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Attributes | |
ACN | 637508 |
Time | |
Date | 200411 |
Day | Thu |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : charter |
Make Model Name | Citation III, VI, VII |
Operating Under FAR Part | Part 135 |
Flight Phase | ground : maintenance ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air taxi |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : instrument pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 213 flight time total : 13580 flight time type : 850 |
ASRS Report | 637508 |
Person 2 | |
Affiliation | company : air taxi |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : repair performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : logbook entry performance deficiency : fault isolation |
Supplementary | |
Problem Areas | Aircraft Company Maintenance Human Performance Flight Crew Human Performance |
Primary Problem | Company |
Narrative:
This report is being made to disclose far violations relative to operations of aircraft that did not have MEL, but were dispatched with known discrepancies, and/or system that were inoperative or in unknown condition. Conditions: aircraft being operated by part 135 carrier who has struggled financially and who have been trying to place aircraft into safe operation. Aircraft maintenance personnel have been in constant change, and this has led to delays in maintenance or failure of items to be 'actually' repaired. When dispatched to the aircraft, I found previously reported discrepancies, un-fixed, or write-ups signed off without work being completed. I questioned the issue, and was placed in a situation that revenue would be lost by the carrier, as well as by myself. I evaluated the discrepancies and determined that they would not place the aircraft in an unsafe situation. (This was not a correct action, and as such I have stopped doing this.) I seemed to be led down the path of 'promises' by the director of operations and director of maintenance and general manager that they will get the items repaired 'once and for all.' these promises kept going on and on and on. Eventually, I could see that a chain of events was starting that could place the aircraft, myself, and the passenger at risk. As such, I no longer would accept the aircraft. (2 different aircraft citation ii and citation 6.) I met with the other pilots in the operation, explained how I was no longer going to be accepting aircraft outside of the operations and specifications of the certification, and/or outside of the FARS. No accidents occurred as a result of my actions. No airspace was violated or were passenger ever hurt or injured. 2 incidents did take place as a result of this, however. They should be noted. While flying the aircraft to a pick-up point for passenger, the CE650 while in center control, at an altitude of FL240 experienced 100% air data computer failure. This aircraft is total EFIS cockpit, and only had 1 air data computer. As a result, the aircraft system became useless, and only emergency flight instruments were available. Because the emergency altimeter is located on the co-pilot's forward right front panel, maintaining assigned altitude was not easy. Additionally, airspeed indicator was erratic at best. Emergency descent to the nearest field was requested. We landed without incident. In addition to the instrumentation failure, the rudder boost was attempting hard over actions. The aircraft had some various electrical and avionics problems that 'had been' troubleshot, but no action to repair them had taken place, prior to this flight. The aircraft was in the repair shop for 4 weeks, and all items were corrected. Left engine would not make cruise power, and we continued to have high itt. I continued to ask for the aircraft to be taken to engine repair facility. The director of maintenance did in-house inspections, and said he could not find anything wrong. This aircraft was operated for an additional 65 hours, then finally during flight at FL370 we had a roll-back on this same engine. We landed and maintenance again did inspection and said they needed more information. I again requested that we take the aircraft to an engine maintenance shop. The company agreed. Due to msp monitoring issues, the owner took the airplane away from the shop, and said that it needed monitoring accomplished in order to know what to do. I did 21 hours more flying. Engine once again rolled back at high altitude. Then I agreed to make 1 flight 10 mins to the repair shop 'only', they agreed, and when they opened the cowling, they found hp line chaffed and leaking, they found that deice valve stuck in open position. (Reason for the high itt.) they found the fire loop damaged, which would have impacted operation of the bottles and alert system. They found that the engine 'had' to come off and be overhauled. Turbine blades were damaged and/or worn beyond limits.
Original NASA ASRS Text
Title: A PLT EMPLOYED BY A STRUGGLING PART 135 CARRIER FLEW A C650 AND C550 ON NUMEROUS OCCASIONS WITH OPEN AND KNOWN MAINT DISCREPANCIES.
Narrative: THIS RPT IS BEING MADE TO DISCLOSE FAR VIOLATIONS RELATIVE TO OPS OF ACFT THAT DID NOT HAVE MEL, BUT WERE DISPATCHED WITH KNOWN DISCREPANCIES, AND/OR SYS THAT WERE INOP OR IN UNKNOWN CONDITION. CONDITIONS: ACFT BEING OPERATED BY PART 135 CARRIER WHO HAS STRUGGLED FINANCIALLY AND WHO HAVE BEEN TRYING TO PLACE ACFT INTO SAFE OP. ACFT MAINT PERSONNEL HAVE BEEN IN CONSTANT CHANGE, AND THIS HAS LED TO DELAYS IN MAINT OR FAILURE OF ITEMS TO BE 'ACTUALLY' REPAIRED. WHEN DISPATCHED TO THE ACFT, I FOUND PREVIOUSLY RPTED DISCREPANCIES, UN-FIXED, OR WRITE-UPS SIGNED OFF WITHOUT WORK BEING COMPLETED. I QUESTIONED THE ISSUE, AND WAS PLACED IN A SIT THAT REVENUE WOULD BE LOST BY THE CARRIER, AS WELL AS BY MYSELF. I EVALUATED THE DISCREPANCIES AND DETERMINED THAT THEY WOULD NOT PLACE THE ACFT IN AN UNSAFE SIT. (THIS WAS NOT A CORRECT ACTION, AND AS SUCH I HAVE STOPPED DOING THIS.) I SEEMED TO BE LED DOWN THE PATH OF 'PROMISES' BY THE DIRECTOR OF OPS AND DIRECTOR OF MAINT AND GENERAL MGR THAT THEY WILL GET THE ITEMS REPAIRED 'ONCE AND FOR ALL.' THESE PROMISES KEPT GOING ON AND ON AND ON. EVENTUALLY, I COULD SEE THAT A CHAIN OF EVENTS WAS STARTING THAT COULD PLACE THE ACFT, MYSELF, AND THE PAX AT RISK. AS SUCH, I NO LONGER WOULD ACCEPT THE ACFT. (2 DIFFERENT ACFT CITATION II AND CITATION 6.) I MET WITH THE OTHER PLTS IN THE OP, EXPLAINED HOW I WAS NO LONGER GOING TO BE ACCEPTING ACFT OUTSIDE OF THE OPS AND SPECS OF THE CERTIFICATION, AND/OR OUTSIDE OF THE FARS. NO ACCIDENTS OCCURRED AS A RESULT OF MY ACTIONS. NO AIRSPACE WAS VIOLATED OR WERE PAX EVER HURT OR INJURED. 2 INCIDENTS DID TAKE PLACE AS A RESULT OF THIS, HOWEVER. THEY SHOULD BE NOTED. WHILE FLYING THE ACFT TO A PICK-UP POINT FOR PAX, THE CE650 WHILE IN CTR CTL, AT AN ALT OF FL240 EXPERIENCED 100% ADC FAILURE. THIS ACFT IS TOTAL EFIS COCKPIT, AND ONLY HAD 1 ADC. AS A RESULT, THE ACFT SYS BECAME USELESS, AND ONLY EMER FLT INSTS WERE AVAILABLE. BECAUSE THE EMER ALTIMETER IS LOCATED ON THE CO-PLT'S FORWARD R FRONT PANEL, MAINTAINING ASSIGNED ALT WAS NOT EASY. ADDITIONALLY, AIRSPD INDICATOR WAS ERRATIC AT BEST. EMER DSCNT TO THE NEAREST FIELD WAS REQUESTED. WE LANDED WITHOUT INCIDENT. IN ADDITION TO THE INSTRUMENTATION FAILURE, THE RUDDER BOOST WAS ATTEMPTING HARD OVER ACTIONS. THE ACFT HAD SOME VARIOUS ELECTRICAL AND AVIONICS PROBS THAT 'HAD BEEN' TROUBLESHOT, BUT NO ACTION TO REPAIR THEM HAD TAKEN PLACE, PRIOR TO THIS FLT. THE ACFT WAS IN THE REPAIR SHOP FOR 4 WKS, AND ALL ITEMS WERE CORRECTED. L ENG WOULD NOT MAKE CRUISE PWR, AND WE CONTINUED TO HAVE HIGH ITT. I CONTINUED TO ASK FOR THE ACFT TO BE TAKEN TO ENG REPAIR FACILITY. THE DIRECTOR OF MAINT DID IN-HOUSE INSPECTIONS, AND SAID HE COULD NOT FIND ANYTHING WRONG. THIS ACFT WAS OPERATED FOR AN ADDITIONAL 65 HRS, THEN FINALLY DURING FLT AT FL370 WE HAD A ROLL-BACK ON THIS SAME ENG. WE LANDED AND MAINT AGAIN DID INSPECTION AND SAID THEY NEEDED MORE INFO. I AGAIN REQUESTED THAT WE TAKE THE ACFT TO AN ENG MAINT SHOP. THE COMPANY AGREED. DUE TO MSP MONITORING ISSUES, THE OWNER TOOK THE AIRPLANE AWAY FROM THE SHOP, AND SAID THAT IT NEEDED MONITORING ACCOMPLISHED IN ORDER TO KNOW WHAT TO DO. I DID 21 HRS MORE FLYING. ENG ONCE AGAIN ROLLED BACK AT HIGH ALT. THEN I AGREED TO MAKE 1 FLT 10 MINS TO THE REPAIR SHOP 'ONLY', THEY AGREED, AND WHEN THEY OPENED THE COWLING, THEY FOUND HP LINE CHAFFED AND LEAKING, THEY FOUND THAT DEICE VALVE STUCK IN OPEN POS. (REASON FOR THE HIGH ITT.) THEY FOUND THE FIRE LOOP DAMAGED, WHICH WOULD HAVE IMPACTED OP OF THE BOTTLES AND ALERT SYS. THEY FOUND THAT THE ENG 'HAD' TO COME OFF AND BE OVERHAULED. TURBINE BLADES WERE DAMAGED AND/OR WORN BEYOND LIMITS.
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.