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|
Attributes | |
ACN | 229507 |
Time | |
Date | 199212 |
Day | Thu |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : pns |
State Reference | FL |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Light Transport, Low Wing, 2 Turboprop Eng |
Navigation In Use | Other Other |
Flight Phase | climbout : takeoff ground : preflight ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi |
Experience | flight time last 90 days : 100 flight time total : 4300 flight time type : 70 |
ASRS Report | 229507 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : private pilot : instrument pilot : commercial pilot : cfi pilot : atp |
Experience | flight time last 90 days : 37 flight time total : 2730 flight time type : 37 |
ASRS Report | 228785 |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : published procedure non adherence : far other anomaly other |
Independent Detector | other other : unspecified |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
First officer did not remove propeller strap on right engine during his preflight inspection. During normal engine start checklist procedures the engine was cleared for start twice each, by both the first officer and the ramp person as requested by the captain. The right engine was started with the propeller strap attached. No abnormalities were noted from the cockpit during the start, except for a slight vibration when the propeller was unfeathered. The captain feathered and recycled the propeller, no vibration was noted. Captain attributed this vibration to possibly cold oil in the propeller hub since this was the first start of the day. The flight continued uneventfully from pns to bna. At bna this crew changed aircraft and continued to atl. Maintenance discovered the remnants of the propeller strap (2 clips attached to the cowling) during a routine maintenance inspection. The company held an informal hearing the following day to obtain information from this crew. During the hearing the first officer stated he had seen the propeller strap during his preflight inspection, but had decided to remove it after completing his inspection of the right wing. He became distracted and forgot about the strap. Conditions at the time of engine start were complete darkness and moderate rain. This caused the visibility from the cockpit to be very poor because of rain on the windows. This may also be attributed to why the ramp person did not see the strap attached to the propeller. Other contributing factors are that the propeller strap is not listed on the preflight inspection checklist which made the first officer unsure that he had to remove the strap or if ground personnel were to remove the strap and mainly the construction of the strap makes it hard to see in low visibility. The captain also noted that he had not been trained on attaching or detaching the propeller strap during training. Currently, the strap is constructed of a 1 inch nylon navy blue strap with 2 cables approximately 8 inches in length attached to it, then 2 clips are attached to each end of these cables. These clips attach to the cowling of the aircraft. The strap slides onto the lower propeller blade and attaches to the lower part of the engine cowling. Attached to the rear of the strap is a þremove before flight' flag. This flag lies along the trailing edge of the propeller when the strap is attached. The flag can easily stick to the propeller when the propeller is wet, making the flag very hard to see unless you look at it from a proper angle. Improvements to the strap can be made to make into more visible. First, construct the nylon portion of the strap from orange, white, or other highly visible color. Attach the þremove before flight' flag to the front of the strap. Finally, put reflective material on the strap so that the crew can see it much easier from the cockpit in darkness and low visibility with the use of a flashlight. These suggestions were made to the company by the captain during the informal hearing and resulting preflight retraining. In summary, the causes in this case were the crew was not trained in attaching/detaching propeller straps, preflight inspection checklist did not include propeller strap, and lastly, poor construction of the strap makes it difficult to see in poor visibility. Actions taken in this case were 1) captain received additional training in preflight inspection including attaching/detaching propeller straps and more initial operating experience training. 2) first officer received same training and was given a letter in personnel file in addition. Supplemental information from acn 228785: contributing factors include an association of blade straps with gear pins as a maintenance, ground personnel item that they will remove/stow as well as tail stand. Low time, 37 total hours in aircraft type. Night conditions. Rain conditions. Ground personnel clearing for start.
Original NASA ASRS Text
Title: LTT ACR FLT STARTS #2 ENG WITH PROP STRAP ATTACHED. POSTFLT INSPECTION REVEALED FACT AT DEST ARPT.
Narrative: FO DID NOT REMOVE PROP STRAP ON R ENG DURING HIS PREFLT INSPECTION. DURING NORMAL ENG START CHKLIST PROCS THE ENG WAS CLRED FOR START TWICE EACH, BY BOTH THE FO AND THE RAMP PERSON AS REQUESTED BY THE CAPT. THE R ENG WAS STARTED WITH THE PROP STRAP ATTACHED. NO ABNORMALITIES WERE NOTED FROM THE COCKPIT DURING THE START, EXCEPT FOR A SLIGHT VIBRATION WHEN THE PROP WAS UNFEATHERED. THE CAPT FEATHERED AND RECYCLED THE PROP, NO VIBRATION WAS NOTED. CAPT ATTRIBUTED THIS VIBRATION TO POSSIBLY COLD OIL IN THE PROP HUB SINCE THIS WAS THE FIRST START OF THE DAY. THE FLT CONTINUED UNEVENTFULLY FROM PNS TO BNA. AT BNA THIS CREW CHANGED ACFT AND CONTINUED TO ATL. MAINT DISCOVERED THE REMNANTS OF THE PROP STRAP (2 CLIPS ATTACHED TO THE COWLING) DURING A ROUTINE MAINT INSPECTION. THE COMPANY HELD AN INFORMAL HEARING THE FOLLOWING DAY TO OBTAIN INFO FROM THIS CREW. DURING THE HEARING THE FO STATED HE HAD SEEN THE PROP STRAP DURING HIS PREFLT INSPECTION, BUT HAD DECIDED TO REMOVE IT AFTER COMPLETING HIS INSPECTION OF THE R WING. HE BECAME DISTRACTED AND FORGOT ABOUT THE STRAP. CONDITIONS AT THE TIME OF ENG START WERE COMPLETE DARKNESS AND MODERATE RAIN. THIS CAUSED THE VISIBILITY FROM THE COCKPIT TO BE VERY POOR BECAUSE OF RAIN ON THE WINDOWS. THIS MAY ALSO BE ATTRIBUTED TO WHY THE RAMP PERSON DID NOT SEE THE STRAP ATTACHED TO THE PROP. OTHER CONTRIBUTING FACTORS ARE THAT THE PROP STRAP IS NOT LISTED ON THE PREFLT INSPECTION CHKLIST WHICH MADE THE FO UNSURE THAT HE HAD TO REMOVE THE STRAP OR IF GND PERSONNEL WERE TO REMOVE THE STRAP AND MAINLY THE CONSTRUCTION OF THE STRAP MAKES IT HARD TO SEE IN LOW VISIBILITY. THE CAPT ALSO NOTED THAT HE HAD NOT BEEN TRAINED ON ATTACHING OR DETACHING THE PROP STRAP DURING TRAINING. CURRENTLY, THE STRAP IS CONSTRUCTED OF A 1 INCH NYLON NAVY BLUE STRAP WITH 2 CABLES APPROX 8 INCHES IN LENGTH ATTACHED TO IT, THEN 2 CLIPS ARE ATTACHED TO EACH END OF THESE CABLES. THESE CLIPS ATTACH TO THE COWLING OF THE ACFT. THE STRAP SLIDES ONTO THE LOWER PROP BLADE AND ATTACHES TO THE LOWER PART OF THE ENG COWLING. ATTACHED TO THE REAR OF THE STRAP IS A þREMOVE BEFORE FLT' FLAG. THIS FLAG LIES ALONG THE TRAILING EDGE OF THE PROP WHEN THE STRAP IS ATTACHED. THE FLAG CAN EASILY STICK TO THE PROP WHEN THE PROP IS WET, MAKING THE FLAG VERY HARD TO SEE UNLESS YOU LOOK AT IT FROM A PROPER ANGLE. IMPROVEMENTS TO THE STRAP CAN BE MADE TO MAKE INTO MORE VISIBLE. FIRST, CONSTRUCT THE NYLON PORTION OF THE STRAP FROM ORANGE, WHITE, OR OTHER HIGHLY VISIBLE COLOR. ATTACH THE þREMOVE BEFORE FLT' FLAG TO THE FRONT OF THE STRAP. FINALLY, PUT REFLECTIVE MATERIAL ON THE STRAP SO THAT THE CREW CAN SEE IT MUCH EASIER FROM THE COCKPIT IN DARKNESS AND LOW VISIBILITY WITH THE USE OF A FLASHLIGHT. THESE SUGGESTIONS WERE MADE TO THE COMPANY BY THE CAPT DURING THE INFORMAL HEARING AND RESULTING PREFLT RETRAINING. IN SUMMARY, THE CAUSES IN THIS CASE WERE THE CREW WAS NOT TRAINED IN ATTACHING/DETACHING PROP STRAPS, PREFLT INSPECTION CHKLIST DID NOT INCLUDE PROP STRAP, AND LASTLY, POOR CONSTRUCTION OF THE STRAP MAKES IT DIFFICULT TO SEE IN POOR VISIBILITY. ACTIONS TAKEN IN THIS CASE WERE 1) CAPT RECEIVED ADDITIONAL TRAINING IN PREFLT INSPECTION INCLUDING ATTACHING/DETACHING PROP STRAPS AND MORE INITIAL OPERATING EXPERIENCE TRAINING. 2) FO RECEIVED SAME TRAINING AND WAS GIVEN A LETTER IN PERSONNEL FILE IN ADDITION. SUPPLEMENTAL INFO FROM ACN 228785: CONTRIBUTING FACTORS INCLUDE AN ASSOCIATION OF BLADE STRAPS WITH GEAR PINS AS A MAINT, GND PERSONNEL ITEM THAT THEY WILL REMOVE/STOW AS WELL AS TAIL STAND. LOW TIME, 37 TOTAL HRS IN ACFT TYPE. NIGHT CONDITIONS. RAIN CONDITIONS. GND PERSONNEL CLRING FOR START.
Data retrieved from NASA's ASRS site as of July 2007 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.