37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 909734 |
Time | |
Date | 201009 |
Local Time Of Day | 1201-1800 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Make Model Name | MD 900/901/902 Explorer |
Operating Under FAR Part | Part 135 |
Flight Plan | None |
Component | |
Aircraft Component | Fan |
Person 1 | |
Function | Single Pilot |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 60 Flight Crew Total 15000 Flight Crew Type 130 |
Events | |
Anomaly | Aircraft Equipment Problem Critical Deviation - Procedural FAR Deviation - Procedural Published Material / Policy |
Narrative:
I departed my home base at xa:55 local time to a local hospital for a patient pickup; arriving at xb:16 local time; the 21 minute flight was without incident. Departed that hospital at xb:59 local time. Arrived at the destination hospital at xc:40 local time. The 41 minute flight was without incident. I departed at xd:17 local time; returning to base; arriving at xd:45 local time; the 28 minute flight was without incident. Note: prior to each departure; and upon each landing a phone call was/is made to our company dispatch center reporting each movement of the aircraft. After my arrival at home base; we made our normal phone call to receive our flight tracking number. At this time we were informed by our maintenance department that our aircraft; model 900 expl; was to be put out of service for mechanical issues. Upon checking with our base mechanic I learned that he had been called at xb:49 local time and been informed that our aircraft had over flown a mandatory tbo on a notar fan part by over 400 hours. I immediately called the communications relay agency director of operations and asked what knowledge he had of this. My phone call to him was his first notification of this event. The director of operations checked with company dispatch and found that they had been notified by maintenance at xb:20 local time that the aircraft had a mechanical irregularity and that it should be put out of service. The company dispatcher told the maintenance representative that the aircraft was on a mission; and asked if he would like the mission aborted and aircraft returned to base. After a moments hesitation the maintenance representative said 'no'; inform the crew at the termination of the mission. This aircraft was purchased approximately three years ago. The previous owner installed the component and apparently recorded it as a new ('0' time) component. The component in question was not new; and was installed as a used serviceable time continued part. Our quality assurance department; in the course of an audit; found the discrepancy and reported it to the director of maintenance. The director of maintenance was asked if the aircraft should be grounded. He decided to keep the aircraft in service until he personally inspected the records and made his own determination that the component was over tbo. I don't know what time frame the initial discovery was made; what time the director of maintenance reviewed the records; or how long between these events and the initial notification to dispatch. The problem arose by the original owner of the aircraft recording the component time incorrectly. Contributing factor was a poorly performed pre-buy inspection. Discovery was made by a properly performed audit of the aircraft records. Human performance issues are the most troubling problems with this situation. A complete lack of good judgment was exercised by the maintenance department; and especially by the director of maintenance. As soon as the issue was raised to the director of maintenance; the prudent course of action would have been to ground the aircraft; then double check the records. The lack of judgment was compounded by allowing the aircraft to continue to operate. As soon as the problem was identified; dispatch should have directed my flight to be terminated at the next landing point; or if in the air I should have been directed to return to base. Looking at the time line as best as I can determine; this discrepancy was found prior to my dispatch on the mission. It was positively discovered prior to my loading a patient on board and transporting them to the receiving hospital. At any point in this mission; the mission could have been terminated or diverted to the nearest airport; and the patient transport continued by ground or another air ambulance. The lack of regard of the lives of myself; my crew; and the patient is inexcusable negligence. Had I known at any point in this mission of the status of the aircraft I would have aborted; landed; and grounded the aircraft. The trust between an operational aircraft crew and maintenance has been severely eroded by this issue.
Original NASA ASRS Text
Title: An air ambulance helicopter pilot reported that his aircraft was allowed to continue flying after the Maintenance QA department discovered NOTAR fan part illegally permitted to remain on the aircraft 400 hours past its allowable time.
Narrative: I departed my home base at XA:55 local time to a local hospital for a patient pickup; arriving at XB:16 local time; the 21 minute flight was without incident. Departed that hospital at XB:59 local time. Arrived at the destination hospital at XC:40 Local time. The 41 minute flight was without incident. I departed at XD:17 local time; returning to base; arriving at XD:45 local time; the 28 minute flight was without incident. Note: Prior to each departure; and upon each landing a phone call was/is made to our company dispatch center reporting each movement of the aircraft. After my arrival at home base; we made our normal phone call to receive our flight tracking number. At this time we were informed by our Maintenance Department that our aircraft; Model 900 EXPL; was to be put out of service for mechanical issues. Upon checking with our Base Mechanic I learned that he had been called at XB:49 local time and been informed that our aircraft had over flown a mandatory TBO on a NOTAR fan part by over 400 hours. I immediately called the communications relay agency Director of Operations and asked what knowledge he had of this. My phone call to him was his first notification of this event. The Director of Operations checked with Company Dispatch and found that they had been notified by Maintenance at XB:20 local time that the aircraft had a mechanical irregularity and that it should be put out of service. The Company Dispatcher told the Maintenance Representative that the aircraft was on a mission; and asked if he would like the mission aborted and aircraft returned to base. After a moments hesitation the Maintenance Representative said 'no'; inform the crew at the termination of the mission. This aircraft was purchased approximately three years ago. The previous owner installed the component and apparently recorded it as a new ('0' time) component. The component in question was not new; and was installed as a used serviceable time continued part. Our Quality Assurance Department; in the course of an audit; found the discrepancy and reported it to the Director of Maintenance. The Director of Maintenance was asked if the aircraft should be grounded. He decided to keep the aircraft in service until he personally inspected the records and made his own determination that the component was over TBO. I don't know what time frame the initial discovery was made; what time the Director of Maintenance reviewed the records; or how long between these events and the initial notification to dispatch. The problem arose by the original owner of the aircraft recording the component time incorrectly. Contributing factor was a poorly performed pre-buy inspection. Discovery was made by a properly performed audit of the aircraft records. Human performance issues are the most troubling problems with this situation. A complete lack of good judgment was exercised by the Maintenance Department; and especially by the Director of Maintenance. As soon as the issue was raised to the Director of Maintenance; the prudent course of action would have been to GROUND the aircraft; then double check the records. The lack of judgment was compounded by allowing the aircraft to continue to operate. As soon as the problem was identified; dispatch should have directed my flight to be terminated at the next landing point; or if in the air I should have been directed to return to base. Looking at the time line as best as I can determine; this discrepancy was found prior to my dispatch on the mission. It was positively discovered prior to my loading a patient on board and transporting them to the receiving hospital. At any point in this mission; the mission could have been terminated or diverted to the nearest airport; and the patient transport continued by ground or another air ambulance. The lack of regard of the lives of myself; my crew; and the patient is inexcusable negligence. Had I known at any point in this mission of the status of the aircraft I would have aborted; landed; and grounded the aircraft. The trust between an operational aircraft crew and maintenance has been severely eroded by this issue.
Data retrieved from NASA's ASRS site as of April 2012 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.