Inventory your tools...and everything else in the work area.

Teller1900

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I am a dad!
It started off as a normal day. The AM crew brought the plane in only 10 minutes late, so CA Jared and I thought we'd stand a pretty good chance of running on time. CA Kris gave us the rundown of the plane's squawks...Hobbs meter MELed, left gen. tie kept opening on first flight of the day, so they replaced the generator in Boston that morning and it's worked fine ever since. The left engine was running about 50-70 degrees warmer than the right during cruise, but then normalized during decent...no big deal. Otherwise, great airplane, and a great day in Boston (calm, 10, and clr). There's no reason we shouldn't be on time for our 8:55pm arrival back home.

OK! We get loaded into the plane, I grab the clearance while CA Jared boards the pax, we get our release from Portland Approach and are ready to go in less than 10 minutes.

"Before takeoff checklist complete, no known or observed traffic," I advice CA Jared, "lets go!"

It's his leg down to KBOS, so he stands on the brakes and runs up the power. Both auto-feather lights come on shortly after the props come up on the governors, so he releases the brakes and advance the power levers to 3500 ft-lbs of torque...takeoff thrust.

"Set power," he asks.

I glance at the engine instruments, "Power set," I reply without having to adjust anything.

"80 kts" is my next call out as I cross-check both airspeeds. "V1, rotate" I call out and Jared hauls back on the yoke to take us flying....


At least, that's how it's supposed to happen.

_____________________________________________________________

"Before takeoff checklist complete, no known or observed traffic," I advice CA Jared, "lets go!"

It's his leg down to KBOS, so he stands on the brakes and runs up the power. Both auto-feather lights come on shortly after the props come up on the governors, so he releases the brakes and advance the power levers toward 3500 ft-lbs of torque...takeoff thrust.

I have my hand right below his on the power levers waiting for the "set power" call out. Through 40kts and it hasn't come yet. I am staring at the engine gauges and he is splitting his attention between the engines and the runway, while fighting - hard - to keep us on centerline. The right engine is at takeoff thrust, but the left has stopped at 2500 ft-lbs of torque and only 82% N1. He rides the brakes a bit to keep us slow. The left power lever hits the fire wall...about four to five inches farther forward than the right lever. That's strange. The 1000 ft markers go under us as we hit 60kts, but still no power on the left engine. At 74kts we simultaneously yell "Woah!" as we watch the ITT unexpectedly and quickly rise over 820 degrees C...over the red line.

"Ok...that's it," Jared exclaims as he closes the power, "Abort, abort, abort, my controls." A short dip into reverse thrust and we're off the runway at Charlie.

"Augusta area traffic, 4970 is clearing runway 35 at Charlie, Augusta."

A Bonanza in the pattern chimes in "wow, that was a quick flight."

"That's why you should fly with us," I reply, "we'll get you to Boston even before we leave."

We run the after-landing checklist as CA Jared regales me with a long series of swear words.

We head back to the gate and deplane all seven of the pax. Contract mx from the other side of the field comes over and tows our plane out of the way as the Albany plane pulls up to take our passengers. CA Jared and the mechanic both think that the fuel-control unit was somehow knocked out of alignment when they replaced the generator and it went from no fuel to "here's all your gas at once" which caused the over-temp and lack of acceleration on the engine. That's a definite problem, but nothing fatal for the plane, since we exceeded the redline for less than the 5-second limitation.

The mechanic removed the cowling around the accessory gearbox where the FCU is. Everything was as it should be. So there's one theory gone. He moves on to the middle cowling over the aft section of the engine...where the air intake is. As soon as he pulls the cowling down, the mechanic starts laughing...Jared and I run for our cameras, because this is what we just found...




That's right...hand towels covering 80-90 percent of the air intake grate. So much restriction, in fact, that the solid metal grates were bent by the paper towels. The first picture shows the left (outboard) side of the engine with the ice light in the foreground. The third picture shows the grates after the paper was removed...the flange on the left should be perfectly flush and round...as should the grates. The fourth picture is the bottom of the engine, with ever more paper packed on and little pieces of shredded paper sitting inside the engine intake.

In the second picture, the mechanic was just getting ready to look to the left (forward) inside the cowl, where he found three or four more towels sitting...untouched...behind the ice vanes (inertial separators) on the bottom of the cowl. This rules out maintenance control's first question of "was it the morning or the afternoon crew that sucked something into the engine?" The point of the ice vanes is to separate thick particles (ice, rain, FOD, etc) from the air flowing into the engine...the vanes were out the entire time we were on the ground and there's no way un-torn towels could come to rest behind the vanes on the bottom of the cowl. Best theory we have is that someone put a stack inside the cowl while replacing the generator, then forgot to take them out before re-cowling the engine. Neither the AM crew nor myself could see them inside the intake during the preflight, and they didn't get sucked up against the engine until they were in flight.

Company mx drove up from Hyannis, MA and spent all yesterday borescopeing the engine and replacing the intake grate. The plane was returned to service shortly after we got home (in our new plane) a little after midnight last night - after a very long, very not-normal day.
 

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In the Navy, we had tool cases with hard, white foam inserts with cutouts for every single item and red painted in the opening the cutouts. If a tool was missing, you saw red. If you don't cover the red with the appropriate tool, your rear will be a bloody red when the tool is later discovered in the plane. :hairraise:

I was once launching a Viking at Cecil Field where a crescent wrench had fallen out of the nose gear well upon a brake stop test. I never learned who the culprit was but if he was an AMH3, he stood a lessor chance of becoming an AMH2. It's bad enough that crescent wrenches are a no-no unless absolutely necessary.

But, there were no place for towels. That's the one thing I can't recall anyone ever leaving in a plane. Normally, they'd stand out pretty well since they were usually varying light colors from the Goodwill rejects.

The only solution here is... Inspect your work and inspect your work area. :yes:
 
Now you know one of the reasons I work on my own plane. I also have a 45 in the other hand when the local mechanics stroll by.
 
Great post. You guys handled that properly, too, obviously!

I know pilots that will not let the mechanic put the cowling and inspection plates back on after maintenance until after they've had a chance to take a close look around.
 
Ah, a classic MIF. (maintenance induced failure)
Good job - Glad all ended well.
 
Great post. You guys handled that properly, too, obviously!

I know pilots that will not let the mechanic put the cowling and inspection plates back on after maintenance until after they've had a chance to take a close look around.

Not a bad policy, but in the commercial world, that's not always possible.
 
While humorous, I find this more disconcerting that I do entertaining, Teller. I think you would do well to find the mechanic responsible and make sure they understand the strife they almost caused you. Had you been in the air and this became an issue, it wouldn't really be so funny... :(
 
Not a bad policy, but in the commercial world, that's not always possible.

That's very true. Even with only 6 1900s left in our fleet, they each cover so many miles at all hours of all days, it's litterally impossible for a pilot to be there to re-check everything before it's returned to service. Our mx dept. is great...I know quite a few of the mechanics personally, and have worked with all of the guys in Boston (there's only 4) quite a bit. The guy that replaced the generator has been working for the company for YEARS and knows more about the 1900 than I could ever hope to. I trusted him completely...and still do...I have to. This was just a very unfortunate mistake with luckily good consequences (could have been really bad for the AM crew if it had done what it did to us while they were cruising). Just makes me wish we were allowed to open inspection panels and such during our pre-flights...as pilots we're not even allowed to open the oil filler/dipstick door...all we're allowed to do is take it 13,000 feet in the air and barrel down the coast at 300+ MPH - go figure. These things go in for inspections about every 5 days...we have to lean pretty hard on our mx staff and they have to bear a lot of load for the company and for the pilots. I wouldn't want their job!
 
huh?? you cant check the oil? wtf!?

Same with the plane I fly. We depend an awful lot on the maintenance folks to do their job and to do it correctly. If someone drops the ball, for what ever reason, you just might get a situation like Teller had. I'll bet the mech is getting some serious scrutiny since it's possible his actions may have toasted an engine.

I had a similar but different issue back in June that was documented on the red board (It finally happened to me) that result in a shutdown shortly after takeoff. The culprit was a plastic plug in the newly replaced oil cooler. This passed through at least 4 QA's (the overhaul company, our company upon receiving it, our company upon shipping it to the out station and the out station prior to installing it).

The problem was that the overhaulers painted it with the plastic plug in there (a no-no). As a result it looked like all the other metal plugs. Unfortunately, our engine does not use the hole that was being blocked by the plastic plug. If it had been in any of the other holes, it would have been detected. An inspection of other coolers we got from this company revealed three more with the same problem. Apparently, the whole lot that was done that day had the same problem. The FAA got involved as a result.

I haven't heard anything about this lately, but I'm guessing the root cause of both of our problems are the same. The fellow doing the deed got distracted and didn't finish the job properly.

As I said initially we, as pilots, put an awful lot of faith in the due diligence of our mechanics. After money, trust is the next biggest thing required to make aircraft fly.
 
That's very well put, Anymouse. Sounds like this was exactly the same issue...just with a different part. I can't imagine putting towels inside the cowl is all too uncommon, my guess is he just got distracted and forgot there was one last thing to do before recowling the engine.

Tony...it's true, strange as it may seem. We're not allowed to open the oil door, the landing gear fill door, or even tighten loose screws on the cowlings. Pilots used to be allowed to check the oil (not add, though) but that's not so anymore. The reason being: only two company 1900s have had to have engines shut down in flight...one of which was because a pilot checked the oil, then failed to put the dipstick cap back on. Low oil pressure is a required shut-down. Ever since then, the ops specs have denyed allowing us to do much of anything. We can't even change reading lights without calling mx control and writing it in the logbook first.

Skyhog: Jared, myself, and the Albany crew went and talked to the mechanics when we went to BOS. He had already heard from mx control a few times that morning, so he knew the basics of what happened. We showed him the pictures and asked if he knew if they were his or if we hit anything. He was quite upset about it, as he knows the potential consequences just as well as we do...besides...he had to get back to working on the Saab that had just come in with a fluctuating oil pressure gauge...he didn't need to deal with us telling him what he already knows, and i'm sure will be reminding of quite a bit in the coming days and weeks. You're right, though...the what-ifs aren't quite as amusing.
 
So, if the pilot is not allowed to fully inspect the aircraft he's held responsible for regarding its airworthiness, is there a mechanic on hand to run through these items before each start up?
 
Its the same as piloting, no mechanic is immune from screwups. Until they replaced by robots there will always be human errors resulting in incidents and wrecks. ('robots'; only to illustrate the point; robots is bad too)
Anyway, what can be done?
The toolbox with dedicated slots is a great idea.
Another idea is when you are done a job, don't button it up right away. Put the tools up, clean up the mess, tidy the shop up, clean hands and sit with a cup of tea for a while, think about what you did, all the things you messed with. Maybe re-read that section of the manual/AD/other reference. Then go back for a fresh look with your inspection mirror, light, torque wrench, and all you are doing is looking, checking. The 'job' is done and the only thing you are doing at this time is eyeballing, testing for security, checking torques again, ensuring safety wire is on and not reversed, wires connected firmly and properly, hoses snug, maybe some operational testing. Unfortunately most professional shops do not allow time for this. Someone doing owner-mx is in a better position to adopt this policy. I have found a lot of other things when doing this, you know - change the oil and looking around later find a cracked exhaust, worn out alt belt. I have found a lot of stuff with my bare hands, I often tug on the alternator, the mags, the exhaust, the baffles -gently of course, with clean hands too, but I have found loose or cracked parts doing this. You must have a bright light, you should not be tired and never ever in a hurry at this point.
I think the best mechanics are kind of twitchy -you know, sort of nervous, very compulsive, always writing things down, always going back to the manual to triple check what they just read, willing to research with other sources of info to make sure they are doing the right thing, usually they are more contemplative and not exuberant when presented with an unusual question or a problem.
Another idea is to always have a dedicated person - another mechanic or at least a mechanically-inclined pilot to look things over when you are done....nothing beats two sets of eyes on stuff. Some say get annuals done by alternating mechanics for that reason. Another person checking things over diligently -not casually- is worth so much in this regard.
 
So, if the pilot is not allowed to fully inspect the aircraft he's held responsible for regarding its airworthiness, is there a mechanic on hand to run through these items before each start up?

Our first flight of day preflight is pretty thourough, and we do a detailed post-flight after EVERY leg. It seems like every couple days at least the mechanics are adding oil. Every few hours the plane goes down for any one of various routeine checks. The simplest being the "pre-flight check." Roughly every five to six days (it's actually based on flight time, of course) the mechanics do their own version of our pre-flight with a check of all the fluids, tire pressures, etc included. The light "A" checks, part of the progressive mx program, take place every week or two with a much more thorough going-over of the airframe and avionics. Not to mention, every time we write something up the plane gets pretty well worked over if it's something that can't be MELed.

Our mx is really good (and this isn't just my company...this is how it is for pretty much any 121, and I would imagine for a lot of the larger 135 operators)...those rules are there because something went wrong when it was done another way (and also because the FAA mandates a lot of it under the progressive mx program). Besides...most FBOs have what...20-30 regular renters that might mess with their planes doing "preventative mx." We have over 400 pilots...neither the company nor the FAA want to give us any leeway to do anything that's not documented and approved to an a/c that's carrying anywhere from two to 21 people at a time for 12-14 hours a day.

So short answer...no...they're not there watching every start up, but - like Anymouse said - we trust them to take care of these things well enough that we don't want them or need them there for every start. It's a lot of faith to be put into a handful of people, isn't it?

This was an unfortunate oversight.
 
Unfortunate, yes. And that wry Maine humor carries us through....in what used to be Caruso's Airline.

We need more of that.
 
Good story, but I don't understand why the mechanic laughed when he saw the rags. Seems he would have been embarrassed/appologetic by his peers' actions. In the Air Force, we also went to foam toolboxes to show tools that were missing. Worked well for tools, but rags, not so good. Our engine mechanics had to do an emergency inspection on our 28 F-16's before they could fly (can't remember what the issue was), and our guys worked for 22 hours straight to get it done. Our one "7 Level" jet mechanic (the guy that inspects work before it can fly) left a rag in the rear nacelle area of one planes and when we launched those planes the next morning, right after rotation, it shot fire out the left rear of the plane. The pilot punched at about 200' agl and the plane went into six feet of water in Biscayne Bay. Pilot was ok. As someone said above, humans error. The 7 Level was extremely remorseful. And no, the Air Force does not eat its young. At least we didn't back then. The only thing we could do was get the word out and incorporate the lesson into future training.
 
I don't think he laughed because he thought it was funny, I think it was more of a reaction to a shock...we were all expecting some sort of wireing problem or something in the accessory section that fell apart...instead we see a huge handful of towels; nothing something any of us where expecting to see.

I'm surprised a rag could do that to the engine in the 16...did i cause a full flameout or did he punch out just in case?
 
Goes to show that those guys screw up as often as pilots do...:D

When one screws up and the other compensates for it successfully, this is called "luck".

Good job, and very educational... paper towels, who knew...! :dunno:
 
I'm surprised a rag could do that to the engine in the 16...did i cause a full flameout or did he punch out just in case?

No flameout that I saw, but the flame was shooting out probably 30 feet from the side of the plane. He also was barely climbing. The Wing Commander called him on the UHF in his car and told him to get out. Right after he punched, the airplane continued to loose altitude and in the bay it went. He might have had high EGT or other bad indications too. It was a good call. That plane could not have made it back and would have surely exploded.
 
When one screws up and the other compensates for it successfully, this is called "luck".
I'd prefer to think of it as "good procedures" "good training" "good CRM" etc. Yes, to err is human. To be trained to watch the gauges and catch your fellow human's error in time to prevent a disaster is not luck.

-Skip
 
Hard to believe -- grounded by a roll of paper towels! It is amazing the damage it did.

Are they phasing out the B1900? I didn't know that. What's replacing it?
 
Hard to believe -- grounded by a roll of paper towels! It is amazing the damage it did.

Are they phasing out the B1900? I didn't know that. What's replacing it?


Amazing what paper will do under massive amounts of pressure isn't it.

Indeed they are. We're getting a bunch of new Q-400s in the comming months, so they don't want three very different types in the fleet. As our leases run out, we're taking the 1900s back to Raytheon and progressivly closing bases, as well. Pretty much all of the 1900 flying is going over to the company's Saab 340s (of which we're getting a handful more), except at these few airports that can't get certified for ARFF (req'd for the Saab's 34 seats), who knows what going to happen to service at these airports...
 
Good story, but I don't understand why the mechanic laughed when he saw the rags. Seems he would have been embarrassed/appologetic by his peers' actions. In the Air Force, we also went to foam toolboxes to show tools that were missing. Worked well for tools, but rags, not so good. Our engine mechanics had to do an emergency inspection on our 28 F-16's before they could fly (can't remember what the issue was), and our guys worked for 22 hours straight to get it done. Our one "7 Level" jet mechanic (the guy that inspects work before it can fly) left a rag in the rear nacelle area of one planes and when we launched those planes the next morning, right after rotation, it shot fire out the left rear of the plane. The pilot punched at about 200' agl and the plane went into six feet of water in Biscayne Bay. Pilot was ok. As someone said above, humans error. The 7 Level was extremely remorseful. And no, the Air Force does not eat its young. At least we didn't back then. The only thing we could do was get the word out and incorporate the lesson into future training.


We have a rag control program now. They are issued in bundles of 5 or 10 and controlled just like other tools. You sign out 5, you better bring back 5.
 
We have a rag control program now. They are issued in bundles of 5 or 10 and controlled just like other tools. You sign out 5, you better bring back 5.
Very good! I'm sure the Navy has probably made such a change by now. Twenty years ago, we just grabbed whatever we wanted from a huge bundle about half the size of a bale of hay. There was no accountability except for picking out the softer ones for polishing personal effects before an inspection.
 
Very good! I'm sure the Navy has probably made such a change by now. Twenty years ago, we just grabbed whatever we wanted from a huge bundle about half the size of a bale of hay. There was no accountability except for picking out the softer ones for polishing personal effects before an inspection.

All 12 years I worked for AIMD Whidbey, we checked out rags 10 at a time .

But it was the cost of the kids taking them home that drove the issue.
 
And no, the Air Force does not eat its young. At least we didn't back then. .

On the other hand the airlines do eat their young. If the mechanic is still employed it is more likely due to the difficulty of finding a replacement than the airline's enlightened HR policies. Is he still employed?
 
On the other hand the airlines do eat their young. If the mechanic is still employed it is more likely due to the difficulty of finding a replacement than the airline's enlightened HR policies. Is he still employed?

Indeed he is. He's one of (if not the) most senior of our mechanics in BOS so, like you said, they can't really afford to lose him. I don't know if that's the only reason he's still around, but he certainly still is. In his favor, he shook it off and spent the rest of that afternoon fixing an oil problem on a Saab to get it back on the line. I will say, though, we were all a little concerned about what would happen to him...
 
Back in the early 90's when I was driving the Shorts at ORD we had a taxi incident where a marshall directed us to taxi into another ship - even though the wing walker was frantically telling her to stop. I was very lucky b/c I saw her eyes get big and hit the brakes despite her wand motion to keep coming forward. We did have a minor scrape of our wing tip with the other a/c but it was so minor it was a non reportable event (no accident - no incident). Nonetheless the following happened. 1) Mtx came out and pulled the circuit breaker on the CVR - it was later reviewed and my stict insistence on checklist and sterile cockpit procedures paid off as the co. found no basis to discipline me - they were looking for one though. 2) The pax were deplaned. 3) I talked to the marshall who told me that a) I did just as she told me, and b) this was her first time marshalling an airplane AND she had no training. After some conversation with the C.P. it became clear that the company was intending to fire her. I was incensed. I told them that they were nuts, they failed to train her and now they want to fire her, the person who should be fired was her manager, and further more, the last person who will EVER make that mistake again was her. I am sure my ranting did nothing to help her, but I was glad that she was in fact not fired. Same with your mechanic, the last person who will ever make that mistake again is the person who made it the first time.
 
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