37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 1127066 |
Time | |
Date | 201308 |
Local Time Of Day | 0601-1200 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Light | Daylight |
Aircraft 1 | |
Make Model Name | S-76/S-76 Mark II |
Operating Under FAR Part | Part 135 |
Component | |
Aircraft Component | Main Rotor |
Person 1 | |
Function | Lead Technician |
Qualification | Maintenance Airframe Maintenance Powerplant |
Experience | Maintenance Lead Technician 25 |
Events | |
Anomaly | Aircraft Equipment Problem Critical Deviation - Procedural FAR Deviation - Procedural Published Material / Policy |
Narrative:
Below is a report sent to company X corporate flight department in response to two maintenance issues and current operating policy. Followed up with my resignation. I would first like to discuss the events that surround the current issue related to aircraft X; a sikorsky S-76 helicopter; followed by my observations related to the damper replacement one week earlier on aircraft Y; and observations related to tool control; hardware control and safety policy. The intent of this report is not meant to be malicious but viewed as an opportunity to improve your safety process. August 2013; I reinstalled the number-two forward firewall on aircraft X; the first panel that I installed had several camlocks that required replacement. The camlocks were in a parts bag and there were no retainers for the camlocks; they were not mentioned in the turnover notes nor was there any mention of the disposal of the retainers. I inspected the area for the missing retainers and requested quality assurance (Q/a) also inspect the area prior to install of the panel; no hardware was found. The missing retainers were mentioned to Q/a; I don't remember the exact response but it was not one of concern. For the installation of the second panel I started by opening the hardware bag and counting the hardware and then counting the number of mounting points on the part. I found that I had three extra bolts and was missing one spacer and four washers. This was brought to the attention of qa and the response was ' I will ask inspector X about it when he comes in'. I received a qa approval to install the panel; the panel was installed minus one bolt at the lower outboard corner; there were several attempts made by inspector Y and myself to start the bolt and we concluded the nutplate was damaged and would need to be replaced at a later date. I entered a discrepancy in the aircraft maintenance book and signed the panel install. Not being sure of what to do with the extra hardware I placed it back in a bag and placed it in my desk knowing that I would need this hardware at a later time. When I left that afternoon; inspectors X and Y were preparing to start the scheduled aircraft inspections. One hour later I received a call asking me for the location of the hardware; I told them exactly where it was. The next day I checked the aircraft; the missing bolt was installed and I could not find a record of the discrepancy that I had entered. I asked mr. X what they did to fix it and the response was 'we bent the tab'. This was followed up by a morning teleconference with mr.X and the director of operations. The purpose of the call was to lecture me about the hardware that was placed in my desk. The previous week a main rotor damper was replaced on another S76 helicopter; the tools that were used to perform the task were out of a personal tool box and there was no tech data readily available; this is a major violation of tool control. That week in the staff meeting there was mention of knowledge of the uncontrolled tool box and that it needed to be removed. The tool control at company X requires improvement. The tool box should be kepted in a secured area when not in use and a record of who used the tool box and on what aircraft it should be maintained. Tool box should be inventoried when signed-out and in and should have an inventory of what is in each draw that alerts the individual as to exactly what they are looking for if a tool is missing. All the junk in the bottom draw of the tool box should be removed because it is uncontrolled and could be considered FOD. During the aircraft post flight inspection; the fuel samples are taken; the proper time to take fuel samples is during pre-flight or when the aircraft has remained static for a minimum of one hour. The fuel samples for the fuel farm should be done at the beginning of the day prior to any aircraft being fueled. Hardware needs to be controlled; and the hardware crib access should be restricted. When new hardware is required the mechanic should provide a part number for the hardware and when new hardware is issued; the old hardware should be properly disposed of so it does not become FOD. The consumable cabinets require an inventory sheet and the expiration dates need to be reviewed. There needs to be a list of what material is flammable and stored in the proper cabinet. One afternoon when I came in; the facilities person came into the office and pointed out that there was still flammable materials being stored in the wrong cabinet. The response from the maintenance crew was 'ok; thanks; we will take care of it' and they went back to what they were doing. They should have made a note or created an action item list. The caulking and the hysol [adhesive] in the refrigerator needs to be removed because it is a health issue and does not require refrigeration. When there is a lost tool or missing hardware there needs to be a process in place for grounding the aircraft until the missing item is found or a satisfactory inspection has been completed. If your safety policy is going to work you need to make it clear that when there are missing items reported; there will be no disciplinary action.
Original NASA ASRS Text
Title: A Lead Aircraft Maintenance Technician (AMT) describes his company's maintenance repair facility work environment for their corporate S-76 helicopters. He lists a lack of: proper maintenance record keeping; lack of shift turnovers; tool control; tool calibration requirements; fuel sampling; hardware part numbers and storage of flammable materials.
Narrative: Below is a report sent to Company X Corporate Flight Department in response to two maintenance issues and current Operating Policy. Followed up with my resignation. I would first like to discuss the events that surround the current issue related to Aircraft X; a Sikorsky S-76 helicopter; followed by my observations related to the damper replacement one week earlier on Aircraft Y; and observations related to tool control; hardware control and safety policy. The intent of this report is not meant to be malicious but viewed as an opportunity to improve your safety process. August 2013; I reinstalled the Number-Two Forward Firewall on Aircraft X; the first panel that I installed had several camlocks that required replacement. The camlocks were in a parts bag and there were no retainers for the camlocks; they were not mentioned in the turnover notes nor was there any mention of the disposal of the retainers. I inspected the area for the missing retainers and requested Quality Assurance (Q/A) also inspect the area prior to install of the panel; no hardware was found. The missing retainers were mentioned to Q/A; I don't remember the exact response but it was not one of concern. For the installation of the second panel I started by opening the hardware bag and counting the hardware and then counting the number of mounting points on the part. I found that I had three extra bolts and was missing one spacer and four washers. This was brought to the attention of QA and the response was ' I will ask Inspector X about it when he comes in'. I received a QA approval to install the panel; the panel was installed minus one bolt at the lower outboard corner; there were several attempts made by Inspector Y and myself to start the bolt and we concluded the nutplate was damaged and would need to be replaced at a later date. I entered a discrepancy in the Aircraft Maintenance book and signed the panel install. Not being sure of what to do with the extra hardware I placed it back in a bag and placed it in my desk knowing that I would need this hardware at a later time. When I left that afternoon; Inspectors X and Y were preparing to start the scheduled aircraft inspections. One hour later I received a call asking me for the location of the hardware; I told them exactly where it was. The next day I checked the aircraft; the missing bolt was installed and I could not find a record of the discrepancy that I had entered. I asked Mr. X what they did to fix it and the response was 'we bent the tab'. This was followed up by a morning teleconference with Mr.X and the Director of Operations. The purpose of the call was to lecture me about the hardware that was placed in my desk. The previous week a Main Rotor Damper was replaced on another S76 helicopter; the tools that were used to perform the task were out of a personal tool box and there was no tech data readily available; this is a major violation of tool control. That week in the staff meeting there was mention of knowledge of the uncontrolled tool box and that it needed to be removed. The tool control at Company X requires improvement. The Tool Box should be kepted in a secured area when not in use and a record of who used the tool box and on what aircraft it should be maintained. Tool Box should be inventoried when signed-out and in and should have an inventory of what is in each draw that alerts the individual as to exactly what they are looking for if a tool is missing. All the junk in the bottom draw of the tool box should be removed because it is uncontrolled and could be considered FOD. During the aircraft post flight inspection; the fuel samples are taken; the proper time to take fuel samples is during pre-flight or when the aircraft has remained static for a minimum of one hour. The fuel samples for the Fuel Farm should be done at the beginning of the day prior to any aircraft being fueled. Hardware needs to be controlled; and the Hardware Crib access should be restricted. When new hardware is required the mechanic should provide a part number for the hardware and when new hardware is issued; the old hardware should be properly disposed of so it does not become FOD. The Consumable Cabinets require an inventory sheet and the expiration dates need to be reviewed. There needs to be a list of what material is flammable and stored in the proper cabinet. One afternoon when I came in; the facilities person came into the office and pointed out that there was still flammable materials being stored in the wrong cabinet. The response from the Maintenance crew was 'OK; thanks; we will take care of it' and they went back to what they were doing. They should have made a note or created an action item list. The caulking and the HYSOL [adhesive] in the refrigerator needs to be removed because it is a health issue and does not require refrigeration. When there is a lost tool or missing hardware there needs to be a process in place for grounding the aircraft until the missing item is found or a satisfactory inspection has been completed. If your safety policy is going to work you need to make it clear that when there are missing items reported; there will be no disciplinary action.
Data retrieved from NASA's ASRS site as of July 2013 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.