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January 2014


Auster J5K: Blackburn Cirrus Minor IIA - Oakham - 30/11/2013 (201316987)

While in the cruise, there was a serious incident when the aileron control snapped.  Landed successfully.  Subject to AAIB AARF investigation.  

Beech 200: P & W PT6 - Porto - 14/11/2013 (201314812)

During initial climb, aircraft returned due to fuel filler cap not properly seated.  This was not detectable during normal pre-departure walk-round as the cap was, in fact, flush.  Shortly after take-off the pilot noticed fuel vapour escaping so made a short circuit to land as a precaution.  He re-seated the fuel cap properly and continued with the flight. 

Supplementary 14/11/13: Although this issue appears to be a handling and pre-departure inspection issue, a check of the LH outer fuel filler cap was performed by the engineering manager and CAM.  It was noted that when correctly fitted, the cap was flush with the wing surface surrounding the opening but it was possible to fit the cap slightly canted and lock it in position.  In this condition, the cap did not lie flush with the wing surface and leakage was possible. The engineering manager suggested that a plastic version of the cap was trialled and this was tested and it was found that the cap could only be correctly fitted in a sealed position.  

Beech 200: P & W PT6 - Yeovilton - 08/01/2014 (201400335)

On taxi in and shutdown, flaps failed to retract.  Following the partial calibration of the PAR, a visual circuit and landing was made on runway 27. The flaps extended as normal during the approach. During the taxi-in the flap lever was selected up but the flaps failed to move to the up position (the indicator suggests the flaps moved fractionally then stopped).  Both the 'Flap Control' and the 'Flap Motor' CBs were intact.  Post flight inspection revealed that there was a small degree of asymmetry between the right hand outboard and inboard flap. Further investigation revealed the bolt linking the actuator to the flap was missing on the right hand outboard flap and this portion of flap was 'loose'.  ATC were notified that the bolt was missing and a FOD inspection was carried out on Runway 27 and the taxiways. The bolt was not found.  Prior to departure on this sortie (the first of the day) the flaps were cycled fully and functioned normally during this test. 

Supplementary 28/01/14:  As the bolt was not recovered it is not known exactly what the problem was but there are two likely scenarios: The retaining stiff nut came off the bolt at some point allowing the bolt to work its way out of the attachment during taxi or the bolt broke and fell out of the attachment during taxi.  Due to the way the bolt is retained this is considered to be unlikely but the possibility can’t be discounted without evidence.  As a precautionary measure the other flap to actuator bolts were checked to ensure they were tight and were found to be so. On return to base all the flap to actuator stiff nuts and bolts were replaced; one being found with insufficient locking function. The other aircraft in the fleet were checked to ensure the bolts were serviceable with correct locking function, no further problems were found. This occurrence has been passed on to CFI's maintenance organisations for information. From the replies received it would appear that there is no consensus about whether the stiff nuts should be replaced as a matter of course or just checked for correct function.  Amendments to the CFI maintenance programmes have been raised to include a check for security of the stiff nuts during pre-flight inspection.  

Cessna 177RG: Lycoming O-360 - Tatenhill - 22/12/2013 (201316574)

During scheduled maintenance an unapproved modification was found to be installed.  Whilst performing an ARC review the following non-compliance was found. A JPI fuel flow device and EDM800 engine data monitoring system was found without any regulatory approval. The reporter suggests there are a number of other aircraft that have been upgraded in a similar fashion by the same maintenance organisation.  

Cessna 406: P & W PT6 - Blackpool - 22/01/2014  (201400853)

Braking capacity found to be inadequate following brake maintenance.  During engineering handover and prior to leaving, the crew were advised by the Maintenance Organisation that due to brake maintenance, the brakes would feel different for a while. On first moving off, the brakes appeared to be working satisfactorily, but when approaching the holding point, the Captain felt that braking was inadequate.  Even at idle power with large braking forces applied at the pedals, the aircraft continued to roll forward. The Captain feathered the propellers and stopped the aircraft short of the holding point. ATC gave permission to enter the runway and then exit back to the maintenance apron.  The propellers were un-feathered and with reduced braking the aircraft was taxied very slowly back to the maintenance area, stopping well clear of any obstacles. During this taxi back the LHS brakes improved, but the P2 found it difficult to stop the aircraft with his brakes. It was found that the burn-in procedure to be accomplished after installation of new brakes, had not been carried out. This requires 3 hard braking sequences from between 39 and 43 knots to glaze new brake blocks and should only be performed by a qualified pilot. Neither pilot had performed this exercise previously nor knew of this maintenance procedure despite many hours on type. No instruction to carry it out was received from the Maintenance Organisation.  

Cessna 421: Continental O-540 - Cranfield - 17/10/2013 (201314236)

In accordance with the 'Before Take-Off' items in the aircraft checklist, the auxiliary fuel pump switches were selected from 'LOW' to 'ON' in turn.  When the right engine auxiliary fuel pump was selected on the right engine continued to operate normally; however, when the left engine auxiliary fuel pump was selected ‘ON’ the left engine slowed to a stop. The left auxiliary fuel pump was selected 'OFF' and the engine restarted. The checklist items were repeated and when the left auxiliary fuel pump was selected 'ON' the left engine once again slowed to a stop. It was suspected that the engine driven fuel pump output pressure switch was indicating low fuel pressure, which was causing the left auxiliary fuel pump to operate in the high flow mode when selected ‘ON’, which was then causing a rich cut of the left engine. The left auxiliary fuel pump was selected ‘OFF’ and the engine restarted; the sortie was cancelled and the aircraft was taxied back to the hangar and shut down normally. The issue was explained to the maintenance organisation and a defect was raised in the aircraft technical log.  Following the reported defect the maintenance organisation carried out an engine ground run and the fault was confirmed.  Initial investigation was to check the LH fuel boost pump control wiring together with its associated switches and relays which were all confirmed to operating correctly with no visual defects evident. The engine driven fuel pump output pressure switch was removed and bench tested and found to be operating at the correct pressure and switching electrically without fault. This test was repeated several times and each time operated correctly. The pressure switch was refitted and a further ground run carried out which revealed the system was now operating correctly without fault.  At least two further longer ground runs were carried and the system continued to operate without fault. Most probably cause was the engine driven fuel pump output pressure switch initially sticking. The aircraft has since flown 13 hours without any further problem.  (GASCo Comment: Have any other operators experienced this?).  

DH82 Tiger Moth: Gipsy Major - Turweston - 24/10/2013 (201317024)

During scheduled maintenance substandard installation of engine parts found.  There had been previous reports that the engine lacked power, so a top end inspection was carried out. After removing cylinder heads, pistons and barrels, it was noted that number 2 connecting rod was very tight to rotate about the crankshaft. The engine was sent for further engineering inspection. The report states that the removed connecting rod was received loose having been removed to investigate a tightness felt upon trying to move the rod. Visual inspection reveals a polished area across the bearing split line. Main bearing lock tabs have had all three locking tabs bent down onto the bearing cap. This method has no locking effect on the main bearing nut. The split pinning is of poor quality and specifically the connecting rod bolts and starter extension bolts do not comply with manufacturer’s standards. The thrust bearing locking ring has been used previously, evidenced by deformation of the outer rim. The visual inspection also reveals a crack like indication through the intermediate bearing panels, with the rear panel showing evidence of a crack through to the outer wall.  Recommendation is for the engine to be dismantled and inspected to ascertain serviceability. Currently awaiting owners instructions.  

Diamond DA42:  Austro E4 AE300 - Repton/Gamston - 19/12/2013 (201316983)

During a Scheduled Maintenance Inspection, port rear main landing gear door hinge was found to be cracked. Hinge part Number D60-5287-73-00.  This is the second such incident found on DA42 aircraft in the space of 3 weeks.  Operator are aware of the issue & he current AMM 7.02.15 Rev 2 does highlight the Issue under ATA 05-28-50 & asks specifically to check the MLG doors & hinges for:- 1. Check for damage to the doors, 2. Check for cracked hinges, 3. Examine the door operating rods.  The above 3 items were revised under Revision 2 of the above AMM.


Agusta 109: P & W - Sywell - 06/01/2014 (201400190)

Aircraft weight and balance information out of date.  During pre-flight preparation it was noticed that the weight and balance information in use locally was out of date.  The aircraft had been swapped three days earlier due to an unservicability and the electronic weight and balance system in use had not been checked to ensure it contained the latest weight and balance figures, the aircraft mass had not been changed for two years.  The computer system had suffered a failure a month earlier and when restored from a backup, the weight and balance software was found to be missing and was restored from an older source, the current base aircraft details were updated but the spare aircraft details were not.  The aircraft could have potentially been flown overweight.  However a review of all of the sectors flown in the previous 3 days proved that this was not the case. The computer failure that occurred a month ago highlighted a lack of a contingency plan for such eventualities.  Likewise the local procedure for accepting a spare aircraft into use, is too informal and will be formalised to prevent recurrence.  Procedures are currently in place for integrity checking the electronic system against a manual calculation but not for checking the weight and balance schedule against this.  

Agusta 109: P &W - Costock - 20/01/2014 (201400650)

During scheduled maintenance an unserviceable replacement oil cooler belt was fitted and the aircraft returned to service. Following scheduled maintenance during which an engine oil cooler belt was replaced; tech records noticed that the fitted belt bore the serial number of an item removed as unserviceable from another aircraft.  By the time this became apparent the aircraft had returned to its base, approx 16 minutes flying time away.  The operator was contacted immediately and the u/s cooler belt was replaced before further flight.  The company's non-conformance process was initiated to investigate the cause of the incident. It was established the belt was removed from another aircraft by a third party engineer and returned in the replacement belt's packaging, complete with log card, but no 'red' u/s label.  On receipt the item was returned to stock as a 's' item as it was thought that it had not been needed for the off-site maintenance and not been used.  Subsequently the u/s belt was issued to the hangar for installation.  Neither the mechanic who installed the belt, the supervising l.a.e. nor the l.a.e. who carried out the duplicate inspection noticed the discrepancy and the aircraft was returned to service following completion of the scheduled inspection.  Company procedures for stores goods-in, component issue and receipt of spares onto the shop floor are being reviewed.  (GASCo Comment:  Well spotted by Tech Records, the event shows the importance of correct procedures).  

Bell 429: P &W PW200 - Turweston - 24/10/2013 (201313753)

LH generator cooling system air scoop missing.  This is a known occurrence on the type and is believed to be caused by stressing of the scoop due to it being used as a hand hold when accessing the upper areas of the fuselage.   It was stressed to all staff on the type rating course, that the scoop should not be used as an aid to climbing and, upon discussion with the company pilots, we are confident that all pilots are aware of the issue and declare that no-one has used the scoop as hand holds.  

Eurocopter EC130: Turbomeca Arriel - Near Borehamwood - 19/10/2013 (201313541)

While in cruise, suffered a complete electrical failure. Unloaded all electrical systems and attempted to re-cycle battery and generator with no results.  Elected to divert.  Due to electrical failure engine was shut down by pulling the fuel shut off lever. Fault was found to be a broken positive battery terminal which had separated from the terminal.  Connection was replaced.  

Eurocopter  EC135 - Turbomeca Arrius - Blackpool - 19/12/2013 (201316506)

On completion of the pre take-off checks, the crew observed double 'DEGRADE' captions on the CAD.  Aircraft shutdown and battery switched off.  On the subsequent power up of the FADEC, after the BITE sequence had completed there were two occasions when the 'DEGRADE' caption flickered and then extinguished on the nr2 engine.  FADEC and battery power selected off and on the subsequent power up of the FADEC, no repeat 'DEGRADE' captions were observed.   The engines were restarted, the aircraft was lifted to a hover and during the after take-off checks, nr1 engine was seen indicating approx 12.5 on the FLI and the nr2 engine was indicating approx 2.0 on the FLI. The OEI countdown timer had activated. The aircraft was landed and shutdown and task cancelled.  Engineering investigation found faulty nr2 engine start switch and faulty nr2 FADEC.  Both units replaced iaw AMM and ground runs carried out before aircraft returned to service.  

Eurocopter EC135 - Turbomeca Arrius - Nr Inverkip -  06/01/2014 (201400199)

During cruise fuel quantity indication display failure.  A flash of the master caution appeared with no caption and a few minutes later 'nr2 F QTY FAIL' caption illuminated.  The associated contents display for nr2 supply tank disappeared.  Although the contents of that tank had been noted (42kg) it was no longer possible to positively confirm how much fuel was in the tank or whether the tank was being replenished.  A PAN call was made and the aircraft diverted.  On approach, the caption cleared so the aircraft continued to the nearby heliport and the PAN was downgraded.  On landing, the caption once again illuminated and the contents display disappeared.  Engineering assistance sought.  Fuel sensor found to be contaminated with water/engine wash fluid.  All fuel sensors cleaned and refitted.  Function check of supply tank and main fuel tank sensors carried out iaw AMM 28-40-00,5-1.  Ground runs carried out to check supply tank indication system and aircraft returned to service.  

Eurocopter EC135: Turbomeca Arrius - Manchester/Barton - 25/01/2014 (201400906)

On return to base, prior to entering the airfield circuit pattern, the 'F QTY FAIL' caption illuminated on the CAD and the nr2 Supply Tank Quantity Indication indicated zero on the VEMD.  Actions completed iaw FRCs. Aircraft landed without further incident, operations informed and engineering assistance sought.  Nr2 supply tank fuel quantity removed, cleaned and refitted iaw AMM.  During removal, 1x electrical connection suspected as cause of failure. Ground run check of Supply Tank Indication system carried out.  During check, the nr1 Supply Tank Fuel quantity sensor found to fail the check. Nr1 Supply Tank Fuel quantity sensor removed, cleaned and refitted. Further ground run check of Supply Tank Indication system carried out. System serviceable, aircraft returned to service.  Investigation under 201316084.  

Eurocopter EC135: P & W - Husbands Bosworth - 25/01/2014 (201400864)

Main rotor blade attachment bolt locking pins incorrectly fitted.  At the commencement of night shift, the Duty Pilot conducted a pre-flight check of the aircraft and discovered that the Locking Pins on the trailing edge of the Yellow Main Rotor Blade Attachment Bolt were incorrectly installed. Aircraft had returned from Base maintenance that morning.  Engineering advice sought, engineers subsequently arrived and reinstalled the pins in accordance with the Maintenance Manual.  Aircraft declared serviceable.  

Eurocopter EC135: Turbomeca Arrius - Glasgow - 02/01/2014 (201400171)

Fuel contents indication discrepancy.   While in the hover, the fuel contents indication showed 46kg/70kg/42kg. The aircraft landed and the main fuel contents indication was observed to decrease to 54kg resulting in a fuel balance of 46kg/54kg/42kg.  Engineering advice sought.  Fault investigation carried out and fuel tanks drained. The main fuel tank probes and the supply tank probes were removed, cleaned and refitted.  Fuel monitoring and quantity indication tests carried out iaw AMM 28-40-00, 5-3.  Fuel transferred from main tank to supply tanks to check Low Fuel captions extinguished at correct indicated levels and amber captions extinguished correctly.  Ground run carried out and system assessed serviceable.  Aircraft returned to service.  

MBB BK117: Turbomeca Arriel  - Lippitts Hill - 10/11/2013 (201314452)

Navigation lights illuminating incorrectly.  On first arrival I saw the aircraft from a distance and noted that the starboard navigation light appeared red.  On pre-flight walk around I turned on electrical power and confirm that the starboard navigation light was illuminating red and the port navigation light was illuminating green.  Aircraft declared unserviceable and engineering informed of findings.  (GASCO Comment: this fault has sometimes been used in a CAA/GASCo Pre-flight Inspection Challenge).   

MD900: P & W - Carr Gate - 16/10/2013 (201313376)

Variable wind speeds during start and shut down caused rotor blades to 'sail' more than usual.  Full engineering visual check carried out with nothing untoward found.  Subsequent inspection of blades found what was believed to be an unrelated crack on nr2 blade leading edge near weight pocket.  Replacement blade fitted.  

MD900: P &W PW200 - En route - 23/10/2013 (201313653)

Nr5 leading edge main rotor blade pin failure.  'Check main rotor balance' displayed on aircraft IIDS (Integrated Instrument Display System) during cruise.  Flight continued to planned landing site (2nm/1min away) with no obvious abnormal vibration.  Post shut down inspection the blades and pins revealed that the nr5 leading edge blade pin to be slightly extended compared with the rest. (5mm from below) and slightly proud of the top washer (2mm from above) indicating that the blade pin had likely sheared.  Engineering advice sought.  

MD900: P & W - Cruise - 11/01/2014 (201400359)

Pitch link bearing failure.  During search task, ‘check rotor balance’ caption illuminated on integrated instrument display system (IIDS).  No excessive vibrations apparent.  Task cancelled and aircraft returned to base. During transit rotor balance check conducted.  Increase in 1r vibration noticed in latter stages of approach, becoming more severe in hover. A/c shut down.  Visual inspection revealed no 5 blade pitch link upper bearing had failed. Engineering advice sought. 

Supplementary 20/01/14:  Pitch change link was fitted only 112:50hrs earlier. It was noted at that time the upper bearing was of the earlier type steel variety, not the later type ceramic variety (both can be fitted and have same part no).  Recommend in the future that only pitch change links with ceramic type bearings issued due to extremely long life of ceramic bearings.

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