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CONFIDENTIAL

APPENDIX “A” TO
AHQ/78930/1/1 DT
11 DEC,18

TO PROBE INTO CIRCUMSTANCE UNDER WHICH


PBB NO 5 L2 AT IIAP COLLAPSED

1. On-site inspection of the occurrence scene was carried out and following observations
were made: -
(a) PBB No 5 L2 was found collapsed on the ground after dislodging from Rotunda
/ fixed tunnel.
(b) The Left side Rotunda Pin was found available at the site of occurrence.
However, its fixing bolt and right-side Rotunda Pin which are the main / primary
evidence of the occurrence could not be found.
2. In the absence of above-mentioned important evidence, the technical investigation is
carried out in light of circumstantial evidence and correlating them with BOI findings.
3. During visual inspection of the collapsed PBB left side (while facing the aircraft)
connecting joints, it was observed that Qty-01 Rotunda Pin installed on each side of the PBB
for its connection with the Rotunda, is the only link between the rotunda (fixed portion) and
the tunnel (moveable portion) and supports entire load of the PBB. These load bearing pins
permit elevation of the gantry in vertical direction to adjust to the height of different aircraft.
In the existing PBB scheme, the security and positive installation of the rotunda pin assembly
is ensured by one fixing bolt which prevents sliding out of the pin under lateral force induced
by sway motion of the tunnel during docking / undocking operation.
4. It was learnt from the BOI members that following were found at the site of occurrence
just after the PBB collapse: -
(a) Left side Rotunda Load Bearing Pin was found not installed in the PBB Yoke
connection / Rotunda Eye End. The missing Rotunda Load Bearing Pin was found
lying near the Rotunda Eye End along with its fixing bolt. The fixing bolt was found not
installed in the flange of the Rotunda load bearing pin.
(b) Right side Rotunda Load Bearing Pin (while facing the aircraft) was found
twisted inside the PBB Yoke connection and dislodged/broken from its flange.
5. Following could be the probable reasons for disconnection of left side PBB connection
from Rotunda: -
(a) Left side Rotunda Load Bearing Pin or its fixing bolt was not installed
(b) Left side Rotunda Load Bearing Pin or its fixing bolt got dislodged from its
intended position during frequent PBB operations.
6. During the course of investigation, records were checked and it was revealed that PBB
No 5 was in operation since 3 May, 2018 at NIIAP. The maintenance record depicted that
last inspection was performed on the PBB on 17 September, 2018 and since then the PBB

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CONFIDENTIAL
CONFIDENTIAL

APPENDIX “A” TO
AHQ/78930/1/1 DT
11 DEC,18

operation was carried out 44 times before the incident. No other evidence of maintenance on
the Rotunda Load Bearing Pin and its fixing bolt after the last scheduled inspection was found.
Hence, possibility of disconnection of left side PBB connection from Rotunda due to non-
installation of Rotunda Load Bearing Pin or its fixing bolt was ruled out because 44 successful
operations are practically not possible with one of the PBB end connection disconnected.
7. After ruling out the above-mentioned probable cause of occurrence, the dislodging of
Rotunda Load Bearing Pin and its fixing bolt under operations came out to be the most
probable cause of occurrence. Following possibilities can contribute towards dislodging of
left Rotunda Load Bearing Pin from Rotunda / PBB connection under frequent operations: -
(a) Rotunda Load Bearing Pin fixing bolt locking mechanism was critically analyzed
and it was observed that as per OEM scheme, Rotunda Load Bearing Pin is welded
with a flange. The flange is further fixed to the PBB structure with a fixing bolt installed
inside a blind threaded hole. This arrangement is made to avoid slipping out of the
Rotunda Pin under lateral movement of the PBB. Hence, fixing bolt acts as locking
provision of the Rotunda Pin. The security / locking of the fixing bolt inside blind
threaded hole is ensured with the help of a spring washer.
(b) Operation of one of the serviceable PBB was carried out to understand and
analyze working of the Rotunda and PBB. It was observed that during vertical
movement of PBB, the PBB Yokes rotate along the axis of respective Rotunda Load
Bearing Pins. During the vertical movement, there is no significant load on the flange
and fixing bolt. However, during lateral motion of the PBB, the PBB Yokes laterally
slide over the Rotunda Pins and a lateral force acts on the flange plate, producing a
shearing effect on the fixing bolt. Moreover, during lateral movement of the PBB, a
pulling force acts on the head of fixing bolts. Under the presence of these shearing
and pulling forces, the shearing and loosening of the bolt cannot be ruled out.
(c) The Rotunda Load Bearing Pins are the critical connection of PBB with the
Rotunda. In order to ensure security of these pins, torqueing / tightness of fixing bolt
is critical. The locking of the fixing bolt inside the blind threaded hole has been provided
with the help of a spring washer. From prima facie, it is transpired that spring washer
material is different from that of the installed fixing bolt. Therefore, the fastening
assembly can act ineffectively to prevent loosening of the fixing bolt due to vibrations
induced during operations. Moreover, use of a mere spring washer for locking of such
a critical bolt is not a failsafe provision. It is pertinent to highlight that no frequency for
mandatory spring washer replacement or on condition change is available in O&M
Manual.
(d) Previous record of defects highlighted by user (CAA Engineering Department)
was also checked and it was noted that loosening of Rotunda Pin Bolts was highlighted
multiple times to the Contractor on different PBBs prior to the occurrence. Hence,
loosening of the Rotunda Pin fixing bolts is a known weak area.

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CONFIDENTIAL
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APPENDIX “A” TO
AHQ/78930/1/1 DT
11 DEC,18

(e) Post occurrence report received from OEM on the incident depicts use of only
single Grower Washer for locking of fixing bolt. However, it was observed that on
multiple PBBs, the contractor used combination of flat and helical spring washer for
locking of fixing bolts. This arrangement depicts non-standardized practice carried out
for locking fixing bolts.
(f) PBB O&M Manual suggest use of M12 bolt as Rotunda Pin fixing bolt and
specifies torque values for grades 8.8, 10.9 and 12.9. However, contrary to O&M
Manual, A4-70 bolts were used by the contractor as fixing bolts.
(g) After the occurrence, an inspection of all PBBs was carried out. During the
inspection; it was noted that previously installed A4-70 bolts were replaced by bolts of
different specifications on the PBBs. This has exacerbated the non-standardization of
the equipment (PBB & fixing bolts), adversely affecting standardization of maintenance
practices.
(h) Maintenance log books of all PBBs (including PBB No 5) were checked to
ascertain the compliance of schedule inspections on PBBs. It was observed that
scheduled maintenance inspections of PBBs were not carried out as per OEM
prescribed frequency and delays in compliance of inspections were observed.
(j) Moreover, SOP check lists were also not duly filled in by the maintenance staff
after the compliance of scheduled inspections on PBBs. Instead, maintenance work
was recorded on a locally made registers without numbered pages.
(k) As per O&M Manual, lubrication of Rotunda Pin is to be carried out quarterly by
using LUBRITERM AL spray. However, WD-40 was being used for said purpose by
the maintenance staff.
(l) The O&M Manual defines tightening of fixing bolts during quarterly inspection.
Since PBB is a moving structure and it is evident that tightening of the bolts takes
place during frequent operations. Hence, tightening of Rotunda Pin fixing bolts may
also be considered on the basis of number of operations. Same may be highlighted to
OEM for any amendment in O&M Manual.
8. On the basis of circumstantial evidence mentioned in para 4(a) & (b) and observations
mentioned in para 7, it was determined that left side PBB connection got disconnected from
the Rotunda due to dislodging of the left side Rotunda Load Bearing Pin. Once the PBB
operator, moved the PBB back to the parking position after embarking / dis-embarking
passengers, the left side PBB connection induced roll over force as its motion was not
restrained due to missing Rotunda Load Bearing Pin. The roll over force induced on the left
free side of the PBB created twisting loads on right PBB side attached with the Rotunda,
thereby dislodging the right-side Rotunda Load Bearing Pin from its flange. Resultantly, the
PBB collapsed on the ground.

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CONFIDENTIAL