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|
Attributes | |
ACN | 581901 |
Time | |
Date | 200305 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | navaid : zzz.vor |
State Reference | US |
Altitude | agl single value : 700 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : zzz.tracon tower : myf.tower |
Operator | Other |
Make Model Name | Helicopter |
Operating Under FAR Part | Part 91 |
Flight Phase | cruise : level |
Flight Plan | None |
Person 1 | |
Affiliation | other |
Function | flight crew : single pilot |
Qualification | pilot : cfi pilot : atp pilot : multi engine |
Experience | flight time last 90 days : 30 flight time total : 3200 flight time type : 60 |
ASRS Report | 581901 |
Person 2 | |
Affiliation | other |
Function | maintenance : technician |
Events | |
Anomaly | ground encounters : fod non adherence : company policies non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
We are always taught that most, if not all, accidents/incidents are a direct result of a chain of events. Recently, I jeopardized my crew's safety and damaged a perfectly good aircraft when I let my lack of attention to detail cause a chain of events to develop. I arrived at the hangar at XA40 to start my shift and shortly thereafter began preflting the aircraft. The plan for the day was to depart at XA45 and fly to our destination and be ground transported to attend CRM training. About 10 mins after beginning my preflight, the base site mechanic came out to the aircraft and began his daily checks of the helicopter. At this point I had checked the tail rotor, checked the can, signed off the airworthiness directive, done the cockpit/lights check, and replaced the aircraft pubs. Since I wanted to check the aircraft after the mechanic completed his checks, I decided to wash the tailboom, since it would be sitting by our parent hospital most of the day. These were the 1ST and 2ND links in the chain. Normally, I am done preflting before the mechanic starts his daily checks. Additionally, I wouldn't normally be washing the aircraft while the mechanic is doing his daily. I had imposed an XA40 takeoff time on myself so we wouldn't be 'late.' I doubt anybody would have said anything if we would have shown up late with a dirty tailboom. Once the mechanic completed his daily check, with the exception of the tailboom, we switched position and I finished my preflight. Since the mechanic was now rinsing the tailboom, I waited until the end of my preflight to check the tail rotor driveshaft. This was the 3RD link in the chain. Never jump around while performing a preflight and always stick to your routine. My normal routine consisted of carrying the ladder and flashlight from the right side to the left side and then going back and checking the tailboom. I didn't follow my normal routine. While opening and checking the driveshaft cover, I placed the blue aircraft flashlight on the left side of the tailboom on the V shaped 'strake.' since this was my last item to preflight and the clock was quickly approaching XA40, I closed the driveshaft cover, turned immediately around, picked up the ladder and creeper and proceeded inside to store them in the hangar. I left the aircraft flashlight on the strake. This was the 5TH link. After a quick crew brief, we headed to the aircraft for our departure. I performed what I thought was a thorough walkaround that, in retrospect, focused entirely too much on ensuring all the latches were latched. The flashlight sat in the 'V' of the strake and was obscured during my walkaround. This was the 6TH link in the chain. I always prided myself on doing a thorough walkaround but in addition to cowlings and doors coming open in-flight, foreign object damage can be just as deadly. Do not rush yourself. The preceding chain of events led to a magnetic flashlight hitting the tail rotor and a main rotor blade. Even though the precautionary landing and shutdown were uneventful, the end result could have been different. What if I would have lost my tail rotor? The tail rotor gearbox? My inattention to detail could have resulted in a tragic event for my family and the family members of the crew members who rely on me to bring them home safely each day. Luckily, the only damage is to the aircraft and my program's reputation. The next time it happens to a pilot it may not be a flashlight but it could be a screwdriver, fuel cap, or other object. I never thought it would happen to me.
Original NASA ASRS Text
Title: HELI PLT RPTED FOREIGN OBJECT DAMAGE STRIKE ON THE ACFT TAIL ROTOR AND MAIN ROTOR DAMAGING THE ACFT.
Narrative: WE ARE ALWAYS TAUGHT THAT MOST, IF NOT ALL, ACCIDENTS/INCIDENTS ARE A DIRECT RESULT OF A CHAIN OF EVENTS. RECENTLY, I JEOPARDIZED MY CREW'S SAFETY AND DAMAGED A PERFECTLY GOOD ACFT WHEN I LET MY LACK OF ATTN TO DETAIL CAUSE A CHAIN OF EVENTS TO DEVELOP. I ARRIVED AT THE HANGAR AT XA40 TO START MY SHIFT AND SHORTLY THEREAFTER BEGAN PREFLTING THE ACFT. THE PLAN FOR THE DAY WAS TO DEPART AT XA45 AND FLY TO OUR DEST AND BE GND TRANSPORTED TO ATTEND CRM TRAINING. ABOUT 10 MINS AFTER BEGINNING MY PREFLT, THE BASE SITE MECH CAME OUT TO THE ACFT AND BEGAN HIS DAILY CHKS OF THE HELI. AT THIS POINT I HAD CHKED THE TAIL ROTOR, CHKED THE CAN, SIGNED OFF THE AIRWORTHINESS DIRECTIVE, DONE THE COCKPIT/LIGHTS CHK, AND REPLACED THE ACFT PUBS. SINCE I WANTED TO CHK THE ACFT AFTER THE MECH COMPLETED HIS CHKS, I DECIDED TO WASH THE TAILBOOM, SINCE IT WOULD BE SITTING BY OUR PARENT HOSPITAL MOST OF THE DAY. THESE WERE THE 1ST AND 2ND LINKS IN THE CHAIN. NORMALLY, I AM DONE PREFLTING BEFORE THE MECH STARTS HIS DAILY CHKS. ADDITIONALLY, I WOULDN'T NORMALLY BE WASHING THE ACFT WHILE THE MECH IS DOING HIS DAILY. I HAD IMPOSED AN XA40 TKOF TIME ON MYSELF SO WE WOULDN'T BE 'LATE.' I DOUBT ANYBODY WOULD HAVE SAID ANYTHING IF WE WOULD HAVE SHOWN UP LATE WITH A DIRTY TAILBOOM. ONCE THE MECH COMPLETED HIS DAILY CHK, WITH THE EXCEPTION OF THE TAILBOOM, WE SWITCHED POS AND I FINISHED MY PREFLT. SINCE THE MECH WAS NOW RINSING THE TAILBOOM, I WAITED UNTIL THE END OF MY PREFLT TO CHK THE TAIL ROTOR DRIVESHAFT. THIS WAS THE 3RD LINK IN THE CHAIN. NEVER JUMP AROUND WHILE PERFORMING A PREFLT AND ALWAYS STICK TO YOUR ROUTINE. MY NORMAL ROUTINE CONSISTED OF CARRYING THE LADDER AND FLASHLIGHT FROM THE R SIDE TO THE L SIDE AND THEN GOING BACK AND CHKING THE TAILBOOM. I DIDN'T FOLLOW MY NORMAL ROUTINE. WHILE OPENING AND CHKING THE DRIVESHAFT COVER, I PLACED THE BLUE ACFT FLASHLIGHT ON THE L SIDE OF THE TAILBOOM ON THE V SHAPED 'STRAKE.' SINCE THIS WAS MY LAST ITEM TO PREFLT AND THE CLOCK WAS QUICKLY APCHING XA40, I CLOSED THE DRIVESHAFT COVER, TURNED IMMEDIATELY AROUND, PICKED UP THE LADDER AND CREEPER AND PROCEEDED INSIDE TO STORE THEM IN THE HANGAR. I LEFT THE ACFT FLASHLIGHT ON THE STRAKE. THIS WAS THE 5TH LINK. AFTER A QUICK CREW BRIEF, WE HEADED TO THE ACFT FOR OUR DEP. I PERFORMED WHAT I THOUGHT WAS A THOROUGH WALKAROUND THAT, IN RETROSPECT, FOCUSED ENTIRELY TOO MUCH ON ENSURING ALL THE LATCHES WERE LATCHED. THE FLASHLIGHT SAT IN THE 'V' OF THE STRAKE AND WAS OBSCURED DURING MY WALKAROUND. THIS WAS THE 6TH LINK IN THE CHAIN. I ALWAYS PRIDED MYSELF ON DOING A THOROUGH WALKAROUND BUT IN ADDITION TO COWLINGS AND DOORS COMING OPEN INFLT, FOREIGN OBJECT DAMAGE CAN BE JUST AS DEADLY. DO NOT RUSH YOURSELF. THE PRECEDING CHAIN OF EVENTS LED TO A MAGNETIC FLASHLIGHT HITTING THE TAIL ROTOR AND A MAIN ROTOR BLADE. EVEN THOUGH THE PRECAUTIONARY LNDG AND SHUTDOWN WERE UNEVENTFUL, THE END RESULT COULD HAVE BEEN DIFFERENT. WHAT IF I WOULD HAVE LOST MY TAIL ROTOR? THE TAIL ROTOR GEARBOX? MY INATTENTION TO DETAIL COULD HAVE RESULTED IN A TRAGIC EVENT FOR MY FAMILY AND THE FAMILY MEMBERS OF THE CREW MEMBERS WHO RELY ON ME TO BRING THEM HOME SAFELY EACH DAY. LUCKILY, THE ONLY DAMAGE IS TO THE ACFT AND MY PROGRAM'S REPUTATION. THE NEXT TIME IT HAPPENS TO A PLT IT MAY NOT BE A FLASHLIGHT BUT IT COULD BE A SCREWDRIVER, FUEL CAP, OR OTHER OBJECT. I NEVER THOUGHT IT WOULD HAPPEN TO ME.
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.