Spectrum Health Hospitals

Sanction: $15,000 · case closed 2016-06-09

Part: FIRE DETECTOR — INTERMITTENT (NR 1 ENGINE) · airframe 13,598 hrs · 42,860 cycles

DURING PILOT TRAINING WHILE ON AN APPROACH TO LAND, THE #1 ENGINE FIRE WARNING SYSTEM INDICATED A FIRE (LIGHTS AND AURAL) FOR 3-4 SECONDS AND THEN THE INDICATIONS WENT AWAY. APPROXIMATELY 5 SECONDS LATER, THE FIRE INDICATIONS CAME BACK ON. THOUGH THERE WEREN'T SECONDARY INDICATIONS OF A FIRE, SINCE THEY WERE ALREADY ON AN APPROACH, THE PILOTS DECIDED TO PULL THE #1 ENGINE OFFLINE AND CONTINUE THEIR APPROACH AND PERFORM A SINGLE ENGINE LANDING. DURING THIS PROCESS, THE FIRE INDICATIONS WENT AWAY AGAIN AND THEN CAME BACK ON FOR THE 3RD TIME. AFTER THE ENGINE WAS PULLED OFFLINE, THE FIRE INDICATIONS WENT AWAY FOR GOOD. UPON LANDING, A VISUAL CONFIRMATION WAS MADE THAT THERE WASN'T A FIRE. MAINTENANCE DID A TEST OF THE TWO FLAME DETECTORS IN THE FIRE WARNING SYSTEM. THE DETECTORS CHECKED OUT AS GOOD. A DECISION WAS MADE TO CHANGE OUT BOTH DETECTORS. AFTER REPLACEMENT OF THE DETECTORS, THE TWO SUSPECT DETECTORS WERE TESTED AGAIN “OFF WING” AND THE DETECTOR THAT WAS IN THE AFT/LOWER POSITION IN THE SYSTEM FAILED. THIS PROBABLY EXPLAINS THE INTERMITTENT NATURE OF THE FIRE SYSTEM INDICATING A FIRE THEN INDICATING THAT THERE WASN’T A FIRE. THE AIRCRAFT HAS FLOWN 3.8 HOURS SINCE THE REPLACEMENT OF THE FLAME DETECTORS WITHOUT FURTHER ISSUES.

Part: STARTER GEN — FAILED (LEFT) · airframe 2,505 hrs · 8,069 cycles

NR 1 STARTER/GENERATOR FAILED. DURING START, THE ENGINE TOOK AN UNUSUALLY LONG TIME TO REACH LIGHT OFF AND IDLE SPEED. AFTER ENGINE START, THE GENERATOR WOULD NOT COME ON LINE. AFTER THE ACFT RETURNED TO THE MAINTENANCE FACILITY, THE STARTER WAS EXAMINED AND THE INTERNAL DAMAGE WAS FOUND TO THE BRUSHES, BRUSH HOLDER CLIPS, ETC. THE STARTER/GENERATOR WAS REPLACED. ALL SYSTEMS CHECKED GOOD.

Part: BRUSHES — BROKEN (STARTER GEN) · airframe 2,270 hrs

NR 2 DC GENERATOR FAILED IN FLIGHT. AFTER THE ACFT RETURNED TO THE MX FACILITY, THE STARTER GENERATOR WAS REMOVED FOR INSPECTION. THE BRUSHES WERE FOUND WORN EXCESSIVELY AND BROKEN. REPLACED WITH AN O/H UNIT, ALL SYS CHECKED GOOD.

Part: SYMBOL GENERATOR — LOOSE · airframe 11,573 hrs

PILOT SIDE EFIS DISPLAY WENT BLACK WITH A RED X ACROSS BOTH DISPLAYS. FAULT FOUND WAS THE MOUNTING RACK LOCKING SCREWS WERE OUT OF ADJUSTMENT, ALLOWING THE SYMBOL GENERATOR TO BE LOOSE IN THE RACK AND THE PINS TO GET COATED WITH A DUST, THUS LOOSING CONTACT. CLEANED BOTH THE PINS IN THE SYMBOL GENERATOR AND THE RACK. READJUSTED THE LOCING SYSTEM. REMOUNTED THE SYMBOL GENERATOR. ALL SYSTEMS TESTED GOOD.

Part: FUEL TANK — LEAKING (LEFT) · airframe 11,445 hrs · 36,737 cycles

LEFT FUEL TANK WAS SEEPING FUEL, IT WAS NOTICED WHILE SETTING IN THE HANGAR. DEFUELED AIRCRAFT, RESEALED FASTENER AT AFT SEAM OF TANK, STA 215.

Part: HMU — MALFUNCTIONED (NR 2 ENGINE) · airframe 2,076 hrs

THE FUEL CONTROL FAILED ON START CAUSING THE ENGINE TO EXCEED TEMPERATURE LIMITS. THE HMU WAS FOUND TO BE AT FAULT. (SUSPECT THE CONSTANT DELTA "P" VALVE FAILED). THE ENGINE ASSEMBLY AND HMU WERE REPLACED. THIS FAILURE COULD HAVE OCCURRED IN FLIGHT CAUSING AN IN FLIGHT SHUT DOWN OF THE ENGINE.

Part: STARTER GEN — FAILED · airframe 11,309 hrs · 36,343 cycles

WHEN THE AIR CONDITIONER WAS TURNED ON, THERE WAS A "POPPING" SOUND IN THE INTERCOMM SYSTEM IN CREW HELMETS. THIS WAS ACCOMPANIED BY AN "AUX BATTERY" LIGHT. INSPECTION OF NR 2 STARTER GEN SHOWED SIGNIFCANT WEAR OF BRUSHES AND AN UNUSUAL WEAR PATTERN ON THE COMMUTATOR. STARTER GEN WAS REPLACED. NOISE WENT AWAY. THERE WAS A SECONDARY DEFECT WITH THE CURRENT LIMITER FOR THE SYSTEM. THAT UNIT WAS REPLACED AND ALL FUNCTIONS RETURNED TO NORMAL.

Part: ENGINE — VIBRATION (NR 1) · airframe 1,844 hrs

INTEGRATED INFORMATION DISPLAY SYSTEM, (IIDS), DISPLAYED A "MINOR" ENGINE FAULT "TQ TRIM LVL L" FOR THE NR 1 ENGINE FROM THE DIGITAL ENGINE CONTROL UNIT (DECU). PILOTS CHECK FOR FAULTS FROM THE DECU AND THE IIDS. A MINOR FAULT WAS NOTED ON THE NR 1 ENG; "TQ. TRIM, LVL 1". FAULT OCCURRED ON THREE SEPARATE FLIGHTS IN AN INTERMITTENT FASHION. ON ALL THREE OCCURRENCES, ACFT DIVERTED AND RETURNED TO MX FACILITY. FIRST OCCURRENCE, TROUBLESHOOTING TOOK PLACE USING BOTH ENGINE AND ACFT MM. THE FAULT CLEARED ITSELF AND NO DEFINITIVE ACTION WAS TAKEN. SECOND OCCURRENCE, TROUBLESHOOTING AGAIN SHOWED NO DEFINED DEFECTS. TORQUE CONFIRMATION BOX WAS REPLACED. THIRD OCCURRENCE, "MINOR" FAULT ADDITIONAL TROUBLESHOOTING DETECTED EXCESSIVE VIBRATION OF THE NR 1 ENGINE. THE ENGINE WAS R & R WITH A 0.0 TSO, ENGINE ASSEMBLY.

Part: ANGLE — CRACKED (FUSELAGE) · airframe 10,021 hrs · 32,447 cycles

DURING INSP, TECH FOUND CRACKED TEE ANGLE P/N 76201-23014-138 AFT SECTION. REMOVED TEE ANGLE FOUND THE ENTIRE ANGLE CRACKED AND THE FWD BATHTUB FITTING P/N 76209-03002-119 CRACKED AT THE MOUNT BOLT HOLE. THE FOLLOWING PARTS WERE REPLACED IAW SRM SA 4047-76-12: TEE FITTING P/N 76201-23014-138 LT FWD BATHTUB FITTING P/N 76209-03002-119 LT AFT BATHTUB FITTING P/N 76209-03002-125.

Part: SKIN PANEL — CRACKED (BS 254) · airframe 10,021 hrs · 32,447 cycles

DURING PRELIMINARY INSP FOUND 6.5 INCH CRACK ON LT SIDE SKIN PANEL AT AC STA 254, WATERLINE 107. THE LT SIDE SKIN PANEL WILL BE REPLACED WITH SERVICEABLE ONE.

Part: FIRE DETECTOR — FALSE ACTIVATION (NR 1 ENGINE)

ENROUTE, WHEN NR 1 ENG FIRE WARNING SYS WAS ACTIVATED. PILOT REPORTED WARNING LIGHTS, HORN AND T-HANDLES ILLUMINATED WITH FIRE WARNING INDICATION. WARNING STAYED ON FOR 30 SECONDS, WENT OUT. AFTER SHORT PERIORD OF TIME, WARNING CAME BACK. PILOT DECLARED EMERGENCY WITH GRR CONTROLLERS. WARNING WENT OUT AND CAME BACK ON 2 ADDITIONAL TIMES. ENG PWR WAS REDUCED TO IDLE,THEN WAS SECURED USING FIRE T-HANDLE. WHEN AC WAS IN SIGHT, IT WAS REPORTED, NO VISIBLE SMOKE TRAILING AC. PILOT CONTINUED, MADE EMERGENCY LANDING W/O INCIDENT. ENG WAS OPENED AND INSPECTED FOR ANY VISIBLE SIGNS OF DAMAGE. NO FIRE INDICATIONS. TROUBLESHOOTING RESULTED FROM DEFECTIVE FIRE WARNING SENSOR, REPLACED. AC RETURNED TO SERVICE.

Part: BREATHER TUBE — DETERIORATED (ACCY GEARBOX)

ENROUTE TO A PICK UP A PATIENT. WITHIN 4 MINUTES OF TAKEOFF, MEDICAL CREW REPORTED, SMELLED SMOKE IN CABIN, BECOMING VISIBLE ALSO. PILOT NOTICED IT ABOUT SAME TIME. PILOT RETURNED WITHOUT DELAY, APPROX 30 SECONDS BEFORE TOUCHDOWN, BAGGAGE COMPARTMENT SMOKE DETECTOR WENT OFF. AC LANDED WITHOUT INCIDENT. INVESTIGATION SHOWED NR 2 ENG ACCY GEARBOX VENT TUBE HAD BROKEN FREE OF ENG DECK FITTING. THIS OVERBOARD BREATHER TUBE MADE OF A VINYL MATERIAL, HAD DETERIORATED TO POINT OF BREAKING OFF OF FITTING ON BOTTOM OF ENG DECK. TUBE RUNS THROUGH AFT CORNER OF BAGGAGE COMPT, WHEN TUBE BROKE, FILLED COMPT WITH OIL MIST/VAPOR THAT ILLUMINATED SMOKE DETECTOR. VINYL TUBE WAS REPLACED, AC RETURNED TO SERVICE. (K)

Part: WINDSHIELD — CRACKED (COCKPIT) · airframe 7,730 hrs · 24,087 cycles

PILOTS WINDSHIELD CRACKED IN FLIGHT WITH THE WINDSHIELD HEAT "ON". WHEN THE CRACK OCCURED, THERE WERE SPARKS COMING FROM THAT AREA. ALSO, THERE WERE TWO AREAS APPROXIMATELY 3 INCH IN LENGTH THAT HAD MELTED PLASTIC EXTRUDED OUT OF THE CRACK. THE INNER LAYER OF GLASS SHOWED NO SIGNS OF DAMAGE.

Part: LINE — BURST (HYD SYSTEM) · airframe 6,682 hrs · 20,043 cycles

NR 2 HYDRAULIC PRESSURE LINE FROM HYDRAULIC PUMP TO BULKHEAD FITTING FAILED ON AIRCRAFT START-UP. LINE BURST FROM INSIDE WITHOUT WARNING, (NO LEAKS NOTED ON PREFLIGHTS). LINE WAS REPLACED, SYSTEM SERVICED AND AIRCRAFT RETURNED TO SERVICE. (X)

Part: GAUGE — FLUCTUATION (ENG OIL TEMP)

REMOVED GAUGE FOR NEEDLE RAPID FLUCTUATION - 20-50 DEGREES, SPIKING WILDLY OCCASIONALLY.

Part: FUEL CONTROL — FAIL TEST (ENGINE)

FCU FAILED MAXIMUM NG CHECK BY MINIMUM OF .8 PERCENT. MINIMUM CHECK OF 101.8 PERCENT MINUS NG EQUALS 101.0 PERCENT. REMOVED FCU FOR REPAIR.