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Final Report

Summary

On 3 November 2015 at about 1400 Western Standard Time (WST), the pilot conducted a maintenance test flight in a Eurocopter AS365 N3 registered VH-WPX, at Jandakot Airport, Western Australia.

The test flight was the third that day, to conduct track and balancing of the main rotor, following reports of vibration.

During the post-flight inspection, following this test flight, a Licenced Aircraft Maintenance Engineer noticed two large gouges to the leading edge of one of the main rotor blades.

A spanner that had been used during the track and balance related adjustments could not be located. It was later located on an adjacent taxiway about 43 m from the hangar. Due to the scuff marks and scratches found on the spanner, it was determined that it had been left in the rotor head area and was likely ejected during the aircraft start up.

While there was a practice of tool control in place prior to the incident, formal procedures had not been documented and incorporated in the maintenance organisation manual (MOM).

As a safety action, the operator will incorporate the tool control procedure into the MOM. This procedure will required that all tools used during any aircraft maintenance are returned to the tool storage location prior to any of the company aircraft being started.

A tool control procedure will be implemented for any maintenance that occurs away from the main base. Additionally, a tool control procedure will be implemented to ensure external maintenance providers (for example avionics specialists) adopt the company tool control procedure.

All maintenance personnel be provided with sufficient training and information to enable them to understand the workings of the organisation, its policies, manuals, procedures and their individual responsibilities.

 

Aviation Short Investigations Bulletin - Issue 48

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