MECHANIC WORKING FOR AN EMERGENCY MEDIVAC SERVICE (EMS) OPERATOR; IS INFORMED THE MBB-B0-105 HELICOPTER HE SERVICED REQUIRED AN EMERGENCY LANDING. SHOP RAG WAS FOUND INGESTED IN #1 ENG INTAKE AND COMPRESSOR.

Date: 2008-07 · Aircraft: BO105

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

Synopsis

MECHANIC WORKING FOR AN EMERGENCY MEDIVAC SERVICE (EMS) OPERATOR; IS INFORMED THE MBB-B0-105 HELICOPTER HE SERVICED REQUIRED AN EMERGENCY LANDING. SHOP RAG WAS FOUND INGESTED IN #1 ENG INTAKE AND COMPRESSOR.

Narrative

I WAS CALLED AT XA30 FOR A MAINT ISSUE ON THE HYD FLT CTL SYS OF THE ACFT. THE PROB WAS DISCOVERED DURING A PREFLT OPS CHK PRIOR TO A PATIENT TRANSPORT FROM ONE HOSPITAL TO ANOTHER. THE FLT WAS ABORTED AND ANOTHER HELI WAS SENT FOR THE MISSION. WHEN I ARRIVED AT THE HOSPITAL HELIPAD AT XB30; THE PLT DISCUSSED THE PROB WITH THE HYD SYS CHK WITH ME. I INSPECTED THE HYD POWER PACKS AND DISCOVERED A MICROSWITCH STICKING; THEREFORE; NOT ALLOWING THE HYD SYS SWITCH SWITCHOVER CHK TO PERFORM PROPERLY. AFTER PERFORMING THE CLEANING AND LUBRICATING OF THE SWITCH; I INSTRUCTED THE PLT TO CHK THE SYS WHILE I WATCH THE CTLS MOVE AND LISTEN FOR THE CLICKING ACTION OF THE MICROSWITCHES. THIS CHK IS PERFORMED WHILE THE ACFT IS NOT RUNNING; SO I STOOD ON THE SKIDS OBSERVING THE HYD SYS AND THE PLT PERFORMED THE SYS CHK AND EVERYTHING WAS FUNCTIONING CORRECTLY. I WAS ABLE TO HEAR THE SWITCH ACTUATION AND THE PLT STATED THAT THE FUNCTIONAL TEST WAS PERFORMING PROPERLY ACCORDING TO THE ANNUNCIATOR PANEL IN THE COCKPIT. THIS PROB WAS NOW CORRECTED AND THE HELI COULD BE RETURNED TO SVC AFTER THE PAPERWORK WAS COMPLETED. THE TIME WAS NOW APPROX XC00. I HAD TAKEN A LIGHT; 1 SPRAY CAN OF CLEANER; 1 SPRAY CAN OF LUBRICANT; AND 3 WASHCLOTH SIZE SHOP RAGS UP TO THE HELI. I LOOKED THE HYD SYS OVER AND CLOSED THE ACCESS DOOR. I TOLD THE PLT EVERYTHING WAS GOOD AND I FILLED OUT THE PAPERWORK SO THAT THE HELI COULD RETURN TO SVC. THIS IS WHERE I MADE THE FIRST MISTAKE. WHEN I LOOKED EVERYTHING OVER; I WAS FOCUSING ON THE HYD POWER PACK AND DID NOT LOOK BACK JUST BEHIND THE POWER PACK ON THE DECK TO SEE THAT I HAD LEFT MY SHOP RAGS SITTING ON THE DECK. THE SECOND MISTAKE WAS MADE WHEN I DID NOT INSIST THAT THE PLT EXAMINE THE ENTIRE AREA AND TELL HIM WHAT EQUIP I HAD TAKEN TO THE JOB LOCATION. THE THIRD MISTAKE WAS WHEN I RETURNED TO MY VEHICLE WITH MY SUPPLIES AND DID NOT PAY ATTN TO THE FACT OF WHAT I HAD TAKEN WITH ME AND WHAT I WAS RETURNING WITH. I HAD ACCOUNTED FOR MY 2 CANS THAT I RETURNED TO MY TOOL BOX AND THE LIGHT; BUT DID NOT REMEMBER MY SHOP RAGS. THE 2 MEDICAL CREW MEMBERS AND PLT LOADED INTO THE HELI AND STARTED THE HELI TO RETURN BACK TO ZZZ1 ARPT. APPROX 3 MI FROM ZZZ1; THERE WAS A LOUD BANG AND THE PLT NOTICED THE #1 ENG INDICATIONS DROPPING OFF. HE SECURED THE DEAD ENG; CONTACTED TWR AND MADE AN EMER LNDG APCH INTO ZZZ1. AFTER HE LANDED SAFELY; I WAS CALLED AND REQUESTED TO COME TO ZZZ1. UPON INVESTIGATION; A SHOP RAG WHICH I HAD LEFT ON THE DECK WAS INGESTED INTO THE #1 ENG INTAKE AND COMPRESSOR ASSEMBLY. I HAD BEEN COMPLACENT ABOUT ONE OF THE MOST BASIC THINGS THAT I WAS TAUGHT AND TRAINED ON WHILE WORKING AROUND ACFT -- THAT ALL TOOLS AND EQUIP MUST BE ACCOUNTED FOR PRIOR TO FLT. THE FACTORS INVOLVED IN THIS INCIDENT ARE MANY THAT ARE FACED ON A REGULAR BASIS IN THE EMS INDUSTRY. I WAS CALLED AT XA30 IN THE MORNING; WOKE UP AND DROVE TO A LOCATION 45 MINS AWAY. THE LIGHTING ON THE HELIPAD WAS DEFINITELY A FACTOR. A SHOP WORK LIGHT WAS THE PRIMARY SOURCE OF LIGHT AND THERE WAS LITTLE OVERHEAD LIGHTING REFLECTING FROM THE HOSPITAL. THE FACT THAT I DID NOT INFORM THE PLT OF WHAT I HAD TAKEN WITH ME AS FAR AS EQUIP. THIS INCIDENT COULD EASILY HAVE BEEN AVOIDED BY JUST FOLLOWING BASIC PROCS AND CHKS. THE INCIDENT HAS DEFINITELY CAUSED THE CREW I WORK WITH TO REALIZE THE IMPORTANCE OF SAFETY AND WHY IT IS NECESSARY TO PAY ATTN TO ALL OF THE TOOLS AND EQUIP AND ASSURE THAT EVERYTHING IS ACCOUNTED FOR. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED THE HYD POWER PACK MICROSWITCHES ARE SUSCEPTIBLE TO STICKING; PREVENTING THE SWITCHING FROM ONE HYD POWER PACK (SYS-1) TO SYSTEM-2. THERE ARE MICROSWITCHES FOR EACH CONTROL SYSTEM FOR THE LATERAL; VERTICAL AND LONGITUDINAL CONTROLS.

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