37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 623252 |
Time | |
Date | 200407 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air taxi |
Make Model Name | Commander 500 |
Operating Under FAR Part | Part 135 |
Flight Phase | ground : maintenance landing : roll |
Person 1 | |
Affiliation | company : air taxi |
Function | maintenance : inspector maintenance : lead technician |
Qualification | technician : powerplant technician : airframe technician : inspection authority |
Experience | maintenance lead technician : 3 maintenance technician : 2 |
ASRS Report | 623252 |
Person 2 | |
Affiliation | company : air taxi |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : manuals performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : installation performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Environmental Factor Company Chart Or Publication Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
During landing rollout, pilot reported right engine feathered and shut down when power was brought to idle. Initial investigation appeared to be failed seal. Further investigation showed 4 sheared bolts on the right propeller and the propeller o-ring installed on the crank shaft rather than on the land in the propeller hub. It appears the o-ring wore and/or compressed and the bolts lost their torque due to a non metal-to-metal fit. Probable cause: during that time we were conducting pilot training and had 1 flying aircraft. In the maintenance manual (air frame, for 500's (model), aeronautical commanders lists 2 different propeller installations varying by serial number the affected aircraft fell into early model when the manual says to put the o-ring on the crankshaft flange and in a separate section, a couple pages later in the manual it shows the installation for later serial number 500's aeronautical commanders. The involved aircraft has propellers from later model aircraft installed on it. The installation was correct for the serial number aircraft, however, the aircraft did not have the original propellers. That combined with moving from aircraft to aircraft of different types and doing propeller installations on both, I did not question the installation. We removed the left propeller to check its installation and found it to be installed the same as the right (incorrectly).
Original NASA ASRS Text
Title: AN AC50 ON LNDG HAD THE R ENG FEATHER AND SHUT DOWN AT IDLE PWR. FOUND 4 SHEARED BOLTS ON PROP DUE TO IMPROPER O-RING SEAL INSTALLATION.
Narrative: DURING LNDG ROLLOUT, PLT RPTED R ENG FEATHERED AND SHUT DOWN WHEN PWR WAS BROUGHT TO IDLE. INITIAL INVESTIGATION APPEARED TO BE FAILED SEAL. FURTHER INVESTIGATION SHOWED 4 SHEARED BOLTS ON THE R PROP AND THE PROP O-RING INSTALLED ON THE CRANK SHAFT RATHER THAN ON THE LAND IN THE PROP HUB. IT APPEARS THE O-RING WORE AND/OR COMPRESSED AND THE BOLTS LOST THEIR TORQUE DUE TO A NON METAL-TO-METAL FIT. PROBABLE CAUSE: DURING THAT TIME WE WERE CONDUCTING PLT TRAINING AND HAD 1 FLYING ACFT. IN THE MAINT MANUAL (AIR FRAME, FOR 500'S (MODEL), AERO COMMANDERS LISTS 2 DIFFERENT PROP INSTALLATIONS VARYING BY SERIAL NUMBER THE AFFECTED ACFT FELL INTO EARLY MODEL WHEN THE MANUAL SAYS TO PUT THE O-RING ON THE CRANKSHAFT FLANGE AND IN A SEPARATE SECTION, A COUPLE PAGES LATER IN THE MANUAL IT SHOWS THE INSTALLATION FOR LATER SERIAL NUMBER 500'S AERO COMMANDERS. THE INVOLVED ACFT HAS PROPS FROM LATER MODEL ACFT INSTALLED ON IT. THE INSTALLATION WAS CORRECT FOR THE SERIAL NUMBER ACFT, HOWEVER, THE ACFT DID NOT HAVE THE ORIGINAL PROPS. THAT COMBINED WITH MOVING FROM ACFT TO ACFT OF DIFFERENT TYPES AND DOING PROP INSTALLATIONS ON BOTH, I DID NOT QUESTION THE INSTALLATION. WE REMOVED THE L PROP TO CHK ITS INSTALLATION AND FOUND IT TO BE INSTALLED THE SAME AS THE R (INCORRECTLY).
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.