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|
Attributes | |
ACN | 539257 |
Time | |
Date | 200202 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl single value : 4000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : zzz.tracon tower : zzz.tower |
Operator | common carrier : air taxi |
Make Model Name | Helicopter |
Operating Under FAR Part | Part 135 |
Flight Phase | cruise : level |
Flight Plan | VFR |
Person 1 | |
Affiliation | company : air taxi |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 71 flight time total : 2337 flight time type : 54 |
ASRS Report | 539257 |
Person 2 | |
Affiliation | company : air taxi |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : chips detector gearbox warning light other flight crewa |
Resolutory Action | flight crew : landed in emergency condition none taken : detected after the fact |
Consequence | other other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : testing performance deficiency : fault isolation performance deficiency : training performance deficiency : repair performance deficiency : inspection |
Supplementary | |
Problem Areas | Maintenance Human Performance Flight Crew Human Performance Company Aircraft |
Primary Problem | Company |
Narrative:
On this date at or about XA30 we were dispatched to a scene mission south of ZZZ near ZZZ1. We had just completed a flight without incident and were requested from dispatch while still at hospital. We fueled and departed to the south toward the scene. We approached the facility and tower handed us off to departure. We were in level flight 4000 ft pressure altitude, 85% torque, and 120 KTS indicated. My plan was to skirt around the west side. Just after being handed off from departure and approximately 1-2 mi south of the facility, the #1 engine chips gear box light illuminated. The power was reduced and an initial scan of the gauges looked normal or in the green, nothing that caught my eye. My initial thought was to land the aircraft there but thinking the airport was close (approximately 5-7 mi) I headed for the airport. At this point I took the #1 engine to idle and further reduced the power. Maximum beep could not be obtained -- it maintained in the low green on the #2 engine. Level flight was maintained and the engine was then shut down. This was just south of the facility. I talked out loud about landing at FBO and the crew asked why we couldn't and I told them they weren't on our ticket, and probably didn't think there was a mechanic available. My thoughts upon passing the facility and the hill was it hadn't been a good idea that I had shut the engine down and tried a restart. The #1 start button was pressed and the start light illuminated, the hg/np or mgt did not rise within the first 5-10 seconds of the sequence as in a normal start. After approximately 15 and still no rise the start disengage button was pressed. Giving time for possible started wind down approximately 15 seconds I again tried to restart the #1 engine with the same results. ATIS reported the winds variable at 4 KTS and the landing direction runway X. Coming abeam the number, I turned toward the hangar following the general direction of the taxiway and also crossing the dirt between. I had initiated a shallow approach for landing and had told the crew that we may start wallowing and to bare with me. Airspeed was still about 30 KTS and 50 ft AGL, as we approached 10-20 ft AGL and probably 20 KTS the low RPM audio and light came on and the aircraft started to settle over the dirt. Torque I remember was set between 90-100% and a run on landing was performed to the dirt, all crew members said they were fine/ok. I contacted tower and notified them that we had landed in the dirt between the txwys and would have to remain there. They then asked if we needed assistance and I replied no. I asked if the aircraft could remain there till maintenance could move it from the dirt and they replied that was alright. I made a call to supervisor and explained the incident, then soon called dispatch. I again tried to start the #1 engine with no results. Found spot light turn off and lying under left aft side of aircraft. Extra: trying to recall the incident and what was seen or heard, I remember that the torque was set between 90-100% on #2, the noise or sounds were not uncommon of a normal shutdown when having to center the cyclic to stop the transmission from rocking the mounts upon landing and shutdown. I cannot remember any further details. Callback conversation with reporter revealed the following information: reporter indicated the engine involved had recently been overhauled, and newly installed on the aircraft. Several previous chip detector warning lights had been received, and listed as maintenance discrepancies. Maintenance was unable to determine what was causing the warning. Maintenance finally replaced the engine at this time. The EMS operator was under contract to the hospital. They have had 2 previous accidents in a short space of time. After this incident, all pilots were fired and a new staff was hired. Throw the baby out with the bath water approach to management.
Original NASA ASRS Text
Title: EMS HELI PLT HAD A TURBINE ENG GEAR BOX FAILURE ON A TWIN ENG ACFT.
Narrative: ON THIS DATE AT OR ABOUT XA30 WE WERE DISPATCHED TO A SCENE MISSION S OF ZZZ NEAR ZZZ1. WE HAD JUST COMPLETED A FLT WITHOUT INCIDENT AND WERE REQUESTED FROM DISPATCH WHILE STILL AT HOSPITAL. WE FUELED AND DEPARTED TO THE S TOWARD THE SCENE. WE APCHED THE FACILITY AND TWR HANDED US OFF TO DEP. WE WERE IN LEVEL FLT 4000 FT PRESSURE ALT, 85% TORQUE, AND 120 KTS INDICATED. MY PLAN WAS TO SKIRT AROUND THE W SIDE. JUST AFTER BEING HANDED OFF FROM DEP AND APPROX 1-2 MI S OF THE FACILITY, THE #1 ENG CHIPS GEAR BOX LIGHT ILLUMINATED. THE PWR WAS REDUCED AND AN INITIAL SCAN OF THE GAUGES LOOKED NORMAL OR IN THE GREEN, NOTHING THAT CAUGHT MY EYE. MY INITIAL THOUGHT WAS TO LAND THE ACFT THERE BUT THINKING THE ARPT WAS CLOSE (APPROX 5-7 MI) I HEADED FOR THE ARPT. AT THIS POINT I TOOK THE #1 ENG TO IDLE AND FURTHER REDUCED THE PWR. MAX BEEP COULD NOT BE OBTAINED -- IT MAINTAINED IN THE LOW GREEN ON THE #2 ENG. LEVEL FLT WAS MAINTAINED AND THE ENG WAS THEN SHUT DOWN. THIS WAS JUST S OF THE FACILITY. I TALKED OUT LOUD ABOUT LNDG AT FBO AND THE CREW ASKED WHY WE COULDN'T AND I TOLD THEM THEY WEREN'T ON OUR TICKET, AND PROBABLY DIDN'T THINK THERE WAS A MECH AVAILABLE. MY THOUGHTS UPON PASSING THE FACILITY AND THE HILL WAS IT HADN'T BEEN A GOOD IDEA THAT I HAD SHUT THE ENG DOWN AND TRIED A RESTART. THE #1 START BUTTON WAS PRESSED AND THE START LIGHT ILLUMINATED, THE HG/NP OR MGT DID NOT RISE WITHIN THE FIRST 5-10 SECONDS OF THE SEQUENCE AS IN A NORMAL START. AFTER APPROX 15 AND STILL NO RISE THE START DISENGAGE BUTTON WAS PRESSED. GIVING TIME FOR POSSIBLE STARTED WIND DOWN APPROX 15 SECONDS I AGAIN TRIED TO RESTART THE #1 ENG WITH THE SAME RESULTS. ATIS RPTED THE WINDS VARIABLE AT 4 KTS AND THE LNDG DIRECTION RWY X. COMING ABEAM THE NUMBER, I TURNED TOWARD THE HANGAR FOLLOWING THE GENERAL DIRECTION OF THE TXWY AND ALSO XING THE DIRT BTWN. I HAD INITIATED A SHALLOW APCH FOR LNDG AND HAD TOLD THE CREW THAT WE MAY START WALLOWING AND TO BARE WITH ME. AIRSPD WAS STILL ABOUT 30 KTS AND 50 FT AGL, AS WE APCHED 10-20 FT AGL AND PROBABLY 20 KTS THE LOW RPM AUDIO AND LIGHT CAME ON AND THE ACFT STARTED TO SETTLE OVER THE DIRT. TORQUE I REMEMBER WAS SET BTWN 90-100% AND A RUN ON LNDG WAS PERFORMED TO THE DIRT, ALL CREW MEMBERS SAID THEY WERE FINE/OK. I CONTACTED TWR AND NOTIFIED THEM THAT WE HAD LANDED IN THE DIRT BTWN THE TXWYS AND WOULD HAVE TO REMAIN THERE. THEY THEN ASKED IF WE NEEDED ASSISTANCE AND I REPLIED NO. I ASKED IF THE ACFT COULD REMAIN THERE TILL MAINT COULD MOVE IT FROM THE DIRT AND THEY REPLIED THAT WAS ALRIGHT. I MADE A CALL TO SUPVR AND EXPLAINED THE INCIDENT, THEN SOON CALLED DISPATCH. I AGAIN TRIED TO START THE #1 ENG WITH NO RESULTS. FOUND SPOT LIGHT TURN OFF AND LYING UNDER L AFT SIDE OF ACFT. EXTRA: TRYING TO RECALL THE INCIDENT AND WHAT WAS SEEN OR HEARD, I REMEMBER THAT THE TORQUE WAS SET BTWN 90-100% ON #2, THE NOISE OR SOUNDS WERE NOT UNCOMMON OF A NORMAL SHUTDOWN WHEN HAVING TO CTR THE CYCLIC TO STOP THE XMISSION FROM ROCKING THE MOUNTS UPON LNDG AND SHUTDOWN. I CANNOT REMEMBER ANY FURTHER DETAILS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR INDICATED THE ENG INVOLVED HAD RECENTLY BEEN OVERHAULED, AND NEWLY INSTALLED ON THE ACFT. SEVERAL PREVIOUS CHIP DETECTOR WARNING LIGHTS HAD BEEN RECEIVED, AND LISTED AS MAINT DISCREPANCIES. MAINT WAS UNABLE TO DETERMINE WHAT WAS CAUSING THE WARNING. MAINT FINALLY REPLACED THE ENG AT THIS TIME. THE EMS OPERATOR WAS UNDER CONTRACT TO THE HOSPITAL. THEY HAVE HAD 2 PREVIOUS ACCIDENTS IN A SHORT SPACE OF TIME. AFTER THIS INCIDENT, ALL PLTS WERE FIRED AND A NEW STAFF WAS HIRED. THROW THE BABY OUT WITH THE BATH WATER APCH TO MGMNT.
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.