|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1201 To 1800|
|Locale Reference||airport : rmg|
|Altitude||msl bound lower : 2000|
msl bound upper : 2000
|Controlling Facilities||tower : rmg|
|Operator||common carrier : air taxi|
|Make Model Name||Helicopter|
|Flight Phase||cruise other|
|Affiliation||company : air taxi|
|Function||instruction : instructor|
|Qualification||pilot : instrument|
pilot : commercial
pilot : cfi
|Experience||flight time last 90 days : 100|
flight time total : 6500
flight time type : 325
|Function||other personnel other|
|Qualification||other other : other|
|Anomaly||non adherence other|
other anomaly other
|Independent Detector||other other : unspecified|
|Consequence||faa : investigated|
|Air Traffic Incident||other|
Had a #1 engine chip light illuminate during an initial qualification training jet with a student pilot. Accomplished emergency shutdown of the engine as described in aircraft flight manual. Made an uneventful single engine landing at richard B russell airport in rome, GA. Removed and inspected full flow oil scavenge debris detector and the rbsh debris detectors. Found one hair-like piece of metal on the rbsh debris detector classified as a type 1 - minor in the manufacturer's service bulletin. Sent the debris to manufacturer, attention: mr a. The company manager of field maintenance mr B and mr a advised me by telephone that the engine was good to fly, even though the airworthiness directed states the engine should be removed from service and inspected. Mr B advised by telephone that the ad was to be changed allowing the provisions for manufacturer's service bulletin making it airworthy for 25 flight hours until the debris could be analyzed by manufacturer. With this information I cleaned and reinstalled the detector. The following day I flew with another student for an additional 2.3 hours. After the flight I discussed what was going on with the engine and how to deal with the paperwork by telephone with mrc, director of quality assurance with FBO helicopters. He stated that the northwest region of the FAA did not agree with the northeast region and the aircraft should be grounded. Additionally, the engine should be removed and inspected before being placed back in service. He also advised in the future situations like this be handled through quality assurance. I then grounded the aircraft and discontinued flight training. In reflection I decided that a flight/maintenance violation could be filed against me for flying the aircraft not in exact compliance with the provisions of airworthiness directive. 4 days later the lab at manufacturers by telephone said the metal was of no concern and that we should continue to run the engine. The company began telefaxing this information to the FAA and the aircraft will remain grounded until actions are confirmed by the northwest region of the FAA. How it was discovered: through my perceptions of the course of events and lack of consistency in the FAA's interpretations of the regulations. Contributing factors: a lack of cohesive decision making within the different regions of the FAA. Corrective actions: all future questions will be handed through quality assurance before acted on. To serve as a one point of contact with the FAA for consistency. At this time it appears that the FAA is going to accept the provisions of the service bulletin since the debris was of no consequence. Human performance considerations. Perceptions, judgements, decisions: at all times during the incident I exercised good judgement based on my own understanding of the requirements, the currently available information, and the advice of mr a, mr B, and mr C. The decision of mr B to release the engine was premature, unverified, and the primary error. It too however, was based on the reasonable assumption that the FAA regions would act as one. The above error resulted in the aircraft being flown possibly out of compliance with the current ad against it. Actions or inactions: confirmation of compliance in the future. Factors affecting the quality of human performance: the lack of consistent decision making on the part of the FAA.
Original NASA ASRS Text
Title: HELICOPTER WAS FLOWN IN VIOLATION OF AN AIRWORTHINESS DIRECTIVE.
Narrative: HAD A #1 ENG CHIP LIGHT ILLUMINATE DURING AN INITIAL QUALIFICATION TRAINING JET WITH A STUDENT PLT. ACCOMPLISHED EMER SHUTDOWN OF THE ENG AS DESCRIBED IN ACFT FLT MANUAL. MADE AN UNEVENTFUL SINGLE ENG LNDG AT RICHARD B RUSSELL ARPT IN ROME, GA. REMOVED AND INSPECTED FULL FLOW OIL SCAVENGE DEBRIS DETECTOR AND THE RBSH DEBRIS DETECTORS. FOUND ONE HAIR-LIKE PIECE OF METAL ON THE RBSH DEBRIS DETECTOR CLASSIFIED AS A TYPE 1 - MINOR IN THE MANUFACTURER'S SVC BULLETIN. SENT THE DEBRIS TO MANUFACTURER, ATTN: MR A. THE COMPANY MGR OF FIELD MAINT MR B AND MR A ADVISED ME BY TELEPHONE THAT THE ENG WAS GOOD TO FLY, EVEN THOUGH THE AIRWORTHINESS DIRECTED STATES THE ENG SHOULD BE REMOVED FROM SVC AND INSPECTED. MR B ADVISED BY TELEPHONE THAT THE AD WAS TO BE CHANGED ALLOWING THE PROVISIONS FOR MANUFACTURER'S SVC BULLETIN MAKING IT AIRWORTHY FOR 25 FLT HOURS UNTIL THE DEBRIS COULD BE ANALYZED BY MANUFACTURER. WITH THIS INFORMATION I CLEANED AND REINSTALLED THE DETECTOR. THE FOLLOWING DAY I FLEW WITH ANOTHER STUDENT FOR AN ADDITIONAL 2.3 HOURS. AFTER THE FLT I DISCUSSED WHAT WAS GOING ON WITH THE ENG AND HOW TO DEAL WITH THE PAPERWORK BY TELEPHONE WITH MRC, DIRECTOR OF QUALITY ASSURANCE WITH FBO HELICOPTERS. HE STATED THAT THE NORTHWEST REGION OF THE FAA DID NOT AGREE WITH THE NE REGION AND THE ACFT SHOULD BE GNDED. ADDITIONALLY, THE ENG SHOULD BE REMOVED AND INSPECTED BEFORE BEING PLACED BACK IN SVC. HE ALSO ADVISED IN THE FUTURE SITUATIONS LIKE THIS BE HANDLED THROUGH QUALITY ASSURANCE. I THEN GNDED THE ACFT AND DISCONTINUED FLT TRAINING. IN REFLECTION I DECIDED THAT A FLT/MAINT VIOLATION COULD BE FILED AGAINST ME FOR FLYING THE ACFT NOT IN EXACT COMPLIANCE WITH THE PROVISIONS OF AIRWORTHINESS DIRECTIVE. 4 DAYS LATER THE LAB AT MANUFACTURERS BY TELEPHONE SAID THE METAL WAS OF NO CONCERN AND THAT WE SHOULD CONTINUE TO RUN THE ENG. THE COMPANY BEGAN TELEFAXING THIS INFORMATION TO THE FAA AND THE ACFT WILL REMAIN GNDED UNTIL ACTIONS ARE CONFIRMED BY THE NORTHWEST REGION OF THE FAA. HOW IT WAS DISCOVERED: THROUGH MY PERCEPTIONS OF THE COURSE OF EVENTS AND LACK OF CONSISTENCY IN THE FAA'S INTERPRETATIONS OF THE REGULATIONS. CONTRIBUTING FACTORS: A LACK OF COHESIVE DECISION MAKING WITHIN THE DIFFERENT REGIONS OF THE FAA. CORRECTIVE ACTIONS: ALL FUTURE QUESTIONS WILL BE HANDED THROUGH QUALITY ASSURANCE BEFORE ACTED ON. TO SERVE AS A ONE POINT OF CONTACT WITH THE FAA FOR CONSISTENCY. AT THIS TIME IT APPEARS THAT THE FAA IS GOING TO ACCEPT THE PROVISIONS OF THE SVC BULLETIN SINCE THE DEBRIS WAS OF NO CONSEQUENCE. HUMAN PERFORMANCE CONSIDERATIONS. PERCEPTIONS, JUDGEMENTS, DECISIONS: AT ALL TIMES DURING THE INCIDENT I EXERCISED GOOD JUDGEMENT BASED ON MY OWN UNDERSTANDING OF THE REQUIREMENTS, THE CURRENTLY AVAILABLE INFORMATION, AND THE ADVICE OF MR A, MR B, AND MR C. THE DECISION OF MR B TO RELEASE THE ENG WAS PREMATURE, UNVERIFIED, AND THE PRIMARY ERROR. IT TOO HOWEVER, WAS BASED ON THE REASONABLE ASSUMPTION THAT THE FAA REGIONS WOULD ACT AS ONE. THE ABOVE ERROR RESULTED IN THE ACFT BEING FLOWN POSSIBLY OUT OF COMPLIANCE WITH THE CURRENT AD AGAINST IT. ACTIONS OR INACTIONS: CONFIRMATION OF COMPLIANCE IN THE FUTURE. FACTORS AFFECTING THE QUALITY OF HUMAN PERFORMANCE: THE LACK OF CONSISTENT DECISION MAKING ON THE PART OF THE FAA.
Data retrieved from NASA's ASRS site as of August 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.