 |
37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
A saab-340B aircraft left/H engine; right/H fwd cowling departed aircraft after rotation. Damage to horizontal and left/H elevator surfaces. Starter also loose.
| Attributes | |
| ACN | 731261 |
| Time | |
| Date | 200701 |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | SF 340B |
| Operating Under FAR Part | Part 121 |
| Flight Phase | climbout : takeoff |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| ASRS Report | 731261 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | oversight : pic |
| Events | |
| Anomaly | maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
| Independent Detector | other flight crewa |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : installation performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
The problem arose from the l-hand engine r-hand forward cowling departing the aircraft after rotation. It was discovered by considerable engine vibration and shutdown. Possible contributing factors: unlatched cowling -- starter coming out of its housing after band busting (weight 40 pounds). Corrective actions: replaced cowling and starter and other damaged pieces on the aircraft stabilizer and elevator. Perceptions; judgement; decisions: investigation by company revealed that the engine cowls were not latched. Factors affecting quality of human performance: radio calls for other aircraft coming in that needed work. Aircraft sat after control check for approximately 1 hour with no crew or anything before takeoff. Numerous human factors involved in the incident. I am not sure what actions could have changed the situation.
Original NASA ASRS Text
Title: A SAAB-340B ACFT L/H ENG; R/H FWD COWLING DEPARTED ACFT AFTER ROTATION. DAMAGE TO HORIZONTAL AND L/H ELEVATOR SURFACES. STARTER ALSO LOOSE.
Narrative: THE PROB AROSE FROM THE L-HAND ENG R-HAND FORWARD COWLING DEPARTING THE ACFT AFTER ROTATION. IT WAS DISCOVERED BY CONSIDERABLE ENG VIBRATION AND SHUTDOWN. POSSIBLE CONTRIBUTING FACTORS: UNLATCHED COWLING -- STARTER COMING OUT OF ITS HOUSING AFTER BAND BUSTING (WT 40 LBS). CORRECTIVE ACTIONS: REPLACED COWLING AND STARTER AND OTHER DAMAGED PIECES ON THE ACFT STABILIZER AND ELEVATOR. PERCEPTIONS; JUDGEMENT; DECISIONS: INVESTIGATION BY COMPANY REVEALED THAT THE ENG COWLS WERE NOT LATCHED. FACTORS AFFECTING QUALITY OF HUMAN PERFORMANCE: RADIO CALLS FOR OTHER ACFT COMING IN THAT NEEDED WORK. ACFT SAT AFTER CTL CHK FOR APPROX 1 HR WITH NO CREW OR ANYTHING BEFORE TKOF. NUMEROUS HUMAN FACTORS INVOLVED IN THE INCIDENT. I AM NOT SURE WHAT ACTIONS COULD HAVE CHANGED THE SITUATION.
Data retrieved from NASA's ASRS site as of January 2009 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.