A BELL 412 EMS PLT DOES NOT NOTE THE THROTTLE CREEP REDUCTION ON #2 ENG DURING A HOVER TAXI PROC AT HIS DEP ARPT. HE DID NOT INTERP THE LOW ROTOR WARNING AS A POSSIBLE 1 ENG SPD REDUCTION AND INCREASES ROTOR BEEP (FUEL CTL ON CYCLIC) FOR BOTH ENGS. THE #1 ENG SUFFERS AN OVERTEMP AND OVERSPD. THE PLT INTERPS THESE SIGNS AS START; NOT FLT; LIMITS AND CONTINUES FLT. CORPORATION LATER GNDS HIM FOR 4 DAYS FOR INCIDENT.

Date: 1998-08 · Aircraft: Bell Helicopter 412

Anomalies: aircraft-equipment-problem-critical|deviation-discrepancy-procedural-published-material-policy

Synopsis

A BELL 412 EMS PLT DOES NOT NOTE THE THROTTLE CREEP REDUCTION ON #2 ENG DURING A HOVER TAXI PROC AT HIS DEP ARPT. HE DID NOT INTERP THE LOW ROTOR WARNING AS A POSSIBLE 1 ENG SPD REDUCTION AND INCREASES ROTOR BEEP (FUEL CTL ON CYCLIC) FOR BOTH ENGS. THE #1 ENG SUFFERS AN OVERTEMP AND OVERSPD. THE PLT INTERPS THESE SIGNS AS START; NOT FLT; LIMITS AND CONTINUES FLT. CORPORATION LATER GNDS HIM FOR 4 DAYS FOR INCIDENT.

Narrative

HOVER TAXIING FOR DEP AT ZZZ; LOW ROTOR RPM WARNING HORN SOUNDED. I INCREASED ROTOR BEEP AND NOTED EXCEEDANCE LIGHT ILLUMINATED ON THE ACFT SYS/ENG MONITORING DEVICE (PAR). I LANDED ON THE HELIPAD AND CHKED THE ACFT THROTTLES. ENG #2 HAD CREPT BELOW FULL THROTTLE. I CHKED THE PAR WHICH INDICATED 3 EXCEEDANCES FOR THE EVENT. 1) (ENG #1) ITT 898 DEGS C FOR 5.8 SECONDS. 2) (ENG #1) ITT 898 DEGS C FOR 7.1 SECONDS. 3) (ENG #1) N1 103.9% FOR 1.4 SECONDS. I MISREAD THE RESULTS; THINKING ABOUT ENG START LIMITATIONS (NOT ABOVE 960 DEGS FOR 2 SECONDS) AND TAKING THE N1 AS TORQUE. I JOINED THE THROTTLES AND PROCEEDED WITH THE FLT. I RECHKED THE PAR UPON RETURN AND CONFERRED WITH MAINT; REALIZING THE EXCEEDANCES. I HAVE BEEN COUNSELED; RECEIVED TRAINING ON THE PAR; FLT AND START LIMITATIONS; AND WAS SUSPENDED FROM FLT DUTIES FOR 4 DAYS. ALL FLT PERSONNEL WILL RECEIVE THE SAME TRAINING. I MISREAD THE INDICATIONS THE PAR DISPLAYED. I FAILED TO CONSIDER THE ITT READINGS AS ONE ENG INOP (OEI) OPS. I FAILED TO READ THE N1 EXCEEDANCE AS SUCH; THINKING IT WAS A MOMENTARY OVER TQ; WHICH THIS RECORDING DEVICE COMMONLY SHOWS. THE FLT MANUAL CAUTIONS PLTS (IN THE NORMAL OPS SECTION) TO ENSURE BOTH THROTTLES ARE ADEQUATELY FRICTIONED. I BELIEVE THIS IS WHAT CAUSED THE DROP IN #2 ENG PWR; THROTTLE CREEP. THE ONLY INTERIOR COCKPIT MONITORING I MANAGED AS I PUT THE HELI ON THE GND WAS TO SEE THE RED PAR WARNING LIGHT AND TO GLIMPSE THE #1 ENG ITT IN THE OEI RANGE. WITHOUT THE PAR; THAT AND THE LOW ROTOR WARNING; WOULD HAVE BEEN THE ONLY INDICATIONS. I REVIEWED THE INDICATIONS AND DID NOT CORRECTLY IDENT THEM; THEN PROCEEDED WITH MY MISSION. IN THE FUTURE; ANY EXCEEDANCE WILL BE MUCH MORE CAREFULLY INTERPRETED. I WILL CONSIDER THE RED PAR CAUTION LIGHT A PROMPT FOR MAINT INTERPRETATION AND POSSIBLE INTERVENTION. THIS IS THE PROC ALL OUR PLTS WILL USE. THESE EXCEEDANCES WILL REQUIRE A HOT END INSPECTION OF THE PTG WHICH I OVER TEMPED/OVER SPED.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.