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|
Attributes | |
ACN | 776869 |
Time | |
Date | 200802 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air taxi |
Make Model Name | AS 350 Astar/Ecureuil |
Operating Under FAR Part | Part 135 |
Person 1 | |
Affiliation | other |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 1 maintenance technician : 4 |
ASRS Report | 776869 |
Person 2 | |
Affiliation | other |
Function | maintenance : technician |
Events | |
Anomaly | maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Company Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
I inspected a main rotor head assembly. After maintenance was performed; I looked over the whole assembly including main rotor suspension bars; servos; and split lines. I signed off a secondary maintenance check; a written write-up in the supplemental page as required after maintenance performed on major components. The inspection by me was performed in feb/08. The aircraft was looked over by 2 other mechanics that performed the work. The rotor was looked over during a preflight and performed operations check flts. The pilot and other mechanics signed off aircraft back into service. A crew from ZZZ picked the aircraft up after the aircraft was returned to service to xfer it to ZZZ. They looked the helicopter over and took off. It was reported to me; after the aircraft landed in ZZZ; that a lower bolt to the r-hand servo had a bolt installed with a nut on it but not torqued or safetied. The result: no one was hurt nor damage to the aircraft. I believed there is no excuse for missing the bolt on my part. I do feel that day there was a lot of pressure to get the job done and the helicopter out the door to ZZZ. My personal involvement: I had a lot of late days and nights performing work. Week before I had 50.5 hours of overtime and was on a trip that wkend before and I just got back from that trip to help the guys due to the huge workload and lack of mechanics. I believe the inspection policy; for looking over the aircraft after maintenance; is set in a way right now that a lot of errors can happen -- not specific enough; and too vague. The policy needs to change to better detail the area to be looked at. The quality department was nowhere to 'buy' off the work. Lack of the quality control after such maintenance was really the cause of the problem. I hope that the company and the maintenance department find a better way to inspect aircraft before it is put back into service and to slow down maintenance performed. I will be more aware of my surroundings and not be pushed to these limits. I'm thankful no one was hurt and I will personally take this as a learning experience.
Original NASA ASRS Text
Title: A HELICOPTER INSPECTOR REPORTS ON INSPECTING THE MAIN ROTOR HEAD ASSY INCLUDING THE MAIN ROTOR SUSPENSION BARS; SERVOS AND SPLIT LINES; BUT MISSING THE RIGHT SERVO BOLT TORQUE AND SAFETY OF THE BOLT NUT.
Narrative: I INSPECTED A MAIN ROTOR HEAD ASSEMBLY. AFTER MAINT WAS PERFORMED; I LOOKED OVER THE WHOLE ASSEMBLY INCLUDING MAIN ROTOR SUSPENSION BARS; SERVOS; AND SPLIT LINES. I SIGNED OFF A SECONDARY MAINT CHK; A WRITTEN WRITE-UP IN THE SUPPLEMENTAL PAGE AS REQUIRED AFTER MAINT PERFORMED ON MAJOR COMPONENTS. THE INSPECTION BY ME WAS PERFORMED IN FEB/08. THE ACFT WAS LOOKED OVER BY 2 OTHER MECHS THAT PERFORMED THE WORK. THE ROTOR WAS LOOKED OVER DURING A PREFLT AND PERFORMED OPS CHK FLTS. THE PLT AND OTHER MECHS SIGNED OFF ACFT BACK INTO SVC. A CREW FROM ZZZ PICKED THE ACFT UP AFTER THE ACFT WAS RETURNED TO SVC TO XFER IT TO ZZZ. THEY LOOKED THE HELI OVER AND TOOK OFF. IT WAS RPTED TO ME; AFTER THE ACFT LANDED IN ZZZ; THAT A LOWER BOLT TO THE R-HAND SERVO HAD A BOLT INSTALLED WITH A NUT ON IT BUT NOT TORQUED OR SAFETIED. THE RESULT: NO ONE WAS HURT NOR DAMAGE TO THE ACFT. I BELIEVED THERE IS NO EXCUSE FOR MISSING THE BOLT ON MY PART. I DO FEEL THAT DAY THERE WAS A LOT OF PRESSURE TO GET THE JOB DONE AND THE HELI OUT THE DOOR TO ZZZ. MY PERSONAL INVOLVEMENT: I HAD A LOT OF LATE DAYS AND NIGHTS PERFORMING WORK. WK BEFORE I HAD 50.5 HRS OF OVERTIME AND WAS ON A TRIP THAT WKEND BEFORE AND I JUST GOT BACK FROM THAT TRIP TO HELP THE GUYS DUE TO THE HUGE WORKLOAD AND LACK OF MECHS. I BELIEVE THE INSPECTION POLICY; FOR LOOKING OVER THE ACFT AFTER MAINT; IS SET IN A WAY RIGHT NOW THAT A LOT OF ERRORS CAN HAPPEN -- NOT SPECIFIC ENOUGH; AND TOO VAGUE. THE POLICY NEEDS TO CHANGE TO BETTER DETAIL THE AREA TO BE LOOKED AT. THE QUALITY DEPT WAS NOWHERE TO 'BUY' OFF THE WORK. LACK OF THE QUALITY CTL AFTER SUCH MAINT WAS REALLY THE CAUSE OF THE PROB. I HOPE THAT THE COMPANY AND THE MAINT DEPT FIND A BETTER WAY TO INSPECT ACFT BEFORE IT IS PUT BACK INTO SVC AND TO SLOW DOWN MAINT PERFORMED. I WILL BE MORE AWARE OF MY SURROUNDINGS AND NOT BE PUSHED TO THESE LIMITS. I'M THANKFUL NO ONE WAS HURT AND I WILL PERSONALLY TAKE THIS AS A LEARNING EXPERIENCE.
Data retrieved from NASA's ASRS site as of May 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.