Aircraft Accident Investigation Report

54 about seven (7) teeth out of alignment with the alignment dot (hole) on the starter bendix gear housing or 16.8 degrees out of time. 9. The engine camshaft showed signs of wear on lobes ranging from worn to extremely worn conditions with heavy pitting and corrosion exhibited. 10. The No. 3 engine cylinder intake and exhaust valve tappets and the No. 4 engine cylinder valve tappet showed heavy wear, pitting and spalling on the faces and edges of the tappets. 11. CATC’s Air Training Organization Manual did not include the name, duties and qualifications of the Quality Assurance Manager. 12. CATC’s Air Training Organization Manual did not include a description of the ATO’s quality assurance system. 13. CATC did not have a quality assurance system which ensures that training and instructional practices comply with the requirements specified in the Civil Aviation Regulations, 2012, the Ninth Schedule. 14. Two management positions listed in CATC’s Operations Specification A6 were vacant at the time of the accident, namely, Chief Flight Instructor and Maintenance Coordinator. 15. Two management positions required by the Civil Aviation Regulations, 2012, for ATO’s namely, Quality Assurance Manager and Assistant Chief Flight Instructor were not listed in CATC’s Operations Specification A6 or in their Air Training Organization Manual. 3.2 Findings as to Risk 1. The Maintenance Program that CATC used to maintain the aircraft (N101KA) was not approved by the State of Registry as required by Regulation No. 29 of the Civil Aviation Regulations, 2012. 2. There were a number of Corrosion Prevention and Control Program Inspections itemized in the ADLOG aircraft maintenance records for the aircraft, however there was no entry made in these records that reflected that the tasks were accomplished. 3. The Airworthiness Directive (AD) records presented by CATC for the aircraft were incomplete. 4. The maintenance records presented reflect that the Pitot/Static Check and Transponder Check were last accomplished on August 18, 2014. 5. Not all reported aircraft defects were being recorded in the aircraft technical log book. 6. That there was a number of service checks which were accomplished on the aircraft for which no Certificates of Release to Service were executed. 7. Not all portions of CATC’s aircraft technical logbook for the aircraft was completed as required. 8. CATC was carrying out maintenance on its US registered aircraft at the time of the accident contrary to instructions in its approved manuals which state that all maintenance on company aircraft will be contacted to an Approved Maintenance Organization. 9. There were no persons approved for the positions of Director of Maintenance and Chief Inspector as set out in Section 2.1 of CATC’s Maintenance Control Manual at the time of the accident.