The Savvy Aviator #17: But It Just Came Out Of Annual!

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When an IA signs off an annual inspection, most owners assume the aircraft is airworthy and safe to fly. That's usually true, but not always. In this month's Savvy Aviator column, AVweb's Mike Busch offers a particularly egregious example.

The Savvy Aviator

This is a true story. The names have been changed, but the rest is unvarnished truth.

If you're an aircraft owner, reading this story should make you angry. If you're an A&P mechanic, it should make you hopping mad. (I'm both an owner and a mechanic, so you can imagine how I feel.)

Over the many years that I've been teaching maintenance seminars for aircraft owners, I've had the opportunity to take a close look at a lot of piston-powered GA airplanes, usually with the engine cowlings removed (for the "show and tell" portion of the seminar), and sometimes with inspection plates or floorboards opened up. Most of the aircraft I look at are in decent mechanical shape, but sometimes I'll spot a problem that concerns me -- perhaps worn brakes, a fuel or oil or exhaust leak, a chafing wire bundle a loose induction clamp, some corrosion -- and I'll discreetly bring it to the attention of the owner and suggest that he might want to get it attended to when he gets back to home base. When that happens, more times than not, the owner will respond with a look of surprise and say something like, "How can that be? It just came out of annual!"

In a perfect world, an aircraft would be in perfectly airworthy condition each year at the completion of the annual inspection. That's theoretically what the IA's signature denotes when he signs off the annual and approves the aircraft for return to service. In the real world, of course, we know that no IA -- no matter how experienced, talented, careful and eagle-eyed -- is capable of inspecting every square inch of aircraft structure or every appliance, line, wire, connector, cable, pulley, rivet, screw, rod end, clevis and crimp on the aircraft.

Inevitably some problems get missed. That's one reason the FAA requires that we repeat the inspection every 12 months. Hopefully, most of what is missed one year will be caught the next year, and sooner or later we hope to catch everything. Realistically, the best we can hope for is that any given annual inspection will find any truly life-threatening problems, and at least a decent percentage of less-than-life-threatening ones. Lather, rinse and repeat, and hopefully in time we ultimately wind up with something approximating a truly airworthy machine.

Unfortunately, that doesn't always happen.

Oscar's Story

About four months ago, I received an email from an aircraft owner -- let's just call him "Oscar the owner." In early 2004, Oscar had purchased a 1965 Cessna 320 Skyknight -- a high-performance turbocharged piston twin -- and based it at an airport in northern New Jersey. In August 2004, the airplane came due for its first annual inspection on Oscar's watch, so he took the airplane to a shop in the northeast U.S. that I'll call "High Maintenance Aviation."

Initially, the shop told Oscar that its flat-rate charge for an annual inspection on a Cessna 320 was $2,160, and that he could expect a bill of "around $2,500 barring any major problems." (Ahem!) As the inspection progressed, the estimate predictably was revised upward to $4,000. Then the shop discovered that several several cylinders would have to be replaced, and the estimate rose to $8,000. Finally, when it was discovered that both turbochargers needed to be overhauled, the estimate jumped to $14,000 and then to $18,000. With increasing reluctance, Oscar approved each of the increased estimates and instructed the shop to proceed with the necessary repairs. He even sent the shop a $10,000 deposit.

Months passed, and when the airplane still was not ready in November 2004, Oscar called High Maintenance Aviation to get a status report. He spoke to an IA -- we'll call him "Ike the IA" -- who told him that they were still working on the airplane and that the bill would be "a bit more than $18,000" because one of the throttle cables had snapped and needed to be replaced. During his conversation with Ike, Oscar mentioned that he'd been having some problems with the left engine -- that it would run out of manifold pressure at about 12,000 feet -- and asked Ike if he could test-fly the airplane at altitude to make sure that this problem had been fixed when the turbochargers were overhauled. In a subsequent phone call, Ike later told Oscar that they experienced problems on the test flight and had to remove the turbochargers and send them back for another overhaul. Later, Ike told Oscar that he "had a problem adjusting the turbochargers."

Finally, in January 2005 -- nearly five months after the airplane went into the shop -- Oscar received a phone call from Ike at High Maintenance Aviation to say that the airplane was ready, and that the final bill was about $46,000. Oscar protested that this was $28,000 more than the highest estimate he'd received, and that he had no intention of paying the shop for overhauling and installing the turbochargers two or three times and for not being able to adjust the systems. The shop later faxed Oscar an adjusted invoice that totaled $42,626.50. Oscar hired an aviation attorney who sent the shop a nasty letter. He also emailed me for advice, which is when I first learned of his plight.

At the end of the day, Oscar agreed to pay High Maintenance Aviation $30,000 and the shop agreed to release the airplane. Oscar licked his wounds, chalked the painful ordeal up to experience, and figured that his long and costly nightmare was finally over. To be fair, I think Oscar's naiveté as an aircraft owner was partially to blame for the colossal miscommunication and misunderstanding with the shop. There was plenty of blame to go around. As it turned out, however, Oscar's nightmare was just beginning.

Fresh Out Of Annual

On the ferry flight home from High Maintenance, Oscar was dumbfounded to discover that the Cessna 320's left engine still lost manifold pressure at altitude. He was not about to take it back to High Maintenance, so he emailed me again for advice. I referred Oscar to someone I'll call "George Goodguy," the owner of "Goodguy Aircraft Maintenance." I told Oscar that George was one of the best twin Cessna mechanics in the country, and that if anyone could solve his turbocharging problem, it was George. Oscar telephoned George, described his turbocharging problem, and asked whether he could fly his airplane to Goodguy and have George take a look at it. "Sure," said George. "It's probably just a loose hose or something. I'm sure we can get it solved for you."

Oscar flew the airplane to Goodguy, and George pulled it into the maintenance hangar. But before George even got the cowlings removed from the left engine, he couldn't help but noticing problems with the airplane. Lots of problems. Serious ones.

The left engine nacelle was literally dripping with oil. Near the right wing tip tank, an excessively long sheet metal screw securing a fairing was screwed right into the aileron. The rudder and elevators had rusty torque tubes and filthy control linkages. Numerous skin panels and other sheet metal components were cracked and badly corroded. Everywhere George looked on this airplane, he could see serious airworthiness issues.

When George got the left engine uncowled, things went from bad to worse. The exhaust system was nothing short of a life-threatening disaster. Fuel and oil lines were loose. The oil cooler was leaking oil like a sieve. Heat shields were missing. Engine cooling baffles were broken and cracked. Cotter pins and safety wire was missing everywhere. The aircraft was literally a flying deathtrap.

George told Oscar that he better plan on renting a car to get home to New Jersey.

Mere words could not do justice to the horrendous condition of Oscar's airplane. George got out his digital camera and started taking photos of some of the most egregious problems he found on Oscar's fresh-out-of-annual airplane. George sent a CD-ROM to me containing more than 120 high-resolution digital photographs. I've included some of those photos below to give you the flavor of what George found:



(Click on any photo to view a higher-resolution image, or click here to see the complete high-resolution photo gallery.)

Cracked exhaust clamp.

Cracked exhaust clamp.

Cracked exhaust clamp.

Damaged engine mount.

Failed exhaust slip joint.

Missing stud at exhaust port.

Cracked exhaust port.

Rusted turbocharger support.

Turbo support end rusted away.

Bad pin, wastegate actuator.

Leaking oil cooler.

Oil, oil everywhere.

Cracked fuel injector line.

Loose fuel supply hose.

Loose induction hose clamp.

Broken baffle support.

Broken cooling baffle.

Broken cooling baffle.

Cracked cooling baffle.

Torn baffle seal.

Cracked generator mount.

Broken prop deice plug.

Fairing screw fouling aileron.

Fairing screw fouling aileron.

No tension, control cables.

Disconnected rudder spring.

Loose rudder trim bolt.

Filthy elevator control pivot.

Filthy rudder bellcrank pivot.

Rusted rudder torque tube.

Bent nose strut fill valve.

Corroded floorboards.

Cracked, filthy floorboards.
(Click on any photo to view a higher-resolution image, or click here to see the complete high-resolution photo gallery.)


And these are just 25% of the photos that George sent me.

Who could have signed off an annual on an aircraft in this dismal condition? Oscar had brought up the maintenance logbooks for the Cessna 320, and George examined them. Sure enough, an IA named Ike had signed off the annual inspection in the airframe logbook, and had signed off 100-hour inspection entries in both engine logbooks. But then George noticed something odd: the entries in both engine logs were dated January 2005, but the entry in the airframe log (in the same handwriting) was dated January 2004.

Perhaps this was an innocent error, George thought. After all, who among us hasn't written a check in January and recorded the previous year by mistake?

George phoned High Maintenance Aviation and asked to speak to Ike. He was told that Ike no longer worked there, and had taken a job with another maintenance facility in another state. George asked whether High Maintenance Aviation could at least fax him a copy of the work order on Oscar's airplane to substantiate that the shop had completed an annual inspection in January 2005. Sorry, he was told, the woman who owns the company was out of town, and had taken all the work orders with her.

Time To Call In The Feds

George has been maintaining airplanes for 42 years, so there's not much he hasn't seen before. But Oscar's airplane was one of the worst he'd ever laid eyes on. It shocked him that any shop or mechanic would sign off an annual inspection as airworthy on an airplane in such abysmal condition. He was mad, and he resolved to do something about it.

George phoned his local FSDO and left a message for his principal inspector, saying that he really needed to come over and take a look at this aircraft. After several days of telephone tag, George reached the inspector in person, but the inspector seemed reluctant to get involved, explaining that the FSDO was overloaded and understaffed. George refused to accept that, and escalated the matter to the inspector's supervisor.

Ultimately, both the FAA inspector and his supervisor paid a visit to George's shop to take a look at Oscar's airplane. The way George tells it, they slowly walked around the uncowled airplane, with eyes dilated in shock and mouths unleashing a steady stream of verbal expletives as they discovered one serious airworthiness discrepancy after another. George filled in the background of how the aircraft had just come out of a five-month annual inspection, and showed the FSDO people the relevant maintenance logbook entries. They shook their heads in disgust.

"So what are you going to do about this?" George asked the FSDO inspector and his boss.

"I'm not sure there's anything we can do," they replied, shaking their heads.

"What?" cried George. "What do you mean you can't do anything? Surely you can come down on the shop like a ton of bricks! Surely you can bring a certificate action against the IA!"

The FAA guys explained to George that it wasn't that easy. The shop was not an FAA repair station, so it was not legally responsible for performing the annual inspection. The IA (Ike) was personally responsible. "But if we try to bring an action against Ike for all these airworthiness discrepancies, he'll simply claim that none of those discrepancies existed when he inspected the aircraft, and must have developed afterwards. Unless we can somehow prove that the aircraft was unairworthy when the IA signed off the annual, we don't have a case. That's why it's usually quite difficult for the FAA to bring a certificate action against an IA."

When George called me one morning and told me what his FSDO people had told him, I was flabbergasted. Surely if ever a shop and mechanic deserved to get heat from the feds, this was the time. Could the FAA really be powerless to act in a situation like this?

As it turned out, I had an appointment that very afternoon with an FAA inspector from my own local FSDO in California to discuss another matter. As I was finishing up my meeting with the inspector, I related the story of Oscar's annual and George's exchange with his FSDO folks. My inspector pretty much confirmed what George's had told him. Under FAA regulations, an IA's representation that an aircraft is airworthy is valid only until the ink dries on his logbook entry. No matter how unworthy an aircraft may subsequently be found to be, the FAA cannot take action against the IA who signed off the last annual unless it can prove that the aircraft was unairworthy at the time of the inspection. And that's often hard to do.

Film At Eleven

George hasn't given up the fight. He's trying to document some "smoking guns" that should help prove that the aircraft was hideously unairworthy at the time Ike signed off the annual. Those cracked, multi-segment V-band exhaust clamps might do the trick, since AD 2000-01-16 requires that they be replaced every 500 hours, and the logbooks don't seem to have any entries showing that this was done. (According to my FAA guy, proving non-compliance with an Airworthiness Directive is one of the best ways to nail a bad-apple IA.)

Meantime, Oscar is talking to his lawyer about the possibility of bringing a civil lawsuit against High Maintenance Aviation. And wondering if his Cessna 320 will ever fly again.

Are you mad yet? Are you wondering what you would do in such a case? And how to stop it from happening in the first place? I'll talk about those issues next month.

See you then.


Want to read more from Mike Busch? Check out the rest of his Savvy Aviator columns.