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During removal of the main gear box on a sikorski S61 helicopter, the rotor head and all 5 blades, including one low time blade, were reinstalled and flown over respective time life limits.
| Attributes | |
| ACN | 560269 |
| Time | |
| Date | 200209 |
| Day | Sun |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Dawn |
| Aircraft 1 | |
| Operator | common carrier : air taxi |
| Make Model Name | S-61A/B/L/N/R Sea King |
| Operating Under FAR Part | other : 133 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air taxi |
| Function | maintenance : lead technician |
| ASRS Report | 560269 |
| Person 2 | |
| Affiliation | company : air taxi |
| Function | maintenance : technician |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : company policies non adherence : published procedure non adherence : far |
| Independent Detector | other other : person 4 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : briefing performance deficiency : installation performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Company Maintenance Human Performance Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
The main gear box and main rotor head were due for overhaul. One main rotor blade had 7.3 hours life remaining, which was to be changed at this time. A second blade had 86.7 hours life remaining. All 5 blades, main gear box and main rotor head were removed. When the main rotor blades were installed the rotor blade with 7.3 hours remaining was reinstalled and the blade with 86.7 hours remaining was removed. This problem was found on a routine inspection of the aircraft. The aircraft was grounded and the rotor blade was replaced. Clear communication between the maintenance crew and not verifying the serial numbers of the blade to be removed are contributing factors.
Original NASA ASRS Text
Title: DURING REMOVAL OF THE MAIN GEAR BOX ON A SIKORSKI S61 HELI, THE ROTOR HEAD AND ALL 5 BLADES, INCLUDING ONE LOW TIME BLADE, WERE REINSTALLED AND FLOWN OVER RESPECTIVE TIME LIFE LIMITS.
Narrative: THE MAIN GEAR BOX AND MAIN ROTOR HEAD WERE DUE FOR OVERHAUL. ONE MAIN ROTOR BLADE HAD 7.3 HRS LIFE REMAINING, WHICH WAS TO BE CHANGED AT THIS TIME. A SECOND BLADE HAD 86.7 HRS LIFE REMAINING. ALL 5 BLADES, MAIN GEAR BOX AND MAIN ROTOR HEAD WERE REMOVED. WHEN THE MAIN ROTOR BLADES WERE INSTALLED THE ROTOR BLADE WITH 7.3 HRS REMAINING WAS REINSTALLED AND THE BLADE WITH 86.7 HRS REMAINING WAS REMOVED. THIS PROB WAS FOUND ON A ROUTINE INSPECTION OF THE ACFT. THE ACFT WAS GNDED AND THE ROTOR BLADE WAS REPLACED. CLR COM BTWN THE MAINT CREW AND NOT VERIFYING THE SERIAL NUMBERS OF THE BLADE TO BE REMOVED ARE CONTRIBUTING FACTORS.
Data retrieved from NASA's ASRS site as of July 2007 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.