Sunday, October 18, 2015

Smoke from engine

CESSNA 404      CONTINENTAL 520              Scheduled maintenance        24/09/2015

                     Smoke from engine on start-up. Caused by a rag which had been inadvertently left inside the engine by a trainee engineer. Appropriate action has been taken.
A pilot was asked to conduct a post-maintenance engine run follow rectification of an oil leak. Engine number one was started normally. On start of engine no.2 smoke was noted from the number 1 engine. After a short period of monitoring the pilot elected to shut down both engines and without further delay, exited the aircraft with the Fire Extinguisher and requested assistance. A fire extinguisher was discharged through the louvre at the rear of the upper engine cowling whilst another engineer gained access to the engine via the side access panel. Investigation Findings Once the engine cowling was opened it was clear to see the cause of the excessive smoke was a smouldering rag on the exhaust stack adjacent to the EGT probe. Root Cause It was immediately obvious one of the two engineers previously deployed to a reported oil leak had failed to remove the rag following the clean-up stage. One of the engineers, a trainee (working alongside a Licensed Engineer) looking into the oil leak, immediately admitted to making a careless mistake. The requirements of 145.A.48 and the procedures of the Company MOE 2.29 and SOP HM9 had not been followed. Remedial Action The fire extinguisher was discharged again to dampen down before removing and fully covering the rag in foam. The Licensed Engineer was asked to clean and inspect the engine. No damage was evident. Instructions have been issued that with immediate effect, rags and cloths are not to be used. An instruction has been given that no further rags are to be ordered, pending the identification of a suitable alternative. Preventative Actions The trainee engineer will continue to work alongside a Licensed Engineer. The trainee should insist that his work is checked. All engineers have been reminded of the content of Company SOP HM9 and the prevention of damage by ‘foreign objects’. All engineers have been reminded of the importance to conduct loose article checks following base and line maintenance. Supplementary Information There has been no previous cause to question the trainee’s abilities and he could generally be trusted to perform to the required standard. The trainee was fully accepting of the severity of the incident. The trainee engineer has been issued with a formal written warning. Human Factors were considered, however no explanation was offered for the lapse in concentration. There were no time pressures, the Trainee did not feel unwell or was distracted in any way.

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