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|
Attributes | |
ACN | 642242 |
Time | |
Date | 200501 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl single value : 1500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air taxi |
Make Model Name | MBB-BK 117A-1 |
Operating Under FAR Part | Part 135 |
Flight Phase | climbout : takeoff cruise : level descent : approach |
Flight Plan | VFR |
Person 1 | |
Affiliation | company : air taxi |
Function | flight crew : single pilot |
Qualification | pilot : instrument pilot : multi engine pilot : commercial |
Experience | flight time last 90 days : 57.4 flight time total : 7428.6 flight time type : 761 |
ASRS Report | 642242 |
Person 2 | |
Affiliation | company : air taxi |
Function | flight crew : single pilot |
Qualification | pilot : instrument pilot : commercial |
Experience | flight time total : 2950 flight time type : 810 |
ASRS Report | 642881 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance maintenance problem : non compliance with mel non adherence : far non adherence : published procedure |
Independent Detector | other other : 5 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other Other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Flight Crew Human Performance Maintenance Human Performance Environmental Factor |
Primary Problem | Maintenance Human Performance |
Narrative:
After landing at xyz hospital in ZZZ for a patient transport; I was notified by the lead mechanic via cell phone that we had overflown a component on the #1 engine and the helicopter was OTS for maintenance. I notified nursing staff and coordination the second aircraft to transport the patient. The component; the #1 engine flow fence actuator; had been overflown by over 60 hours. Contributing factors for this incident include: 1) failure of the pilots and mechanics to verify the total time for the total engine time versus the component change time. 2) failure of the company to provide timely maintenance status records. 3) assumptions that the most current and timely components are tracked by the company records section and contract sites will be notified if a component is due to be changed. 4) assumption by the pilots that the mechanics are keeping track of all component change times and vice versa. 5) a recent change of the company record keeping policies. Callback conversation with reporter revealed the following information: the cause of the overfly is the flight crew's and technician's failure to monitor engine total time and check with component change time. The function of the flow fence is control and limit the air and fuel feed to the engine.
Original NASA ASRS Text
Title: AN MBB-BK117 A4 HELI WAS GNDED WHEN IT WAS DISCOVERED #1 ENG FLOW FENCE ACTUATOR HAD EXCEEDED REPLACEMENT TIME LIMIT BY 60 HRS.
Narrative: AFTER LNDG AT XYZ HOSPITAL IN ZZZ FOR A PATIENT TRANSPORT; I WAS NOTIFIED BY THE LEAD MECH VIA CELL PHONE THAT WE HAD OVERFLOWN A COMPONENT ON THE #1 ENG AND THE HELI WAS OTS FOR MAINT. I NOTIFIED NURSING STAFF AND COORD THE SECOND ACFT TO TRANSPORT THE PATIENT. THE COMPONENT; THE #1 ENG FLOW FENCE ACTUATOR; HAD BEEN OVERFLOWN BY OVER 60 HRS. CONTRIBUTING FACTORS FOR THIS INCIDENT INCLUDE: 1) FAILURE OF THE PLTS AND MECHS TO VERIFY THE TOTAL TIME FOR THE TOTAL ENG TIME VERSUS THE COMPONENT CHANGE TIME. 2) FAILURE OF THE COMPANY TO PROVIDE TIMELY MAINT STATUS RECORDS. 3) ASSUMPTIONS THAT THE MOST CURRENT AND TIMELY COMPONENTS ARE TRACKED BY THE COMPANY RECORDS SECTION AND CONTRACT SITES WILL BE NOTIFIED IF A COMPONENT IS DUE TO BE CHANGED. 4) ASSUMPTION BY THE PLTS THAT THE MECHS ARE KEEPING TRACK OF ALL COMPONENT CHANGE TIMES AND VICE VERSA. 5) A RECENT CHANGE OF THE COMPANY RECORD KEEPING POLICIES. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE CAUSE OF THE OVERFLY IS THE FLT CREW'S AND TECHNICIAN'S FAILURE TO MONITOR ENG TOTAL TIME AND CHK WITH COMPONENT CHANGE TIME. THE FUNCTION OF THE FLOW FENCE IS CTL AND LIMIT THE AIR AND FUEL FEED TO THE ENG.
Data retrieved from NASA's ASRS site as of January 2009 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.