A beech duchess 76 incurred propeller damage on engine start when a non standard tool was used to fa...

Attributes
ACN	393348
Time
Date	199802
Day	Sat
Local Time Of Day	0001 To 0600
Place
Locale Reference	airport : zzz
State Reference	US
Altitude	agl bound lower : 0 agl bound upper : 0
Environment
Light	Dawn
Aircraft 1
Operator	general aviation : instructional
Make Model Name	Duchess 76
Operating Under FAR Part	Part 91
Flight Phase	other
Flight Plan	None
Person 1
Affiliation	Other
Function	other personnel
Qualification	other other : other
ASRS Report	393348
Events
Anomaly	aircraft equipment problem : critical non adherence : far non adherence : published procedure other anomaly other
Independent Detector	other other : unspecified
Resolutory Action	none taken : detected after the fact
Consequence	other Other
Supplementary
Primary Problem	Aircraft
Air Traffic Incident	other

Narrative:

A bucking bar was inadvertently left in the engine compartment, following routine maintenance to replace a starter. Upon shutdown of the left engine the bucking bar fell out of the engine compartment, striking the propeller. No other damage was found. The bar, 5/16 inches X 2 inches X 1.5 ft was used to hold down the baffling, while installing the cowling. Normally a red rag is placed under the bar and draped out the front of the engine, but no red rags were available. Without the rag it was difficult to detect (see) the bar, and was therefore not removed prior to starting the aircraft. Callback conversation with reporter revealed the following information: the reporter said the bar, a non standard tool with a red rag attached, is used to hold down the air baffles when installing the cowling and is pulled out when the cowling is fastened but the red rag was omitted and the reporter missed removing the bar. The reporter stated when the engine was started the bar slipped out into the propeller arc and banged around in the propeller for a few moments. The reporter said when the propeller blades were checked 2 of the 3 blades had to be replaced and the damaged blades had evidence of striking the bar at least 20 times. The reporter stated a special tool has been fabricated with a large red flag to be used in cowling replacement.

Original NASA ASRS Text

Title: A BEECH DUCHESS 76 INCURRED PROP DAMAGE ON ENG START WHEN A NON STANDARD TOOL WAS USED TO FASTEN THE COWLING SLIPPED OUT INTO THE PROP.

Narrative: A BUCKING BAR WAS INADVERTENTLY LEFT IN THE ENG COMPARTMENT, FOLLOWING ROUTINE MAINT TO REPLACE A STARTER. UPON SHUTDOWN OF THE L ENG THE BUCKING BAR FELL OUT OF THE ENG COMPARTMENT, STRIKING THE PROP. NO OTHER DAMAGE WAS FOUND. THE BAR, 5/16 INCHES X 2 INCHES X 1.5 FT WAS USED TO HOLD DOWN THE BAFFLING, WHILE INSTALLING THE COWLING. NORMALLY A RED RAG IS PLACED UNDER THE BAR AND DRAPED OUT THE FRONT OF THE ENG, BUT NO RED RAGS WERE AVAILABLE. WITHOUT THE RAG IT WAS DIFFICULT TO DETECT (SEE) THE BAR, AND WAS THEREFORE NOT REMOVED PRIOR TO STARTING THE ACFT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR SAID THE BAR, A NON STANDARD TOOL WITH A RED RAG ATTACHED, IS USED TO HOLD DOWN THE AIR BAFFLES WHEN INSTALLING THE COWLING AND IS PULLED OUT WHEN THE COWLING IS FASTENED BUT THE RED RAG WAS OMITTED AND THE RPTR MISSED REMOVING THE BAR. THE RPTR STATED WHEN THE ENG WAS STARTED THE BAR SLIPPED OUT INTO THE PROP ARC AND BANGED AROUND IN THE PROP FOR A FEW MOMENTS. THE RPTR SAID WHEN THE PROP BLADES WERE CHKED 2 OF THE 3 BLADES HAD TO BE REPLACED AND THE DAMAGED BLADES HAD EVIDENCE OF STRIKING THE BAR AT LEAST 20 TIMES. THE RPTR STATED A SPECIAL TOOL HAS BEEN FABRICATED WITH A LARGE RED FLAG TO BE USED IN COWLING REPLACEMENT.

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.

A beech duchess 76 incurred propeller damage on engine start when a non standard tool was used to fasten the cowling slipped out into the propeller.