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Attributes | |
ACN | 810065 |
Time | |
Date | 200811 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Aircraft 1 | |
Controlling Facilities | tower : lax.tower |
Operator | common carrier : air carrier |
Make Model Name | Brasilia EMB-120 All Series |
Operating Under FAR Part | Part 135 |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance lead technician : 1 maintenance technician : 10 |
ASRS Report | 810065 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact other |
Consequence | other |
Factors | |
Maintenance | contributing factor : briefing performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I must testify that it was late. I used an assistant to help me place the inlet duct. When in position; we installed a v-band clamp -- the main support holding it in place. In securing the rest of the duct work; I loosened the clamp to reposition; aligning the aft portion which; once the aft portion was secured; I ended my shift. In my pass down I opened paperwork for the front portion; the chin cowl to be installed; which it was; but the clamp I had loosened did not get safetied or tightened; thus resulting in the duct dropping down and causing significant loss of power that the crew returned to base. After several power runs the aircraft was about to be returned to service. After a look at the engine; that is when it was discovered. New clamp on order and no damage; no personnel injured. Callback conversation with reporter revealed the following information: reporter stated the 'south' duct is attached to the lower side of the pw-118 engine at the air inlet. The duct is secured to the engine inlet by a mormon v-type clamp that is tightened and than safety wired with 040 inch wire. Reporter stated they had a problem aligning the 'south' duct with the engine inlet because the alignment dowels on the duct that help position the duct to the engine inlet were missing. He had earlier tightened the mormon clamp; but had to loosen the clamp nut to get alignment with the forward and aft sections of the duct bellows clamps. Reporter stated he should have flagged the mormon clamp as a reminder to retighten the nut; but he did not and forgot to make a shift turnover to have the clamp resecured. As a result; the #2 engine air inlet duct dropped down; inflight; reducing air intake; and requiring an air turnback of the emb-120 aircraft.
Original NASA ASRS Text
Title: MECHANIC REPORTS ABOUT A BRASILIA EMB-120 AIR TURNBACK; CAUSED BY PW-118 ENGINE AIR INLET 'S' DUCT SEPARATING FROM THE ENGINE INLET; RESULTING IN A SIGNIFICANT LOSS OF POWER ON THE #2 ENGINE.
Narrative: I MUST TESTIFY THAT IT WAS LATE. I USED AN ASSISTANT TO HELP ME PLACE THE INLET DUCT. WHEN IN POSITION; WE INSTALLED A V-BAND CLAMP -- THE MAIN SUPPORT HOLDING IT IN PLACE. IN SECURING THE REST OF THE DUCT WORK; I LOOSENED THE CLAMP TO REPOSITION; ALIGNING THE AFT PORTION WHICH; ONCE THE AFT PORTION WAS SECURED; I ENDED MY SHIFT. IN MY PASS DOWN I OPENED PAPERWORK FOR THE FRONT PORTION; THE CHIN COWL TO BE INSTALLED; WHICH IT WAS; BUT THE CLAMP I HAD LOOSENED DID NOT GET SAFETIED OR TIGHTENED; THUS RESULTING IN THE DUCT DROPPING DOWN AND CAUSING SIGNIFICANT LOSS OF PWR THAT THE CREW RETURNED TO BASE. AFTER SEVERAL PWR RUNS THE ACFT WAS ABOUT TO BE RETURNED TO SVC. AFTER A LOOK AT THE ENG; THAT IS WHEN IT WAS DISCOVERED. NEW CLAMP ON ORDER AND NO DAMAGE; NO PERSONNEL INJURED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED THE 'S' DUCT IS ATTACHED TO THE LOWER SIDE OF THE PW-118 ENGINE AT THE AIR INLET. THE DUCT IS SECURED TO THE ENGINE INLET BY A MORMON V-TYPE CLAMP THAT IS TIGHTENED AND THAN SAFETY WIRED WITH 040 INCH WIRE. REPORTER STATED THEY HAD A PROBLEM ALIGNING THE 'S' DUCT WITH THE ENGINE INLET BECAUSE THE ALIGNMENT DOWELS ON THE DUCT THAT HELP POSITION THE DUCT TO THE ENGINE INLET WERE MISSING. HE HAD EARLIER TIGHTENED THE MORMON CLAMP; BUT HAD TO LOOSEN THE CLAMP NUT TO GET ALIGNMENT WITH THE FORWARD AND AFT SECTIONS OF THE DUCT BELLOWS CLAMPS. REPORTER STATED HE SHOULD HAVE FLAGGED THE MORMON CLAMP AS A REMINDER TO RETIGHTEN THE NUT; BUT HE DID NOT AND FORGOT TO MAKE A SHIFT TURNOVER TO HAVE THE CLAMP RESECURED. AS A RESULT; THE #2 ENGINE AIR INLET DUCT DROPPED DOWN; INFLIGHT; REDUCING AIR INTAKE; AND REQUIRING AN AIR TURNBACK OF THE EMB-120 AIRCRAFT.
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.