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A C402 returned to the field with assumed engine fire. Found loose slip joint clamp on the right engine exhaust. Clamp nuts found not safetied.
| Attributes | |
| ACN | 608080 |
| Time | |
| Date | 200402 |
| Day | Tue |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air taxi |
| Make Model Name | Cessna 402/402C/B379 Businessliner/Utiliner |
| Operating Under FAR Part | Part 135 |
| Flight Phase | climbout : takeoff ground : preflight ground : maintenance ground : takeoff roll |
| Person 1 | |
| Affiliation | company : air taxi |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : airframe |
| Experience | maintenance technician : 8 |
| ASRS Report | 608080 |
| Person 2 | |
| Affiliation | company : air taxi |
| Function | flight crew : single pilot |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure other anomaly |
| Independent Detector | aircraft equipment other aircraft equipment : rt engine fire warning other flight crewa |
| Resolutory Action | flight crew : diverted to another airport other |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : schedule pressure performance deficiency : scheduled maintenance performance deficiency : inspection performance deficiency : installation |
| Supplementary | |
| Problem Areas | Aircraft Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
The aircraft departed on a normal part 135 cargo run after having a 100/200 hour inspection completed earlier in the day. The pilot landed at his first stop, loaded his cargo and departed. Upon departure, he noticed what he correctly assumed to be an engine fire and returned to the airport. Landing was uneventful. The maintenance department was contacted and inspection determined that the cause was a loose slip joint clamp on the right engine exhaust. The clamp was refastened and the airplane was safely flown back to the home airport. Discussion about the maintenance department revealed that the amt working on the right engine had been distraction by other things in the shop due to a shortage of mechanics. As a result, he forgot to safety the nuts on the clamp, which later vibrated loose. The maintenance department has implemented a quality assurance program requiring all inspections and work to be signed off by the amt doing the work and a second amt signing off an inspection of the work completed. Only then will an airplane be returned to service.
Original NASA ASRS Text
Title: A C402 RETURNED TO THE FIELD WITH ASSUMED ENG FIRE. FOUND LOOSE SLIP JOINT CLAMP ON THE R ENG EXHAUST. CLAMP NUTS FOUND NOT SAFETIED.
Narrative: THE ACFT DEPARTED ON A NORMAL PART 135 CARGO RUN AFTER HAVING A 100/200 HR INSPECTION COMPLETED EARLIER IN THE DAY. THE PLT LANDED AT HIS FIRST STOP, LOADED HIS CARGO AND DEPARTED. UPON DEP, HE NOTICED WHAT HE CORRECTLY ASSUMED TO BE AN ENG FIRE AND RETURNED TO THE ARPT. LNDG WAS UNEVENTFUL. THE MAINT DEPT WAS CONTACTED AND INSPECTION DETERMINED THAT THE CAUSE WAS A LOOSE SLIP JOINT CLAMP ON THE R ENG EXHAUST. THE CLAMP WAS REFASTENED AND THE AIRPLANE WAS SAFELY FLOWN BACK TO THE HOME ARPT. DISCUSSION ABOUT THE MAINT DEPT REVEALED THAT THE AMT WORKING ON THE R ENG HAD BEEN DISTR BY OTHER THINGS IN THE SHOP DUE TO A SHORTAGE OF MECHS. AS A RESULT, HE FORGOT TO SAFETY THE NUTS ON THE CLAMP, WHICH LATER VIBRATED LOOSE. THE MAINT DEPT HAS IMPLEMENTED A QUALITY ASSURANCE PROGRAM REQUIRING ALL INSPECTIONS AND WORK TO BE SIGNED OFF BY THE AMT DOING THE WORK AND A SECOND AMT SIGNING OFF AN INSPECTION OF THE WORK COMPLETED. ONLY THEN WILL AN AIRPLANE BE RETURNED TO SVC.
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.