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A109 helicopter pilot experienced an over torque on engine start but did not notice the exceedance alert until the second start after a patient had already been loaded for transport. Pilot completed the mission; but later had second thoughts about flying without a maintenance inspection and release.
| Attributes | |
| ACN | 1044881 |
| Time | |
| Date | 201210 |
| Local Time Of Day | 0001-0600 |
| Place | |
| Locale Reference | ZZZ.Airport |
| State Reference | US |
| Environment | |
| Flight Conditions | VMC |
| Light | Night |
| Aircraft 1 | |
| Make Model Name | A109 All Series |
| Operating Under FAR Part | Part 135 |
| Flight Phase | Takeoff |
| Route In Use | Direct |
| Component | |
| Aircraft Component | Turbine Engine |
| Person 1 | |
| Function | Captain Pilot Flying Single Pilot |
| Qualification | Flight Crew Commercial Flight Crew Instrument |
| Experience | Flight Crew Last 90 Days 60 Flight Crew Total 6500 Flight Crew Type 200 |
| Events | |
| Anomaly | Aircraft Equipment Problem Less Severe Deviation - Procedural FAR Deviation - Procedural Published Material / Policy |
Narrative:
On a previous flight; I experienced an over torque; but considered it at the time to be 'within limits' and after helping to unload the critical patient; I neglected to check the displays upon shutdown. The crew was awakened for another flight. I rushed through my start sequence and apparently didn't notice or comprehend the exceedance alert on the first screen as I jumped to the auxiliary page to monitor battery voltage and amps during the start. It was only on the second start when I already had the crew and patient on board; that I noticed the exceedance. I quickly checked the values; (xmsn torque 109% for 1 second); determined them to be within limits (up to 107% for 6 second; 110% maximum) and elected to continue the flight and notify maintenance upon completion of the flight. In hindsight; I let the self-imposed pressures of completing the mission cloud my judgment and I should have contacted maintenance when I noticed the exceedance and sent the medical team and their patient on by other means; not flying the aircraft until it had been inspected and released by maintenance. I might be able to rationalize the first time I missed the exceedance annunciation; but should have followed a different course of action once I recognized it.
Original NASA ASRS Text
Title: A109 helicopter pilot experienced an over torque on engine start but did not notice the Exceedance Alert until the second start after a patient had already been loaded for transport. Pilot completed the mission; but later had second thoughts about flying without a maintenance inspection and release.
Narrative: On a previous flight; I experienced an over torque; but considered it at the time to be 'within limits' and after helping to unload the critical patient; I neglected to check the displays upon shutdown. The crew was awakened for another flight. I rushed through my start sequence and apparently didn't notice or comprehend the Exceedance Alert on the first screen as I jumped to the AUX page to monitor battery voltage and amps during the start. It was only on the second start when I already had the crew and patient on board; that I noticed the exceedance. I quickly checked the values; (XMSN torque 109% for 1 second); determined them to be within limits (up to 107% for 6 second; 110% maximum) and elected to continue the flight and notify Maintenance upon completion of the flight. In hindsight; I let the self-imposed pressures of completing the mission cloud my judgment and I should have contacted Maintenance when I noticed the exceedance and sent the medical team and their patient on by other means; not flying the aircraft until it had been inspected and released by Maintenance. I might be able to rationalize the first time I missed the exceedance annunciation; but should have followed a different course of action once I recognized it.
Data retrieved from NASA's ASRS site as of July 2013 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.