37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 587498 |
Time | |
Date | 200307 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | Other |
Make Model Name | BO105 |
Operating Under FAR Part | Part 135 |
Flight Phase | climbout : takeoff ground : preflight |
Flight Plan | VFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : single pilot |
Qualification | pilot : atp |
Experience | flight time last 90 days : 30.8 flight time total : 8700 flight time type : 250 |
ASRS Report | 587498 |
Person 2 | |
Affiliation | Other |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : logbook engine time record other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : inspection |
Supplementary | |
Problem Areas | Flight Crew Human Performance Maintenance Human Performance Company Aircraft |
Narrative:
The ambulance B pilot stated that he had not brought the logbook up to date and that he did not know the 'next inspection due' or the 'next component due' types or times. I asked about the status of these items per the aircraft's status sheet. I then discovered that the status sheet contained in the logbook was dated jun/sun/03, thus making it 13 days out of date, the most current status sheet having been published by maintenance on jul/wed/03. I found this to be quite unusual, for the pilot who was xferring his aircraft for use by the base has a reputation for being very thorough. At this point, my pilot's cell phone rang. It was the ambulance G aircraft technician. I explained to our aircraft technician what was going on and my concerns about the logbook and outdated status sheet. After the maintenance service manager and the aircraft technician present at the helipad in ZZZ1 had assured me that the helicopter was flyable and that all that was required was an engine power check en route, I departed with my crew for ZZZ. Over ZZZ6 at 7000 ft I performed the required power check on the #2 engine only to discover that I did not have sufficient rotor RPM or N2 to complete the test. There was no ability to 'beep' switch the #2 engine up to the 100% nr or N2 required for the test and that any attempt to pull power 'drooped' the system parameters into the low transient range. I could beep RPM up and down with both engines operating. I tried the power check again over the coast as I attributed the failure of the first test to high density altitude and hot conditions. The actual factor later turned out to be an engine out of rigging. The aircraft was landed at ZZZ and I tried again to 'beep' the #2 engine without any success. I shut down the aircraft and called the aircraft OTS. During the process of this scenario the aircraft had flown 4.3 hours over required inspections: 1) I flew it 1.4 hours which included the 2 attempts at making power checks. 2) the pilot I took the aircraft from had just completed a flight .9 hours in duration and had not a clue about the status sheet or the required next inspections/components due. 3) another pilot had flown the aircraft from ZZZ3 to ZZZ in order to reposition the aircraft. I do not have the logbook, but am assuming approximately .7 hours. 4) yet another pilot, flew the aircraft from ZZZ4 to ZZZ3 with the remaining 1.3 hours. So, 1.4 + .9 + .7 + 1.3 equals 4.3 hours over inspection with 4 pilots to include myself, several aircraft technicians, and maintenance service manager involved in the process. In brief, trust no one and do not let the pressures of crowded helipads, movie crews making demands, and being out of your service area contribute to being 'pushed' into flying an unairworthy aircraft.
Original NASA ASRS Text
Title: AN MBB BO105 HELI WAS OPERATED IN NON COMPLIANCE WHEN FLOWN 4 PT 3 HRS OVER REQUIRED PWR PLANT INSPECTION LIMITS.
Narrative: THE AMBULANCE B PLT STATED THAT HE HAD NOT BROUGHT THE LOGBOOK UP TO DATE AND THAT HE DID NOT KNOW THE 'NEXT INSPECTION DUE' OR THE 'NEXT COMPONENT DUE' TYPES OR TIMES. I ASKED ABOUT THE STATUS OF THESE ITEMS PER THE ACFT'S STATUS SHEET. I THEN DISCOVERED THAT THE STATUS SHEET CONTAINED IN THE LOGBOOK WAS DATED JUN/SUN/03, THUS MAKING IT 13 DAYS OUT OF DATE, THE MOST CURRENT STATUS SHEET HAVING BEEN PUBLISHED BY MAINT ON JUL/WED/03. I FOUND THIS TO BE QUITE UNUSUAL, FOR THE PLT WHO WAS XFERRING HIS ACFT FOR USE BY THE BASE HAS A REPUTATION FOR BEING VERY THOROUGH. AT THIS POINT, MY PLT'S CELL PHONE RANG. IT WAS THE AMBULANCE G ACFT TECHNICIAN. I EXPLAINED TO OUR ACFT TECHNICIAN WHAT WAS GOING ON AND MY CONCERNS ABOUT THE LOGBOOK AND OUTDATED STATUS SHEET. AFTER THE MAINT SVC MGR AND THE ACFT TECHNICIAN PRESENT AT THE HELIPAD IN ZZZ1 HAD ASSURED ME THAT THE HELI WAS FLYABLE AND THAT ALL THAT WAS REQUIRED WAS AN ENG PWR CHK ENRTE, I DEPARTED WITH MY CREW FOR ZZZ. OVER ZZZ6 AT 7000 FT I PERFORMED THE REQUIRED PWR CHK ON THE #2 ENG ONLY TO DISCOVER THAT I DID NOT HAVE SUFFICIENT ROTOR RPM OR N2 TO COMPLETE THE TEST. THERE WAS NO ABILITY TO 'BEEP' SWITCH THE #2 ENG UP TO THE 100% NR OR N2 REQUIRED FOR THE TEST AND THAT ANY ATTEMPT TO PULL PWR 'DROOPED' THE SYS PARAMETERS INTO THE LOW TRANSIENT RANGE. I COULD BEEP RPM UP AND DOWN WITH BOTH ENGS OPERATING. I TRIED THE PWR CHK AGAIN OVER THE COAST AS I ATTRIBUTED THE FAILURE OF THE FIRST TEST TO HIGH DENSITY ALT AND HOT CONDITIONS. THE ACTUAL FACTOR LATER TURNED OUT TO BE AN ENG OUT OF RIGGING. THE ACFT WAS LANDED AT ZZZ AND I TRIED AGAIN TO 'BEEP' THE #2 ENG WITHOUT ANY SUCCESS. I SHUT DOWN THE ACFT AND CALLED THE ACFT OTS. DURING THE PROCESS OF THIS SCENARIO THE ACFT HAD FLOWN 4.3 HRS OVER REQUIRED INSPECTIONS: 1) I FLEW IT 1.4 HRS WHICH INCLUDED THE 2 ATTEMPTS AT MAKING PWR CHKS. 2) THE PLT I TOOK THE ACFT FROM HAD JUST COMPLETED A FLT .9 HRS IN DURATION AND HAD NOT A CLUE ABOUT THE STATUS SHEET OR THE REQUIRED NEXT INSPECTIONS/COMPONENTS DUE. 3) ANOTHER PLT HAD FLOWN THE ACFT FROM ZZZ3 TO ZZZ IN ORDER TO REPOSITION THE ACFT. I DO NOT HAVE THE LOGBOOK, BUT AM ASSUMING APPROX .7 HRS. 4) YET ANOTHER PLT, FLEW THE ACFT FROM ZZZ4 TO ZZZ3 WITH THE REMAINING 1.3 HRS. SO, 1.4 + .9 + .7 + 1.3 EQUALS 4.3 HRS OVER INSPECTION WITH 4 PLTS TO INCLUDE MYSELF, SEVERAL ACFT TECHNICIANS, AND MAINT SVC MGR INVOLVED IN THE PROCESS. IN BRIEF, TRUST NO ONE AND DO NOT LET THE PRESSURES OF CROWDED HELIPADS, MOVIE CREWS MAKING DEMANDS, AND BEING OUT OF YOUR SVC AREA CONTRIBUTE TO BEING 'PUSHED' INTO FLYING AN UNAIRWORTHY ACFT.
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.