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|
Attributes | |
ACN | 974116 |
Time | |
Date | 201110 |
Local Time Of Day | 0601-1200 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Light | Daylight |
Aircraft 1 | |
Make Model Name | Super King Air 200 |
Operating Under FAR Part | Part 91 |
Flight Phase | Parked |
Component | |
Aircraft Component | Propeller Assembly |
Person 1 | |
Function | Technician |
Qualification | Maintenance Airframe Maintenance Inspection Authority Maintenance Powerplant |
Experience | Maintenance Inspector 6 Maintenance Lead Technician 13 Maintenance Technician 23 |
Events | |
Anomaly | Aircraft Equipment Problem Critical Deviation - Procedural Published Material / Policy |
Narrative:
Was tasked with removing; inspecting and lubricating lh propeller mounting bolts due to improper torque at prior installation. I removed the oil line from the torque transducer to facilitate bolt removal/installation and safety wiring. Placed caps on ends of transmitter and lines to protect debris ingestion and to prevent oil leaking into cowl. Caps were hand tight only as it was only temporary. Moved line behind another line to hold out of way. After completion of task; I inadvertently forgot to remove the caps and reconnect the oil line to transmitter. I cowled engine; stated to my boss that it was good to go and completed a logbook entry for propeller bolts. Later that night; aircraft was needed for a flight. According to pilot's story; he started lh engine and noticed no torque indication. Rather than shut down and have the situation investigated; he chose to continue on the flight thinking the torque gauge was an item that could be placed on MEL deferred list. At no time was torquemeter working nor was it ever placed on deferred list. Aircraft flew from one leg; where upon landing and shutdown; engine seized and would not rotate. Contract maintenance called out and the disconnected line was found with oil leaking from caps due to being hand tight only. Pilot stated he had no indication of low oil pressure. I feel that had the pilot performed the proper procedures for an MEL item it would have been found that it was not allowed to be MEL'd and needed to be addressed before departure. By choosing to ignore the inoperative torquemeter the pilot's actions induced the engine seizure. Had he performed a shutdown when realizing he had no torque indication; the line could have been found before departure and secured; resulting in an embarrassing situation; but without the catastrophic results that ensued. This scenario could have been prevented in the following ways:1. Maintenance personnel should have had a second set of eyes inspecting area before closure of cowlings.2. Mechanic should have tagged removed line to remind [him] to reconnect before closure of cowlings.3. Pilot in command (PIC) should have shutdown engine and contacted maintenance when realizing he had no torque indication.4. PIC failed to follow proper MEL procedures.human performance considerations: 1. Mechanic was not fatigued nor under influence of drugs or alcohol at time of incident.2. Was feeling pressured to complete task quickly; as customer had previously complained about time being spent on repairs.3. Distractions from outside vendor may have caused lack of situational awareness during work.
Original NASA ASRS Text
Title: Mechanic removed an oil line to a Torque Transducer and installed an end cap finger tight. Pilot later flew the Beechcraft King Air 200 without torque indication. The Pratt-Whitney PT6A engine later seized on shutdown due to oil loss.
Narrative: Was tasked with removing; inspecting and lubricating LH propeller mounting bolts due to improper torque at prior installation. I removed the oil line from the Torque Transducer to facilitate bolt removal/installation and safety wiring. Placed caps on ends of transmitter and lines to protect debris ingestion and to prevent oil leaking into cowl. Caps were hand tight only as it was only temporary. Moved line behind another line to hold out of way. After completion of task; I inadvertently forgot to remove the caps and reconnect the oil line to transmitter. I cowled engine; stated to my boss that it was good to go and completed a logbook entry for propeller bolts. Later that night; aircraft was needed for a flight. According to pilot's story; he started LH engine and noticed no torque indication. Rather than shut down and have the situation investigated; he chose to continue on the flight thinking the Torque Gauge was an item that could be placed on MEL deferred list. At no time was torquemeter working nor was it ever placed on deferred list. Aircraft flew from one leg; where upon landing and shutdown; engine seized and would not rotate. Contract Maintenance called out and the disconnected line was found with oil leaking from caps due to being hand tight only. Pilot stated he had no indication of low oil pressure. I feel that had the pilot performed the proper procedures for an MEL item it would have been found that it was not allowed to be MEL'd and needed to be addressed before departure. By choosing to ignore the inoperative torquemeter the pilot's actions induced the engine seizure. Had he performed a shutdown when realizing he had no torque indication; the line could have been found before departure and secured; resulting in an embarrassing situation; but without the catastrophic results that ensued. This scenario could have been prevented in the following ways:1. Maintenance Personnel should have had a second set of eyes inspecting area before closure of cowlings.2. Mechanic should have tagged removed line to remind [him] to reconnect before closure of cowlings.3. Pilot in Command (PIC) should have shutdown engine and contacted Maintenance when realizing he had no torque indication.4. PIC failed to follow proper MEL procedures.Human Performance Considerations: 1. Mechanic was not fatigued nor under influence of drugs or alcohol at time of incident.2. Was feeling pressured to complete task quickly; as customer had previously complained about time being spent on repairs.3. Distractions from outside Vendor may have caused lack of situational awareness during work.
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.