What happened
The FAA’s narrative, in sentence case. The FAA writes it in capitals and removes private details.
privacy data omitted Holder of both airframe and power plant ratings (cert privacy data omitted) was involved with the regulatory deviation. The specific regulatory requirement that was not met was 14 CFR 43.13 (b). The deviation occurred on February 27, 2020 at the maintenance facility of heart of Virginia aviation, privacy data omitted. A latent failure of the oil filter housing was caused by the improper orientation of a newly installed exhaust riser; thus chaffing into the oil filter housing resulting in oil starvation to the engine and subsequent complete failure. The deviation occurred due to complacency. The results of the root cause analysis (rca) revealed that privacy data omitted did not utilize FAA approved data when replacing a cracked exhaust riser on a Rotax 912 power plant; thus resorting to memory while performing the maintenance task. The identified hazards that led to the regulatory deviation were the improper installation of a critical engine component that subsequently caused latent failures resulting in a catastrophic engine failure. The behaviors were rooted in a practice of not referring to the manufactures maintenance manual, relying on memory, and failing to cross check the work to affirm other components on the engine are not affected. Human factors were discussed to unveil potential risk. privacy data omitted Conceded that despite having performed maintenance task in the past by memory without incident, he now realizes the brevity of following published procedures in manufactures maintenance manuals consistently. Merely relying on memory led to improper maintenance, causing a latent failure that compromised the integrity of the national airspace system.
The mitigation/corrective actions taken by the airman included eliminating the complacent behavior of performing maintenance task by memory and participation in a company-wide maintenance safety briefing that emphasized the importance of referencing current manufactures maintenance manuals and looking at the ?big picture? To mitigate any maintenance induced latent failures.
No additional training/remedial training is needed; CA counseling is sufficient.
As the FAA filed it
^PRIVACY DATA OMITTED^ HOLDER OF BOTH AIRFRAME AND POWER PLANT RATINGS (CERT ^PRIVACY DATA OMITTED^) WAS INVOLVED WITH THE REGULATORY DEVIATION. THE SPECIFIC REGULATORY REQUIREMENT THAT WAS NOT MET WAS 14 CFR 43.13 (B). THE DEVIATION OCCURRED ON FEBRUARY 27, 2020 AT THE MAINTENANCE FACILITY OF HEART OF VIRGINIA AVIATION, ^PRIVACY DATA OMITTED^. A LATENT FAILURE OF THE OIL FILTER HOUSING WAS CAUSED BY THE IMPROPER ORIENTATION OF A NEWLY INSTALLED EXHAUST RISER; THUS CHAFFING INTO THE OIL FILTER HOUSING RESULTING IN OIL STARVATION TO THE ENGINE AND SUBSEQUENT COMPLETE FAILURE. THE DEVIATION OCCURRED DUE TO COMPLACENCY. THE RESULTS OF THE ROOT CAUSE ANALYSIS (RCA) REVEALED THAT ^PRIVACY DATA OMITTED^ DID NOT UTILIZE FAA APPROVED DATA WHEN REPLACING A CRACKED EXHAUST RISER ON A ROTAX 912 POWER PLANT; THUS RESORTING TO MEMORY WHILE PERFORMING THE MAINTENANCE TASK. THE IDENTIFIED HAZARDS THAT LED TO THE REGULATORY DEVIATION WERE THE IMPROPER INSTALLATION OF A CRITICAL ENGINE COMPONENT THAT SUBSEQUENTLY CAUSED LATENT FAILURES RESULTING IN A CATASTROPHIC ENGINE FAILURE. THE BEHAVIORS WERE ROOTED IN A PRACTICE OF NOT REFERRING TO THE MANUFACTURES MAINTENANCE MANUAL, RELYING ON MEMORY, AND FAILING TO CROSS CHECK THE WORK TO AFFIRM OTHER COMPONENTS ON THE ENGINE ARE NOT AFFECTED. HUMAN FACTORS WERE DISCUSSED TO UNVEIL POTENTIAL RISK. ^PRIVACY DATA OMITTED^ CONCEDED THAT DESPITE HAVING PERFORMED MAINTENANCE TASK IN THE PAST BY MEMORY WITHOUT INCIDENT, HE NOW REALIZES THE BREVITY OF FOLLOWING PUBLISHED PROCEDURES IN MANUFACTURES MAINTENANCE MANUALS CONSISTENTLY. MERELY RELYING ON MEMORY LED TO IMPROPER MAINTENANCE, CAUSING A LATENT FAILURE THAT COMPROMISED THE INTEGRITY OF THE NATIONAL AIRSPACE SYSTEM.
THE MITIGATION/CORRECTIVE ACTIONS TAKEN BY THE AIRMAN INCLUDED ELIMINATING THE COMPLACENT BEHAVIOR OF PERFORMING MAINTENANCE TASK BY MEMORY AND PARTICIPATION IN A COMPANY-WIDE MAINTENANCE SAFETY BRIEFING THAT EMPHASIZED THE IMPORTANCE OF REFERENCING CURRENT MANUFACTURES MAINTENANCE MANUALS AND LOOKING AT THE ?BIG PICTURE? TO MITIGATE ANY MAINTENANCE INDUCED LATENT FAILURES.
NO ADDITIONAL TRAINING/REMEDIAL TRAINING IS NEEDED; CA COUNSELING IS SUFFICIENT.
Other reports on N353TA · 2
Matched to the same aircraft by N-number and date.