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June 2014

FIXED WING 

Beech 200: P & W PT6 - Alicante - 21/04/2014 (201404914)

During start up, taxi and line up, all systems appeared to be operating normal. Whilst setting take-off power, found that the RH engine was not responding to power lever input. ATC advised and returned to stand and shut down.  Medical operations and maintenance informed.  Investigation revealed that the power lever cable to engine attachment rod end bolt had detached and bolt had moved from the eye end, resulting in full disconnect of the system. The nut and split pin were not located in the cowling and it is assumed these fell out of vent holes of the cowling during flight/Taxi.  A new nut/split pin were installed and the aircraft released to service. The details of the incident were passed to the Maint.Org. for investigation and review. 

Beech 200: P & W PT6 - Exeter - 25/05/2014 (201406724)

On initial climb out the RH engine fire light came on, however, there were no other indications of fire. SOPs followed and returned to airport and landed with RFFS in attendance.

CAA Closure:
RH engine cowlings removed and fire detection wiring inspected with no faults found.  No evidence of fire warning light extinguished when aircraft powered down and powered back up. Unable to determine root cause for this event and no other occurrences reported.  However, a detailed follow-up inspection discovered one detector assembly appearing to be damaged, with body cap of detector housing coming adrift. The suspect detector was replaced and function tested satisfactorily with no further pilot reports since original occurrence. CAM has reviewed recent history and although has been advised of the occasional “spurious” fire warning on other fleet aircraft of this type, there was nothing recently. 

Beech 200: P & W PT6 - en-route - 23/05/2014 (201406776)

Whilst in the climb passing FL250 the port engine suffered a significant drop in torque before increasing again to the set output.  Pilot levelled the aircraft off and whilst doing this the port engine torque began to fluctuate again, concurrent with the drop in toque a small amount of smoke emitting from the exhaust. Suspecting fuel contamination, he requested immediate vectors back to departure airport.  The torque of the left engine stopped fluctuating and I made a safe landing with no emergency declared.

Supplementary 26/06/14:
Tech log entry on 2045 dated 23/05/2014-Engine surging-Returned to Base. Engineering action-Water drains checked. Water found in fuel filter. Drained until clear, ground run satis.  Await further reports. After ascertaining that the fault occurred on the LH engine only, the left hand fuel tanks drained using all tank and nacelle drains.  Evidence of water and some debris observed but most water found from filter drain which is at the rear of the nacelle. Once all lines and tanks were correctly drained, ground runs and subsequent flights have not had a re-occurrence of the reported problem.  Right hand tanks and other aircraft in the fleet fuel drains checked as a precaution but no significant amount of water found. Discussion with Part 145 and air crew following the event centred on how was water getting into the fuel and are water fuel checks being done correctly and regularly. The majority of fuelling actions are done using the company fuel bowser which has rigorous delivery and daily sample checks performed.  Pilots are required to request fuel check information from any other supplier away from base and I am assured this is carried out.  Although the pilot of this flight did perform a fuel water check prior to take off, due to the nature of the bag tanks on the aircraft, it would be possible for trapped water to migrate to the collector during aircraft manoeuvring.  Also, it may be that the difficult to reach nacelle aft drain (filter) is not always being correctly drained.  Crew need to be reminded that all drains are to be checked as part of every A Check.  Suitable action taken.  Chief Pilot asked to re-iterate to the crews the importance of comprehensive daily fuel checks, (although he does maintain that the crews are completing this task as part of their checks). 

DHC6: P & W PT6 - St. Mawgan  - 11/03/2014 (201404277)

Aircraft suffered a double generator failure. Reset carried out IAW Emergency check-list.  Left reset/Right did not. Standard VFR flight.  No impact on flight.  Engineering investigation carried out.  The Right hand generator and current relay were replaced. The aircraft runs carried out to verify serviceability then released as serviceable.  Last flight of the day another double generator failure.  Again reset carried out IAW Emergency check-list. Left reset/Right did not. Starboard generator was replaced for a serviceable spare and ground run the aircraft with no change. Starboard Reverse current relay then replaced and both generators came on line as normal. The aircraft carried out some further flights without incident but then failed again, as it was confirmed that the RCB and the generator were operating correctly the voltage regulators were checked and there was a .42 vdc split between the two. This was corrected so that both generators produced a voltage of 28.50 in accordance with 24-30-00 in the M/M. This has now cleared the fault as there have been no further failures.  Type Certificate Holder was contacted throughout our investigation to confirm they were satisfied with our investigation and outcome of our findings.  Since then we have received a reply from TCH stating the following: “Your troubleshooting and repair actions were appropriate, we don’t see any further actions that would be required”.  

Diamond DA42: Austro E4 AE300 - Repton/Gamston - 14/04/2014 (201404676)

During a scheduled Maintenance inspection the Autopilot bridal Cable was found to be badly frayed.  During the refit of the new cable the Maintenance Data was found to be ambiguous resulting in the cable being short. An e-mail was sent to the Manufacturer for clarification at which point the correct procedure was obtained allowing the cable to be fitted correctly.  Both the cable wear issue and the maintenance data have been brought to the attention of the Manufacturer, Airworthiness and Quality departments for their investigation and correction.  

Grob 115: Lycoming O-360 - Syerston - 02/06/2014 (201407131)

Whilst flying straight and level in IMC conditions at 5,500 feet, the student made initial contact with approach in preparation for a radar recovery back to base when almost immediately a Total Electrical Failure was experienced.  All electrical instrumentation including radios, engine instruments and intercom failed and both attitude indicators displayed OFF warning flags.  This was accompanied by a smell of burning and a haze of smoke entering the cockpit.  Instructor took control from the student and commenced a steep and rapid descent to break cloud as soon as possible.  During this descent the burning smell became quite strong and acrid with distinct plumes of smoke being visible particularly on the student’s side of the cockpit, Gen and Battery switches turned off.  By shouting instructor was able to communicate with the student and told him to turn on the ELT.  Student indicated, by pointing, the smoke that continued to enter the cockpit.  Student told to check his parachute.  No flames were visible.  Continued the rapid descent into the overhead a suitable gliding site and positioned for a flapless landing on the most into wind runway.  Canopy was opened when aircraft had slowed, remaining Middle instrument Panel Switches turned off, engine shut down at the end of the landing run and aircraft promptly vacated. 

Supplementary 06/04/14:
All of the following work carried out iaw AMM Iss 2, Rev 7 and the aircraft Wiring Diagrams & Electrical Parts List where applicable. Aircraft battery disconnected to make safe. AMM CH 24-10, 24-31 & 24-61 Trouble Shooting guide referred to, no symptoms for total electrical failure listed. Using a Remote Visual Aid (RVA) access was made, without disturbance, to the RH instrument panel. EHSI released to aid further inspection with the RVA, no damage apparent. Same procedure using the RVA was carried out behind the LH instrument panel. COM 1 (UHF) controller released to aid further inspection. No indications of fire damage, chaffing of cable looms or equipment damage evident. RH and then LH instrument panel released. With both panels removed there was evidence of a very faint electrical overheat/burning smell. Close visual inspection of looms and equipment carried out. Slight overheat evident of the Generator Relay P/No 0 332 002 256 Terminal Wire PC 02E10-P.  No other evidence of damage or fire.  Further investigation continuing, in the meantime fleet to operate VFR only until further notice.     

Piper PA31: Lycoming 540 - Liverpool - 06/06/2014 (201407541)


Approaching 3000ft to level off pilot noticed what appeared to be a puff of smoke from the left engine which was then followed by an oil stream which eventually stopped.  He checked the oil temperature and pressure gauges which appeared normal, reduced the power on the left engine as a precaution and landed back at departure airport.  Aircraft was checked by a LAE who found that an elbow on the breather pipe had perished.

Supplementary 26/06/14: 
Tech log 3164-Pilot report-Suspect oil leak-Action Taken-LH engine lower breather elbow found spilt, serviceable elbow fitted.  Top cowl refitted. Local Part 145 assisted in investigating the defect. LH engine silicon elbow breather tube found split. Engineer dispatched with required spares on aircraft positioning to take over from this aircraft.  Engine had been recently replaced (due overhaul) and the original breather tubing assembly re fitted after cleaning and inspection. No oil leaks were observed during post installation runs.  The aircraft also had a check 2 performed where no defects were noted regarding this engine breather installation. CAM noted 1981 Service letter No 878A for the correct alignment of the LH breather tubing and Part 2 which revised the layout of the tube.  Alignment was not the issue here nor would of modifying the tube layout have prevented this defect. Part 145 provider advised.  Suitable action taken.  

Schemp Hirth Ventus S2CT: Solo 2625? - Parham,West Sussex  - 21/04/2014 (201407680)

The engine pylon had been inspected during the Annual check ARC Renewal and, subsequently, the aircraft was flown for thirty minutes and the engine started briefly to test it. Following this, it was flown three times for a total of 14 hours. On the last flight, the engine was started twice for a total of approximately 20 minutes. Prior to each flight, the owner carried out the required daily inspection of the pylon diligently. Up to this point, there were no cracks visible during either the Annual or Daily inspection despite careful examination of the area. During the daily inspection before flying the glider again a significant crack was discovered in the rear side of the port leg of the pylon at the point where there is a nut welded to it. It became evident that, after a moderate operation of the engine, the crack had developed and progressed rapidly. It appears that the crack inspection procedure may not be sufficient to detect the early onset of a developing crack especially if the cracks start under the painted finish.  The consequences of a failure of this part are extremely worrying due to the close proximity of the propeller to the canopy and pilot. This pylon had an in service time of 18.05 hours. It is understood that other reports indicate a similar failure time in service.  

Sportcruiser: Rotax 912 - Membury - 13/06/2014 (201407683)

Failure of hardware securing undercarriage attachment bracket to fuselage spar carry-through (shear web) was discovered during a Special Inspection arising from a recently issued Service Bulletin, causing separation & compromise of surrounding structure & skin.  The non-mandatory Service Bulletin was issued in March, requiring compliance at next 100hr or Annual Inspection & assessed by the Continuing Airworthiness Manager as Mandatory due to previous occurrences of working rivets on the main spar shear-web to wing skins on this type (but not this aircraft). This is the first aircraft of type (of 7 maintained by us) inspected since issue of this SB. It has typical private utilisation & total flying hours, but is one of the oldest (calendar) factory built aircraft known to us & has suffered from being kept outdoors. The inspection area is extremely difficult to access & a failure would not easily be noticed in routine maintenance. Failure is restricted to structural rivets & appears to be due to vibration/load, not corrosion. The remaining bolts show signs of wear. Fuselage skins have separated due to failed attaching hardware. Holes in the fuselage carry-through (shear web) have been elongated. Repair will be carried out in accordance with the SB -replacement of 3mm rivets with 3/16" AN bolts. Customers are very adverse to carrying out this SB as it is labour intensive, requiring the wings to be removed to gain access to the fuselage side. However we consider, based on 5 years experience of the build quality of this type that it is mandatory.

Suggestions: An MPD should be issued mandating this inspection for Permit to Fly types. EASA should be encouraged to issue an AD for RTC (CofA).  As these aircraft age, an increasing number of airworthiness & maintenance issues are arising & causing concern. These aircraft are built down to a weight & ultimately will have a finite operational life, the OEM airframe life inspection of 5000hrs is wildly optimistic & perhaps these aircraft would benefit from a UK GR reducing that interval or introducing a calendar interval (e.g. 5 years).  

SINGLE ENGINED ROTARY WING 

Bell 206: Allison 250 - over Reading - 17/05/2014 (201406585)

Approx 10 mins into a flight of 18 min duration, Nr tach needle fell to zero. N2 indication remained consistent and representative of Nr.  Flight continued to destination, which was a private site, with a schedule of short pleasure flights arranged for the day. On landing, organiser of event was advised of the problem, and that CAT flights could not occur. Pilot, in consideration of the fact that it could just be a loose connection, restarted, hovered and flew a couple of quick stops, executed 2 or 3 landings to see if the gauge could be lightly jolted to work. Nr indication remained zero. Prior to this the MO had been contacted, and provision made to divert the aircraft there for engineering inspection if tach remained u/s. Pilot and one crew member (a type rated pilot and employee of the owner of the aircraft) flew the aircraft there. Engineering inspection over the next 2 hours, surmised that the dual tach instrument was defective. Aircraft remained at MO. It is questionable whether the pilot should have flown to the maintenance organisation from the private site, however due consideration was made to the flight duration of only 12 mins, that Nr low rpm indication was operational, and that a greater chance of a resolution would exist at the aircrafts base station, and that N2 was operational. Most noteworthy however in this incident are the CRM issues which are worth disseminating. At the private site 7 or 8 ground personnel were present, the site was being / had been set up, 20 or so members of the general public had already arrived. There was pressure for CAT flights to go ahead. Staff were under pressure from customers, they were concerned with the financial issues of not flying that day. There was an unsubstantiated comment from representatives of the aircraft owner, which was on the lines of “weIl, so and so might have done 2 or 3 or a few flights...” and other suggestions such as “N2 still gives you rotor rpm...” These are commercial pressures where both the a/c owner and the event organiser stand to lose significant revenue. The pilot stands alone in representing the safe operation of the aircraft.



 

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