Jet Aviation Flight Services, Inc.

Sanction: $14,500 · case closed 2024-08-16

Part: COMPRESSOR — CONTAMINATED (ENGINE) · airframe 2,196 hrs · 1,371 cycles

AIRCRAFT DEPARTED BCT, ON INSTRUMENT FLIGHT PLAN IN VMC CLIMBING THROUGH 4,000’ MSL, CREW NOTICED AN ODOR, PASSENGERS ALERTED CREW OF A FOG & SMELL IN CABIN. FLT ATTENDANT EVACUATED HER SEAT TO INVESTIGATE POSSIBLE SOURCE & CONFIRMED SOURCE WAS NOT ORIGINATING FROM CARGO BAY OR GALLEY. THE FOG IMMEDIATELY STARTED DISSIPATING (LESS THAN 1 MINUTE) & THE ACFT CLIMBING TO LEVEL OFF AT 10,000’. ACFT HAD UNDERGONE SERVICE TO ECS, SPECIFICALLY THE STARTER AIR VALVES, THE EVENING PRIOR & ODOR WAS CONSISTENT WITH THAT OF A PACK. WHILE ABNORMAL, CREW DECIDED TO CONTINUE FLT BECAUSE OF RAPID DISSIPATION, IMMEDIATE DISCONTINUATION OF THE ANOMALY & ASSOCIATED MX OF AFFECTED ACFT SYS. ANOMALY HAD RESOLVED ITSELF PRIOR TO 10,000’ MSL BUT CREW HAD DISCUSSED & IDENTIFIED POTENTIAL DIVERSION AIRPORTS BOTH IMMEDIATELY & ACTIONS TO TAKE IN EVENT ANOMALY REOCCURRED. PAX BRIEFED ON NATURE OF ANOMALY AND CONTINGENCY PLAN IN THE EVENT OF REOCCURRENCE. REMAINDER OF FLT COMPLETED WITHOUT INCIDENT OR REOCCURRENCE. NO PAX OR CREW REPORTED ADVERSE REACTIONS OR LINGERING SYMPTOMS. SUBSEQUENT INSPECTION OF SYS FOLLOWING GUIDANCE FROM GULFSTREAM TECH OPS & DISCUSSION WITH RROYCE FIELD SERVICE IDENTIFIED PREVIOUS MAINTENANCE ACTIONS INDUCED OIL INTO THE ENG COMPRESSOR SECTION VAPORIZING DURING THE TAKEOFF EVENT.

Part: SKIN PANEL — CORRODED (LT WING) · corrosion level 2 · airframe 3,443 hrs · 2,251 cycles

CORROSION IDENTIFIED ON L/H UPPER WING SKIN LWS 37 STRINGER # 2 TO CENTER SPAR

Part: SKIN PANEL — CORRODED (ZONE 600) · corrosion level 2 · airframe 3,443 hrs · 2,251 cycles

CORROSION FOUND ON CENTER WING, RH INNER SKIN FS 410 AND RBL 32.

Part: BEARING SEAL — FAILED (ZONE 400) · airframe 3,372 hrs · 2,212 cycles

CLIMBING THROUGH ABOUT 12K FEET SMELLED A FAINT ODOR OF SOMETHING INSIDE THE CABIN. SMELL CONTINUED AND LOOKING BACK, SAW A FAINT WHITE SMOKE ENTERING AND FILLING THE CABIN WORKING ITS WAY INTO THE COCKPIT. IT WAS CLEAR THAT SMOKE WAS COMING INTO THE AIRCRAFT THROUGH OUR BLEED AIR SUPPLY. UPON SHUTDOWN NOTED OIL DRIPPING FROM #2 ENGINE COWL. SUBSEQUENT INVESTIGATION REVEALED THE ENGINE #2 BEARING CARBON SEAL HAD FAILED PERMITTING OIL INTO THE BLEED AIR SYSTEM.

Part: UNKNOWN — UNKNOWN (UNKNOWN) · airframe 2,960 hrs · 1,717 cycles

CREW REPORTED ACRID SMELL IDENTIFIED DURING THE FLIGHT. ADDITIONAL COMMUNICATIONS BETWEEN MX AND CREW MEMBERS IDENTIFIED A BURNING / BURNING RUBBER SMELL. THIS WAS IDENTIFIED DURING CLIMB ROUGHLY ONE HOUR INTO FLIGHT. ADDITIONAL CONVERSATIONS WITH MX MANAGER IDENTIFIED A SIMILAR SMELL HAD BEEN NOTED BY THE CREW DURING THE PREVIOUS LEG. IN BOTH EVENTS DISCUSSIONS WITH MX AND CREW TOOK PLACE DURING FLIGHT. CABIN TEMPERATURE WAS REDUCED ON THE 1ST LEG AND THE SMELL DISSIPATED WITHIN 3 MINUTES. ON THE SECOND LEG THE CREW CONTACTED MX AND WAS ADVISED TO SELECT WINDSHIELD HEAT OFF AND SMELL DISSIPATED AS WELL. A/C WAS REMOVED FROM SERVICE AND COCKPIT WINDOWS AND ASSOCIATED COMPONENTS WERE INSPECTED. WINDOW HEAT ELEMENT / SENSOR RESISTANCE WAS CHECKED. FOUND A BURNED MOTH NEAR THE PILOT FRONT WINDSHIELD TERMINAL BOARD. ENGINE / APU RUNS WERE PERFORMED ALONG WITH FUNCTIONAL TESTS OF WINDSHIELD HEAT AND BLEED SYSTEMS AFTER CONSULTATION WITH GULFSTREAM. NO DISCREPANCIES OR ADDITIONAL ODORS NOTED PRIOR TO RTS. TWO EVALUATION FLIGHTS PERFORMED AFTER RTS WITH NO FURTHER ODORS NOTED. WILL CONTINUE TO MONITOR THROUGH CASS.

Part: LANDING GEAR — FAILED (ZONE 700) · airframe 7,787 hrs · 2,789 cycles

LANDING GEAR FAILED TO RETRACT AFTER TAKE OFF.

Part: DUCT — DISCONNECTED (321-322) · airframe 3,119 hrs · 2,062 cycles

CLIMBING THROUGH FLIGHT LEVEL 240 AIRCRAFT RECEIVED AN AMBER CABIN ALTITUDE MESSAGE, FOLLOWED BY A RED MASTER CAUTION CABIN ALTITUDE. THIS INDICATES CABIN PRESSURIZATION HAD FAILED IN SOME WAY AND THE ALTITUDE IN THE CABIN HAD CLIMBED ABOVE 10K FEET. SUBSEQUENT INSPECTION DISCOVERED THAT THE PRESSURE DUCT FROM THE ENVIRONMENTAL CONTROL UNIT (ECU) TO THE WATER SEPARATOR HAD BECOME DISCONNECTED AT THE ECU. RECENT MAINTENANCE IN THE VICINITY OF THIS DUCT REQUIRED ITS REMOVAL AND REINSTALLATION WHICH WAS DETERMINED TO BE PERFORMED INCORRECTLY.

Part: ENGINE — ODOR · airframe 5,946 hrs · 2,504 cycles

EMERGENCY DECLARED AFTER SMOKE FROM BOTH ENGINES WAS REPORTED FROM TOWER AND FUMES WERE PRESENT IN THE COCKPIT. POST INCIDENT OPERATIONAL CHECKS AT 65%, 85% N1 AND FULL POWER PER AMM 71-00-00-866-806 REVEALED NO INTERIOR ODOR OR ENGINE SMOKE EMISSIONS AND NORMAL OPERATION PARAMETERS OBSERVED. PERFORMED GVI WITHIN ENGINE COWLING PER SPM CHAPTER 20-70-00 WITH NO DEFECTS NOTED. CONSIDERING ALL ENGINE PARAMETERS WERE NORMAL CONSULTATION WITH ROLLS ROYCE REVEALED THAT IN SERVICE VARIATIONS IN FUEL AROMATIC CONTENT COULD DRIVE SMOKE EMISSIONS.

Part: REU — FAILED (ZONE 600) · airframe 377 hrs · 88 cycles

CRUISING FL400 AND SPEED M.90 WITH AUTOPILOT ON, WE HAD “FCS MAINTENANCE REQUIRED” CAS MESSAGE. APPROXIMATELY 4 HOURS FROM TAKEOFF. QRH PROCEDURES FOLLOWED. THE AUTOPILOT DISCONNECTED AND THE AIRCRAFT SUDDENLY ROLLED TO RIGHT WHEN I PRESSED FLT CNTL RESET SW. CREW SAW NEW CAS MESSAGE “R AILERON FAIL” AT THAT TIME. QRH REQUIRED LANDING AT NEAREST SUITABLE AIRPORT. MAINTENANCE TROUBLESHOOTING AND DOWNLOADS REVEALED THE MAIN SUSPECT AS THE MALFUNCTIONING OF REU4 (REMOTE ELECTRONIC UNIT)WHICH CREATED SEVERAL FORCE FLIGHT COMPENSATION DISAGREEMENTS. REU4 ALSO HAD SOME FLAT SPOTS IN THE POSITION / FOLLOWING COMMANDS WITH AN INTERNAL FAULT REPORTED 20 SECONDS BEFORE THE OCCURRENCE EVENT. SECONDARY SUSPECT COMPONENT WAS THE AILERON EB MANIFOLD WHICH MAY OR MAY NOT HAVE CONTRIBUTED TO THE SCENARIO. REU4 AND EB MANIFOLD WERE REPLACED AND TEARDOWN REPORTS HAVE BEEN REQUESTED. EB MANIFOLD P/N 60P2713301Z004, S/N 1731D. TIME SINCE NEW: 366.3 HOURS / 84 CYCLES. INSTALLED MAY 2018. AIRCRAFT MAINTENANCE COMPLETED WITH RTS ON 6/28/19.

Part: WARNING SYSTEM — FALSE ACTIVATION (COCKPIT) · airframe 3,481 hrs · 1,212 cycles

AFTER DEPARTING, UPON INITIAL CLIMB OUT, AT 1,000, WE HEARD SOME NOISE FROM THE DOOR AREA, AS IF SOMETHING HAD BECOME UNLATCHED, AND WE SIMULTANEOUSLY SAW A YELLOW DOOR INDICATION ON THE STATUS SYNOPTIC PAGE. WE DECLARED AN EMERGENCY, CONTINUED OUR CLIMB TO 2,000', WHERE WE ENTERED A DOWNWIND LEG FOR LANDING ON THE RUNWAY OF OUR CHOOSING, AS WE WERE CLEARED TO LAND ON ANY RUNWAY BY THE CONTROL TOWER. WE LANDED WITH NO DIFFICULTIES. AIRCRAFT WAS REMOVED FROM SERVICE AND MAINTENANCE INSPECTED THE MAIN ENTRANCE DOOR (MED) WITH NO DISCREPANCIES NOTED. OPERATIONAL CHECKED SEVERAL TIMES WITH NO DEFECTS NOTED. ALL WORK PERFORMED IAW AMM 52-11-00-010-801 & 52-11-0-410-801. NOTE: CREW MENTIONED TO MAINTENANCE THAT THE MED HANDLE MAY NOT HAVE BEEN FULLY DOWN. AIRCRAFT HAS FLOWN 14 ADDITIONAL LANDINGS TO DATE WITH NO FURTHER FAULTS NOTED.

Part: CONVERTER — ODOR (AC BAY) · airframe 2,368 hrs · 1,239 cycles

CREW ADVISED OF "BURNING SMELL IN CABIN" AND THAT "SMOKE FUMES WERE SMELLED IN THE CABIN". AIRCRAFT DIVERTED BACK TO POINT OF DEPARTURE AT KBDL. SUSPECT SMELL TO BE FROM INSTALLATION OF "NEW" UPPER AND LOWER OZONE CONVERTERS INSTALLED PRIOR TO DEPARTURE TO COMPLY WITH 2500HR INSPECTION / RESTORATION REQUIREMENT. REMOVED AND INSPECTED OZONE CONVERTERS WITH NO DEFECTS NOTED. GROUND AND LEAK CHECKS PERFORMED SATISFACTORY WITH NO FURTHER SMELL NOTED IN CABIN OR COCKPIT. AIRCRAFT RETURNED TO SERVICE.

Part: ENGINE — MALFUNCTIONED (NR 1) · airframe 2,020 hrs · 1,063 cycles

WE WERE CLEARED TO CLIMB TO 15000FT ON RUNWAY HEADING. CLIMBING THROUGH 7000FT A VIBRATION WAS FELT, FOLLOWED BY AN ENGINE VIBRATION CAS MSG AND ENGINE EXCEEDANCE CAS MSG. THE LEFT THRUST LEVER WAS PULLED TO IDLE (THE ENGINE EXCEEDANCE CAS MSG WENT AWAY) AND AN EMERGENCY WAS DECLARED. A VECTOR TO DOWNWIND 36R WAS GIVEN ALONG WITH A DESCENT TO 5000FT. I SET THE AVIONICS FOR LANDING AND RAN THE ENGINE VIBRATION CHECKLIST FROM QRH 2 WITH INSTRUCTED TO LEAVE THE ENGINE RUNNING AT IDLE. THEN THE SINGLE ENGINE LANDING CHECKLIST WAS COMPLETED. THE ENGINE WAS SHUT DOWN VIA FADEC INSIDE OF THE FINAL APPROACH FIX DUE TO A RISE OF ITT AND VIBRATION (THE ENGINE EXCEEDANCE CAS MSG REAPPEARED). DUE TO THE CLOSE PROXIMATE TO LANDING, WE ELECTED TO SELECT THE ENGINE RUN SWITCH TO OFF TO AVOID INADVERTENT RESTART VIA FADEC. THRUST REVERSER WAS NOT USED ON LANDING. THE FMS INDICATED A 700LB OVER WEIGHT LANDING. MAINTENANCE PERSONAL OBSERVED METAL DEBRIS INSIDE THE MIXING NOZZLE AFTER THE EVENT.

Part: ENGINE — LOCKED (LEFT) · airframe 1,391 hrs · 732 cycles

ON CLIMBOUT BEFORE 10,000', HEARD ENGINE POP, THEN MADE GRINDING NOISE WITH VIBRATION. FUEL FLOW AND ITT SLIGHTLY HIGHER IN AFFECTED ENGINE. REDUCED POWER ON AFFECTED ENGINE AND TOLD ATC THAT AIRCRAFT WAS HAVING AN ENGINE ISSUE AND RETURNING TO AIRPORT VFR. NO EMERGENCY DECLARED, KEPT ENGINE RUNNING ON REDUCED POWER. ENGINE SYNC FAIL (CYAN) CAS MESSAGE. LANDED & SHUTDOWN ENGINE UPON CLEARING RUNWAY. BORESCOPED HPC CORE AND FOUND NO DEFECTS BUT THE HP HOT AND FOUND HPT1 BLADES HAVE HEAVY DAMAGE. NO METAL NOR CHIP EVENTS FROM THE DOWNLOAD. I BELIEVE THE HPC CORE HAS LOCKED UP IN THE BACK END AND NOT CORE. THIS COULD BE REPAIRED OUT IN FIELD NOT REQUIRING AN ENG R&R” ORIGINAL ENGINE TO BE SENT IN FOR FURTHER EVALUATION AND REPAIR.

Part: ACCESS PANEL — CORRODED (APU BAY) · corrosion level 2 · airframe 3,020 hrs · 930 cycles

APU ENCLOSURE MOUNTING FLANGE UNDER PANEL 312BL HAS EXCESSIVE CORROSION.

Part: CONTROL MODULE — FAULTY (CARGO BAY) · airframe 2,646 hrs · 1,851 cycles

CREW REPORTS FIRE BAG COMP RED CAS MESSAGE ILLUMINATED IN FLIGHT ON APPROACH 30 MILES OR 10 MINUTES FORM KMDW. SMOKE IN THE BAGGAGE COMPARTMENT WAS VERIFIED BY THE PIC AND AN EMERGENCY WAS DECLARED. UPON INITIAL INSPECTION AND TROUBLESHOOTING BY MAINTENANCE AFTER AN UNEVENTFUL LANDING IT WAS DISCOVER THAT THE SATELLITE TV ANTENNA CONTROL MODULE WAS THE SOURCE OF THE SMOKE DISCOVERED IN THE BAGGAGE COMPARTMENT. A PART SUPPLIER INVESTIGATION HAS BEEN REQUESTED. PART TEARDOWN REPORT HAS ALSO BEEN REQUESTED AND IS NOT YET AVAILABLE AT THIS TIME. PART WAS ORIGINAL EQUIPMENT INSTALLED AT AIRCRAFT COMPLETION. TIME IN SERVICE WAS 2618.2 HOURS AND 1840 LANDINGS.

Part: DUCT — SEPARATED (AC BAY) · airframe 4,287 hrs · 2,185 cycles

AT CRUISE FLIGHT AT 41,000 FT HEARD A LOUD BANG & CABIN ALTITUDE WAS CLIMBING AT A RATE IN EXCESS OF 2000 FPM. UPON INITIAL INSPECTION BY MX AFTER AN UNEVENTFUL LANDING, IT WAS DISCOVER THAT THE COOLING TURBINE EXIT DUCT PN 25-8VF565-1A HAD BECOME SEPARATED FROM THE COOLING TURBINE. PART TIME IN SERVICE SINCE LAST MX WAS 2.2 HOURS & 1 LANDING.

Part: DUCT — SEPARATED (AC BAY) · airframe 4,287 hrs · 2,185 cycles

CREW REPORTS AT CRUISE FLIGHT AT 41,000 FT HEARD A LOUD BANG & CABIN ALTITUDE WAS CLIMBING AT A RATE IN EXCESS OF 2000 FPM. UPON INITIAL INSPECTION BY MX AFTER AN UNEVENTFUL LANDING IT WAS DISCOVER THAT THE COOLING TURBINE EXIT DUCT, PN 25-8VF565-1A, HAD BECOME SEPARATED FROM THE COOLING TURBINE. PART TIME IN SERVICE SINCE LAST MX WAS 2.2 HOURS & 1 LANDING.

Part: WINDSCREEN — DELAMINATED (COCKPIT) · airframe 2,944 hrs · 1,868 cycles

WINDSHIELD FAILURE.

Part: UNKNOWN — SMOKE (COCKPIT) · airframe 6,377 hrs · 3,516 cycles

FAINT SMOKE ODOR & BARELY VISIBLE SMOKE NOTICED AT LOWER VENT IN CLIMB. OBSERVED INCREASING COCKPIT PACK, TURNED PACK OFF.

Part: UNKNOWN — SMOKE (UNKNOWN) · airframe 3,000 hrs · 807 cycles

UNIDENTIFIED SMOKE ON TAKEOFF.

Part: SEAL — FAILED (MLG OLEO) · airframe 3,251 hrs · 3,052 cycles

AFTER TAKEOFF, CREW REPORTED THE LANDING GEAR WOULD NOT RETRACT. CREW RETURNED TO DEPARTURE FOR AN UNEVENTFUL LANDING. UPON INSPECTED BY MX, IT WAS FOUND THAT THE RT MLG OLEO SEAL HAD ROLLED, PREVENTING THE GEAR FROM FULLY EXTENDING WHICH WOULD NOT ALLOW THE GEAR TO RETRACT.

Part: STARTER — FAILED (ZONE 100) · airframe 457 hrs

STARTER FAILED TO ENGAGE, TECH CHECKED ELECTIRCAL CIRCUITS, THEY HAD POWER. STEPPED THE CREW TO A SPARE ACFT.

Part: STARTER — FAILED (ENGINE) · airframe 382 hrs

AIRPLANE HAD FLOWN 3 TIMES ON THIS DAY, ON THE 4TH FLIGHT STARTER FAILED TO START. A CLICK NOISE COULD BE HEARD WHEN TURNING KEY FROM BOTH TO START. FLIGHT WAS ABORTED.

Part: STARTER — SLOW (ENGINE) · airframe 366 hrs

(U43R) WHILE ATTEMPTING TO START THE AIRPLANE, THE STARTER TURNED THE ENGINE VERY SLOWLY. THIS WAS TO BE THE 2ND FLIGHT OF THE DAY, THE AIRPLANE HAD THE PROPER VOLTAGE SUPPLIED TO THE STARTER. R & R THE STARTER, ACFT WAS RETURNED TO SERVICE.

Part: TIRE — UNSERVICEABLE (RT MLG)

PILOTS REPORTED THAT ON TAKEOFF, THEY FELT A BUMP FOLLOWING THE VR CALLOUT. AFTER LANDING, IT WAS DISCOVERED THAT THE NR 3 MAIN TIRE TREAD HAD COMPLETELY SEPARATED FROM THE TIRE DOWN TO THE CORD AREA. THE TREAD COMING OFF DAMAGED THE FLAP TORQUE TUBE, SEVERED THE CONTROL CABLES FOR THE SPOILERS AND SPEED BRAKES FOR THE RT WING, AND ALSO PUNCTURED THE WING JUST IB OF THE FLAPS. THE ENGINE NACELLE, FUSELAGE AND WINGS EXHIBITED DENTS OF VARIOUS SIZES AND DEPTH ALONG WITH BLACK RUBBER SCUFF MARKS FROM THE TIRE TREAD. THE NR 3 TIRE PRESSURE WAS FOUND TO BE 161 PSI AT 67450 LBS RAMP WEIGHT 2 DAYS AFTER THE INCIDENT. (K)

Part: MOUNT — BROKEN (LIGHT)

LIGHT MOUNT IS BROKEN. FOUND THE SHOCK MOUNT TORN. INSTALLED SHOCK MOUNT.

Part: DOOR — BROKEN (NLG LT DOOR)

THE LEFT NOSE GEAR DOOR CAME IN CONTACT WITH THE NOSE WHEEL AND BROKE THE LEFT DOOR ACTUATING LEVER ROLLER BEARING AND THE LEFT DOOR. AGUSTA SB B.T. 109-84 REV A PERTAINS TO THIS SUBJECT, BUT DOES NOT APPLY TO THIS AIRCRAFT S/N. THIS AIRCRAFT WAS MODIFIED AT THE FACTORY. THIS REPAIR STATION HAS FOUND 2 OTHER AIRCRAFT (A109C) WITH B.T. 109-84 REV 1 C/W THAT HAVE BROKEN THE LEFT NOSE GEAR DOOR. THE NOSE STRUT PRESSURE ON THIS AIRCRAFT WAS FOUND TO BE 25 PSI LOW. THIS COULD BE THE CAUSE. INSTALLED NEW LEFT NOSE GEAR DOOR AND LEVER. SERVICED NOSE STRUT WITH NITROGEN. PERFORMED RETRACTION/EXTENSION CHECK.