the applicable maintenance manual effectivity ... on
15 the B, C, and D cards?
16 A It's a good idea, but it's nearly impossible with
17 a very diverse fleet. You would have to -- and I looked
18 into this at one point -- and what you would have had to do
19 was develop about five different maintenance work card
20 decks, which is a huge effort, in order to make them
21 specific.
22 Q So you wouldn't try to establish a technical file
23 for each airplane? One that would contain work cards that
24 were applicable to that particular airplane?
25 A No, that's not true. I mean we did try to do
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1 that, and the -- this took place after I left, but there was
2 an effort to digitize the manual to make one manual which
3 would have facilitated on a -- even an MSG-2 card, or an
4 MSG-3, which I think they were working toward -- to make
5 those specific links to the maintenance manual. That was a
6 work in process or progress.
7 Q You talked about pilot debrief forms before. You
8 said you've seen a few of them. How many approximately over
9 the years did you actually see? Just say an estimate. I
10 realize you're not going to be able to give me an accurate
11 number?
12 A Fifteen. Something like that.
13 Q How many do you think were actually generated?
14 A Oh, I have no idea.
15 Q From a maintenance standpoint, as the director of
16 engineering, if you want to look at a few of them, who
17 would they have gone to? Who would have looked at the rest
18 of those?
19 A I don't know the actual stops. I know they went
20 to various people within maintenance and operations, and
21 because I wasn't directly involved with line operations, I
22 didn't get involved that heavily. A lot of them came to my
23 attention to -- purposely I was trying to validate the pilot
24 report, but like I said, most of them I did not get involved
25 with.
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1 Q Did you have distribution problems coming from
2 flight operations to maintenance, is that why you'd only see
3 a few of them?
4 A No. I don't know if at the time I was in the
5 distribution list, selected to receive the debriefs or
6 whatever.
7 Q And you were the director of engineering at that
8 point?
9 A Yes. Well, a portion of the time, yes.
10 Q You expressed the opinion that you thought
11 management was trying to do a good job, trying to do things
12 correctly. Were you provided the necessary tools and
13 funding to do that?
14 A I can speak for my own situation, that when I
15 asked for funding that was properly justified, I can't
16 recall ever being denied funding for tooling, personnel,
17 anything.
18 Q So you believe the engineering department was
19 properly staffed for the size airline?
20 A It was being built up at the time.
21 Q At the time that you left, approximately how many
22 people worked in engineering?
23 A Roughly 25 to 30 people.
24 Q Out of that number, approximately how many
25 supervisors or management people in engineering?
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1 A Three managers in the engineering department.
2 Q All full time?
3 A All full time? Yes.
4 MR. GUNTHER: I have no further questions.
5 CHAIRMAN GOGLIA: Thank you. The Boeing Company.
6 DIRECT EXAMINATION
7 BY MR. BREUHAUS:
8 Q Yes, just one follow on question from Mr.
9 Gunther's questioning. How many of your employees were
10 engineers?
11 A Four engineers and there were two assistants that
12 were -- had associates degrees.
13 MR. BREUHAUS: Thank you.
14 CHAIRMAN GOGLIA: Tennessee Technical Services.
15 DIRECT EXAMINATION
16 BY MR. PORTER:
17 Q Yes, we have a few questions, thanks. Are you
18 familiar with the MPPM which basically outlined the
19 qualifications for the director of engineering?
20 A At this time?
21 Q Uh-huh.
22 A No.
23 Q How about when you took the position, sir? Or
24 accepted the position?
25 A Do I recall what it was at the time, no.
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1 Q Okay. Did it require the director of engineering
2 to hold a Bachelor of Science degree, Aeronautical degree or
3 equivalent and an A&P license -- did it sound like something
4 like that?
5 A I don't -- I don't know.
6 Q Okay. Before you took the position as director
7 of engineering, you were I believe, a manager of training?
8 A That's correct.
9 Q So you would have been responsible for, I think
10 basically you touched on it, assembling the training
11 programs, tracking the people that would have been trained
12 or what have you, and insuring that the people that needed
13 recurrent training or what have you would receive that. Was
14 that part of that role?
15 A That was part of it.
16 Q Okay. If we can go back to a Harold Camden
17 interview, which was the PMI in Cincinnati, and it's Exhibit
18 7-Charlie Charlie, I wanted to read a few excerpts from that
19 if I may, which is on page 18, and see if you can help me to
20 understand what he was prescribing.
21 A Can you give me a second to get that?
22 Q Sure.
23 A 7-Charlie Charlie?
24 Q Yes.
25 CHAIRMAN GOGLIA: Did you say seven or 17?
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1 MR. PORTER: Seven.
2 CHAIRMAN GOGLIA: I don't think we go that high
3 in seven.
4 MR. PORTER: It is --
5 CHAIRMAN GOGLIA: 17-Charlie Charlie.
6 MR. PORTER: That would be 17, I'm sorry.
7 Q Are you there?
8 A What page?
9 Q It's page 18. It actually starts on 17, and I
10 might jump around between 17 and 18 a little bit, but I'll
11 try not to be confusing.
12 A Page 18.
13 Q Basically, this is an interview with Harold
14 Camden in Cincinnati, and they were asking his
15 interpretation of -- earlier in here, the relationship
16 between Emery and the FAA, and problems that they had
17 identified or what have you, or were working to resolve or
18 improve with their relationship in Cincinnati. And when you
19 get on to page 18, he was asked the question, -- let me
20 start here -- there's a question actually on line 25 on page
21 17, and I'll read it -- and you don't really get the full
22 sense of the build up to this, but if it doesn't work out,
23 I'll go back a couple page and read both of them to you.
24 It says, "What about all the time that was going
25 on, the pilot union collected an enormous amount of data to
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1 concern repeated discrepancies, writeups that they were very
2 concerned about. Did you ever get involved with any of
3 these?" And his answer is, "On repeat writeups?" and the
4 question, "Yes." He said, "We were working with it every
5 week. It got to the point that I had weekly meetings with
6 my staff and Emery staff, the managers, and we would go over
7 the problem areas of the past week where they had found, in
8 places that they needed to address. I mean normally a PMI
9 doesn't do this, but we saw a need that just had in order to
10 keep going" -- and that's how the transcript reads. "There
11 was very cooperation and we had, I think the meetings we had
12 solved a lot of their problems." There's a few words that
13 are missing there.
14 Now, on line 16 through 19, --
15 A On page 18?
16 Q On page 18, line 16 through 19, Mr. Camden, I
17 think is trying to point out, "The biggest problem was, I
18 think, the training breakdown. They trained, but the
19 tracking of it wasn't the best in the world because a lot of
20 the mechanics hadn't been to training for two to three
21 years." And I was just wondering what the problem might
22 have been in the training program for actually tracking the
23 people that were trained and who was requiring training at
24 given intervals, what the shortfall may have been at the
25 time?
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1 A This is -- first of all -- this is two years
2 after I've -- nearly two years after I left.
3 Q Okay, do you remember what dates you were in the
4 manager of training? I think you were there like for six
5 years, right?
6 A About six years, yes.
7 Q Okay. Do you think that it's possible that it
8 might take six years or a little bit of time for a system to
9 break down to where you would have holes, as he seems to be
10 speaking to here to where you would have people who weren't
11 getting their recurrent training?
12 A Do I think it takes six years for what?
13 Q Do you think it's -- you were in -- alright, let
14 me rephrase that. As the manager of training, can you tell
15 us how you tracked the training that was given to the Emery
16 mechanics?
17 A We had training files on every mechanic.
18 Q Okay, now was there a system that would flag you
19 in any way when somebody was due for recurrent training?
20 A No, at the time the managers or the line station
21 managers were required to track that.
22 Q Okay, were the supervisors ever given the
23 opportunity to say, hey, I've got somebody here that is
24 either exceptional or needs some work or what have you and
25 would want to put them in some additional training, or get -
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1 - have them receive some more training? Was that an option
2 or was the system closed to where you got the minimum amount
3 of training and that was it?
4 A No, it happened quite frequently with someone
5 that was highly motivated or needed some additional training
6 at another time, we made room for everybody.
7 Q So you wouldn't have any recollection or any idea
8 why the PMI in Cincinnati would be mentioning this as one of
9 their -- one of the issues that he saw was a major problem?
10 A As I said, this is two years after I've been
11 gone.
12 Q Okay, thank you. Now you've been through this
13 with Mr. Pudwill and Mr. Carbone's been through it here a
14 little while back, I was wondering -- the three FCDs that
15 were issued after it was determined, or the bolt was not
16 found at the scene of the accident and it was determined
17 that that could have been a proximate cause, though there's
18 no final on that yet, and Emery issued three FCDs -- 27-7,
19 27-8, 27-8 revision one, and I was wondering if anybody at
20 Emery had a complete tally on what the results of each one
21 of them were? What the findings were on the aircraft for
22 the fleet?
23 A I assume that there is. I haven't seen it. I
24 don't know.
25 Q Do you know if that data was ever provided to the
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1 maintenance providers?
2 A I don't know.
3 Q You think that it might have been smart to turn
4 it over to the 145s or the other heavy maintenance
5 facilities that were doing that type of work for you?
6 A Well, as I was talking with ALPA, depending upon
7 the results of that, if the results were negative or
8 inconclusive or whatever, like I said there would be -- I
9 believe that the prudent thing to do is to provide some
10 basis of -- some analysis with the data so that -- I mean if
11 you just give them a bunch of numbers of a page, somebody
12 should do some compilation and figure out what exactly is
13 going on. So, and once again, I can't speak for the
14 disposition of these FCDs.
15 Q Okay. When you were -- you were pretty much
16 responsible for the reliability program there for some time,
17 correct?
18 A I was the director over it, yes.
19 Q Okay. Now when you send -- how do you measure
20 your reliability, or what gauges that you would use to
21 decide that you have a problem with some system on the
22 aircraft, that you would absolutely say, hey, maybe we need
23 to sit down and rethink the maintenance intervals or the
24 type of maintenance that we're doing on this specific system
25 on the aircraft? What would you use to measure that?
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1 A You can use -- there's over pars, there's repeat
2 writeups, there's any number of mechanisms that will trigger
3 a look at the maintenance programs.
4 Q So was there any -- was there any thought to
5 looking at the findings from components that would be sent
6 out to 145s to try to understand different conditions that
7 would be identified during the tear down reports, initial
8 inspections or what have you, and then try to build that in
9 to the maintenance package to try and prevent some of those
10 occurrences from happening again?
11 A At the time I was over it, the components that
12 came in and out of heavy maintenance facilities did not get
13 put into the data because they were not - it was not
14 operational barriers, it was not operational problems. In
15 other words, we tracked operational issues. When the
16 aircraft was flying and had a failure, we would track
17 components on that basis, but components coming in and out
18 of a heavy maintenance provider, the system was not set up
19 to do that.
20 Q Do you think that that would have helped you get
21 your arms around maybe, or help prevent some wear and tear
22 on the airplane, or staying ahead of issues that could
23 possibly hinder your dispatch reliability?
24 A I think that yes, in some cases, the purchasing
25 or procurement would flag some items that they were having
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1 problems with -- having a hard time finding a vendor that
2 could provide a workable unit. Those things did happen.
3 But yes, I think a better -- an improvement to the program
4 would have been to, maybe not mix it with the operational
5 data, but at least perform some sort of analysis on it.
6 Q So analysis of components that may have come back
7 from reliability program to try and understand their
8 condition, basically, would have been driven by economics,
9 if we started to see, or you started to see that components
10 were wearing out a little bit faster, or you were having to
11 spend money twice to get something fixed, that would --
12 A Economics is not really the driver. The driver
13 is dispatch reliability and safety - those types of things.
14 If you start seeing failures, those are the things you want
15 to get. Obviously, the money goes up when you have high
16 failure rate. So I mean it's definitely a consideration in
17 that, but it's not the driver.
18 Q Okay. Do you know if Emery tracked zero time
19 failures from vendors to try and understand who is maybe
20 outperforming --
21 A Back to stock items?
22 Q Yes.
23 A It depends on the way the -- it depends on the
24 status of the part, the parts tag. The parts tag made it
25 through the system, then it would be caught. If the parts
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1 tag, if it was identified and they just filled out the tag
2 and said bad from stock and sent it back, the system was not
3 set up to catch those items, so it was a mixed bag on those.
4 Q Okay. Let me see -- in a previous interview with
5 Mr. Obromski (ph), which I believe is out of the San Jose
6 office in California, he spoke to Emery not providing or not
7 having reliability reports for a four month period of time,
8 and would you have been familiar with or been involved with
9 any of that while you were out in California, or were you
10 still training at that point?
11 A I was the manager of training at that time.
12 Q I'd like to get back to, if I may,
13 troubleshooting of the elevator system. When we were
14 talking several times in the past couple days and getting
15 several opinions on troubleshooting procedures and what is
16 trained and not trained and what is standard procedure from
17 an experienced A&P and what we do -- I'm an A&P mechanic as
18 well. When the aircraft landed on November 25, '99, with
19 the -- I've got it right here, we've probably all have got
20 it memorized by now -- "Elevator requires more back pressure
21 than normal flare of the aircraft, also during elevator
22 checks CG to 25.4, 2F 23.3 percent".
23 When you were speaking to this one with Mr.
24 Pudwill, you listed or you spoke to a series of scenarios
25 that could possibly have caused this log book entry, or the
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1 pilot to find the elevator system to be deficient in some
2 way on that landing, and you spoke to air speed, weight,
3 possible trim problems, flap settings, stuck cable,
4 bearings, and then we got into possibly the elevator being
5 iced. And I wanted to just touch on one of them. And that
6 would be a potential jam or frozen bearing in the system,
7 and I wanted to just kind of get your opinion and get a feel
8 for what you would think, referencing to the maintenance
9 manual, of course, what you would need to do to isolate
10 different sections of the system to identify a potential
11 frozen bearing that you may feel in the control column.
12 A There's a procedure listed in the maintenance
13 manual for isolation of the system.
14 Q Okay, so in your opinion, if you're isolating the
15 elevator from the system, you're -- obviously you're up in
16 the tail cone now.
17 A Correct.
18 Q And you're disconnecting your torque tube input
19 to the elevator drive crank, and then you're probably going
20 to disconnect your cables to the crank that would go to your
21 control tab. Is that correct so far?
22 A That's according to the procedure, yes.
23 Q Okay. Now, you've got the elevator completely
24 eliminated from the cable system coming from the control
25 column. Okay, now you could manipulate the elevator and try
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1 and listen or feel or -- we all know what the elevator's
2 supposed to do with the damper, we know it's mass balanced
3 forward or what have you, and try to identify any kind of a
4 squeaking or -- you know the routine. A bearing that could
5 possibly be frozen or a bolt that doesn't like the way it's
6 installed or something like that-- over torqued or -- if you
7 were going to isolate the control tab from the elevator,
8 would you not have to disconnect the control tab input rod
9 at the aft end so that you could feel the bearings and feel
10 the control tab on the elevator and try to identify a frozen
11 bearing or something of that nature? A bolt that's over
12 torqued and that maybe the clevis is being squeezed?
13 A In the case of the push rod, I would go with the
14 easiest access, which was the forward end where the
15 inspection panel is for the adjustment and open that up
16 before I went to all those screws on that faring.
17 Q So you wouldn't go to the aft bolt?
18 A No, I would not.
19 Q So you wouldn't check and see if perhaps the
20 bolt's over torqued, the clevis is squeezed at the rod end
21 itself?
22 A Only if that -- if the isolation of the forward
23 end relieved the problem, then I would obviously go further
24 aft.
25 Q Okay. When you're changing -- when you're
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1 actually changing or swapping back the elevator dampers, we
2 know they're at the inboard hinge point and sometimes they
3 can be a challenge to remove. And the procedure tells you
4 that if you do need to -- if you do need to gain more
5 elevator travel in order to extract the damper from its
6 installation point, to disconnect the torque tube inside of
7 the tail of the aircraft. Is it possible that a lesser
8 experienced A&P mechanic could discern the torque tube
9 inside the tail cone of the aircraft as the control tab push
10 rod? He may disconnect that believing he's doing the right
11 thing?
12 A There's a big difference between a push rod and a
13 torque tube, and --
14 Q They essentially do the same thing.
15 A They do essentially the same thing, but there's a
16 difference in their literal function. You're asking me my
17 opinion, I don't think --
18 Q It wouldn't be possible for a younger guy out on
19 the line --
20 A Or a possibility, there's a possibility, but I
21 think that the level of mechanics -- the majority of
22 mechanics that I'm aware of out there, and particularly the
23 people that were working on this, they had more than enough
24 experience to make a distinction between a torque tube and a
25 push rod and knew where the location was.
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1 Q Okay. Earlier today, Mr. Hoffstetter, while
2 being questioned by Mr. McGill, was speaking to some
3 alarming maintenance that was taking place in Dayton that
4 was observed by some people that we had on site supplying
5 manpower. And he was describing cotter pins, jam nuts, and
6 aileron rigging procedures and such that turned out to not
7 be per the maintenance manual or per what you would believe
8 would be an acceptable maintenance practice.
9 And I guess what I'm getting at is if something
10 like that could take place on the line, why would it be --
11 in your opinion, what do you think that it would be
12 outrageous that a younger mechanic could confuse the torque
13 tube inside of the tail of the aircraft with the input rod
14 in the control panel? We're already hearing of examples of
15 some -- well some stories that are kind of hard to believe,
16 kind of a challenge to think that that goes on on the flight
17 line.
18 A There's a question?
19 Q Yes, the question would be do you think that it
20 would be, based on things that you've heard here, with
21 maintenance practices that have taken place on the line in
22 Dayton, that somebody could perhaps mistake the maintenance
23 manual and go to that rod, believing they were doing the
24 right thing?
25 A Anything is possible. Based on my experience and
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1 my knowledge, no.
2 MR. PORTER: That's all I have. Thanks a lot.
3 CHAIRMAN GOGLIA: Okay, thank you. Federal
4 Aviation Administration.
5 MR. STREETER: We have no questions, sir.
6 CHAIRMAN GOGLIA: Okay, to the Board of Inquiry,
7 Mr. DeLisi?
8 DIRECT EXAMINATION
9 BY MR. DeLISI:
10 Q Thank you. Mr. Robbins, are you an engineer?
11 A No, sir.
12 Q Mr. Pudwill frequently, in his testimony, asked
13 you to share your engineering opinion with him, and you did
14 so without qualification. Why was that?
15 A For about the last five years, give or take, I've
16 been intimately involved with many engineering projects from
17 concept through design, certification, those type of things.
18 I feel I'm capable in some respects to answer questions.
19 Q And for the record, at the time of the accident,
20 there was no requirement for the director of engineering at
21 Emery to be an engineer.
22 A Not that I'm aware of.
23 Q Thank you. Mr. Robbins, were you the right
24 person to share with us Emery's position that it was not
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1 required to take the faring off when doing the B-9 card
2 check?
3 A If you're asking whether in the course of the
4 duties of director of engineering, I would be the one to
5 make the distinction as to does the faring stay on or does
6 the faring come off, that would not have been my role at
7 Emery.
8 Q You earlier gave us a presentation, and in the
9 presentation it stated that it was not required to take that
10 faring off to do the inspection.
11 A To do the inspection as I've been instructed that
12 that's the level of the inspection that's called for.
13 Q When you gave us that presentation and you put
14 that on the record and you shared that with us, what was the
15 basis for the statement that the faring did not need to come
16 off?
17 A The basis for that statement was that my
18 understanding of what I have been told -- and this goes to
19 years at Emery -- that where it says a visual inspection,
20 it's a visual inspection that requires a flashlight and a
21 mirror, basically, and that there's no panel removal.
22 Q When you gave us that presentation, it came
23 across as a fact that it was not required, and I interpreted
24 that to be Emery's position that it is not required. But
25 perhaps now should there be a qualification to the clarity
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1 with which that presentation was made earlier today?
2 A The presentation that I made, and the comments I
3 made, are -- I mean they stand as far as I'm concerned.
4 Whether or not I'm the proper person to make that statement,
5 I -- I can't really answer that.
6 Q Okay, well --
7 A Sorry.
8 Q You did make the statement.
9 A You're asking whether or not I was the proper
10 person.
11 Q You gave us that presentation --
12 A Yes, I did.
13 Q -- you made that statement.
14 A Yes, I did.
15 Q One final question, if there was a maintenance
16 problem that was difficult to resolve, is there technical
17 support available from the Boeing Company for the DC-8?
18 A In some cases.
19 Q When you were with Emery as the director of
20 engineering, are you aware of times where technical support
21 from Boeing was requested?
22 A Yes.
23 MR. DeLISI: Thank you. No further questions.
24 CHAIRMAN GOGLIA: Okay, the Chairman does not
25 have any questions. So back to the technical panel, is
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1 there anything on wrap up?
2 HEARING OFFICER HILLDRUP: No, sir.
3 CHAIRMAN GOGLIA: Okay, back to the ALPA, any
4 additional questions? Clarification?
5 REDIRECT EXAMINATION
6 BY MR. GUNTHER:
7 Q Yes, we'd like to do some clarification if we
8 could. And I realize it's getting late so I really just
9 have just a couple questions. Mr. Robbins, can you look at
10 your previous interview, which is Exhibit 17-Y.
11 A 17-Y.
12 CHAIRMAN GOGLIA: Okay, just hang on a second
13 while we provide the witness with --
14 THE WITNESS: Okay.
15 BY MR. GUNTHER:
16 Q And if you can turn to page five, line 10.
17 A Yes.
18 Q During the interview, Mr. McGill from NTSB asked
19 you about reliability, and the question that he asked was,
20 "Talk a little about the -- we keep hearing about how you
21 keep having repeat writeups." And his question to you is,
22 "How do you track that from a reliability standpoint?"
23 Could you read your answer?
24 A Beginning on line three?
25 Q Line 13 would be the answer to the question he
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1 asked you.
2 A Line 13 starts out with the word "adequate", page
3 five -- that's on my page five.
4 Q No, if you could find the question --
5 A Okay, is it --
6 Q It starts off at line 11, the question --
7 A Okay, I see it.
8 Q It says, "Talk a little about the -- we keep
9 hearing about you have repeat writeups. How did you track
10 that from a reliability standpoint?" And could you read
11 your answer which begins on line 14?
12 A Sure. "We use the pilot reports to determine if
13 there is a problem on the aircraft that is repeating itself.
14 Obviously, it's not being addressed properly or maintenance
15 has been ineffective in fixing or identifying the problem.
16 In some cases, particular with aircraft with a lot of
17 wiring, you have a situation where there's a problem on the
18 aircraft that only rears its head every so often, and
19 maintenance may or may not be able to find that, depending
20 on the condition of the aircraft at the time you are looking
21 at it." Do I continue?
22 Q No, thank you. I have no further questions.
23 CHAIRMAN GOGLIA: The Boeing Company? No
24 questions from Boeing. Tennessee Technical Services?
25 One question. Proceed.
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1 REDIRECT EXAMINATION
2 BY MR. PORTER:
3 Q Earlier, when you were speaking with Kevin
4 Pudwill, you made a statement that said maintenance would
5 like to provide an aircraft with everything working almost
6 all the time. And I was just wondering when would you like
7 to provide an aircraft when everything isn't working?
8 A I think the word almost should have been left
9 out. That's certainly not the correct statement. Speaking
10 for myself, I would always like to have a 100 percent
11 aircraft.
12 Q And when you had the reliability department, when
13 you were still with Emery, what was the minimum amount of
14 people you had working for you in the department?
15 A In reliability?
16 Q Yes, sir.
17 A Seven or eight.
18 Q And they were analysts --
19 A Analysts, yes, a whole variety of positions.
20 Engineers came in through engineering. Reliability did not
21 have engineers on their staff, it was accomplished within
22 the department. There were analysts and --
23 Q Maintenance planners?
24 A Not planners.
25 Q No planners. Just all data entry type people.
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1 A No, analysts, one data entry -- one data entry
2 person.
3 MR. PORTER: Okay, that's all we have. Thanks a
4 lot.
5 CHAIRMAN GOGLIA: The Boeing Company? FAA?
6 Emery Worldwide? Mr. DeLisi?
7 One question. When you were employed with Emery,
8 do you remember a person by the name of Booker?
9 THE WITNESS: Yes.
10 CHAIRMAN GOGLIA: Did he work for you?
11 THE WITNESS: No.
12 CHAIRMAN GOGLIA: Who did he work for?
13 THE WITNESS: He reported to the vice president
14 of technical services.
15 CHAIRMAN GOGLIA: Okay, thank you. Mr. Robbins,
16 you are released as a witness for the proceedings.
17 (The witness was excused.)
18 CHAIRMAN GOGLIA: All the other witnesses that
19 I've asked to stay are released.
20 (The witnesses were excused.)
21 CHAIRMAN GOGLIA: Does anybody have anything
22 additional they would like to raise to me at this time?
23 Because I am about to take some action here. And I guess I
24 will just proceed.
25 Ladies and gentlemen, as Chairman of this
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1 proceedings, one task for me is to help create a complete
2 record for the use of the full Board in determining
3 accurately the probable cause, and to make meaningful
4 recommendations so that we can have a reasonable expectation
5 that we will not have another accident. For the same
6 reasons -- another accident for the same reasons.
7 It is painful to me, as a maintenance person, to
8 recognize at this point that I cannot inform my peers on the
9 Board that I have accomplished that task. I believe at this
10 point we have been unable to fully develop the record in
11 this accident. In preparation for this public hearing, we
12 asked the parties to the accident to provide the most
13 knowledgeable persons to provide the information that we
14 need to complete the record. Unfortunately, that did not
15 happen here. The list of areas that still need to be
16 developed is long. And I do not wish to consume any more
17 time of those present here today. So I am now required to
18 recess these hearings so that we can return at a later date
19 in time to continue to develop the record. The parties to
20 the investigation will be advised when, where and how we
21 will proceed with developing a complete record.
22 This hearing is recessed.
23 (Whereupon, at 8:10 p.m., the hearing in the
24 above captioned matter was adjourned, to be reconvened at a
25 future date, time and location to be determined.)
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