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|
Attributes | |
ACN | 616012 |
Time | |
Date | 200404 |
Day | Thu |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : phl.tower |
Operator | common carrier : air taxi |
Make Model Name | Caravan II F406 |
Operating Under FAR Part | Part 135 |
Flight Phase | ground : takeoff roll |
Person 1 | |
Affiliation | company : air taxi |
Function | maintenance : technician oversight : supervisor |
ASRS Report | 616012 |
Person 2 | |
Affiliation | company : air taxi |
Function | flight crew : single pilot |
Events | |
Anomaly | aircraft equipment problem : critical |
Independent Detector | aircraft equipment other aircraft equipment : r engine indications other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : engineering procedure performance deficiency : inspection |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
Primary Problem | Chart Or Publication |
Situations | |
Publication | ENGINE MANUAL |
Narrative:
Engine failed on takeoff run. Pilot aborted and stopped on runway. No injuries, no damage to aircraft except internal engine damage. This aircraft had reported a previous propeller strike 3 weeks ago, approximately 22 hours previous to failure. Maintenance personnel followed P&west propeller strike inspection procedures and recorded all results positive for continued operation. 4 days before failure, the required daily rgb inspection was not completed and the pilot continued to operate without the required inspection, this continued to failure. The engine had not reached the 25 hour minimum recommended filter check and after failure the rgb chip detector was still clean. If this failure is eventually attributed to the propeller strike, then I believe the propeller strike inspection parameters contained in the engine manufacturer's manual is not sufficient to prevent failure. Callback conversation with reporter revealed the following information: the reporter stated the report on the engine failure was one turbine blade broken with evidence of rubbing prior to failure. The reporter said the findings may be the propeller strike was the cause of the engine failure. The reporter stated the propeller strike occurred 22 flight hours prior to the engine failure and incurred minimal damage to the propeller. The reporter said maintenance accomplished all pratt & whitney propeller strike inspection procedures and recorded all positive results for continued operations. The reporter stated only one daily reduction gear box chip detector check was missed through logbook oversight. The reporter said the shop overhauling the engine has not submitted a final report determining if the propeller strike caused the engine failure. The reporter stated if the propeller strike is the main factor in the engine failure, then the pratt & whitney inspection parameters contained in the engine manufacturer's manual is not sufficient to prevent engine failure.
Original NASA ASRS Text
Title: A CESSNA F406 ON TKOF ROLL HAD THE R ENG FAIL. TKOF REJECTED AND STOPPED ON RWY.
Narrative: ENG FAILED ON TKOF RUN. PLT ABORTED AND STOPPED ON RWY. NO INJURIES, NO DAMAGE TO ACFT EXCEPT INTERNAL ENG DAMAGE. THIS ACFT HAD RPTED A PREVIOUS PROP STRIKE 3 WKS AGO, APPROX 22 HRS PREVIOUS TO FAILURE. MAINT PERSONNEL FOLLOWED P&W PROP STRIKE INSPECTION PROCS AND RECORDED ALL RESULTS POSITIVE FOR CONTINUED OP. 4 DAYS BEFORE FAILURE, THE REQUIRED DAILY RGB INSPECTION WAS NOT COMPLETED AND THE PLT CONTINUED TO OPERATE WITHOUT THE REQUIRED INSPECTION, THIS CONTINUED TO FAILURE. THE ENG HAD NOT REACHED THE 25 HOUR MINIMUM RECOMMENDED FILTER CHECK AND AFTER FAILURE THE RGB CHIP DETECTOR WAS STILL CLEAN. IF THIS FAILURE IS EVENTUALLY ATTRIBUTED TO THE PROP STRIKE, THEN I BELIEVE THE PROP STRIKE INSPECTION PARAMETERS CONTAINED IN THE ENG MANUFACTURER'S MANUAL IS NOT SUFFICIENT TO PREVENT FAILURE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE RPT ON THE ENG FAILURE WAS ONE TURBINE BLADE BROKEN WITH EVIDENCE OF RUBBING PRIOR TO FAILURE. THE RPTR SAID THE FINDINGS MAY BE THE PROP STRIKE WAS THE CAUSE OF THE ENG FAILURE. THE RPTR STATED THE PROP STRIKE OCCURRED 22 FLT HOURS PRIOR TO THE ENG FAILURE AND INCURRED MINIMAL DAMAGE TO THE PROP. THE RPTR SAID MAINT ACCOMPLISHED ALL PRATT & WHITNEY PROP STRIKE INSPECTION PROCS AND RECORDED ALL POSITIVE RESULTS FOR CONTINUED OPS. THE RPTR STATED ONLY ONE DAILY REDUCTION GEAR BOX CHIP DETECTOR CHECK WAS MISSED THROUGH LOGBOOK OVERSIGHT. THE RPTR SAID THE SHOP OVERHAULING THE ENG HAS NOT SUBMITTED A FINAL RPT DETERMINING IF THE PROP STRIKE CAUSED THE ENG FAILURE. THE RPTR STATED IF THE PROP STRIKE IS THE MAIN FACTOR IN THE ENG FAILURE, THEN THE PRATT & WHITNEY INSPECTION PARAMETERS CONTAINED IN THE ENG MANUFACTURER'S MANUAL IS NOT SUFFICIENT TO PREVENT ENG FAILURE.
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.