Csl 1036

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EXPORT CONTROLLED COMMERCIAL SERVICELETTER clRolls-Roycew

Technical aspects are FAA appro

MODEL 250 REPORTINGm This letter introduces the revised Model 25 0 Report form, Form GT 8117-1 , Rev. 01-01, and cancels allprevious Model 250 Report forms with prior revision dates. All previous issues are to be discarded.

The purpose of the Model 250 Report is to provide a rapid and vital means of communication whereb yI

Rolls-Royce is supplied with valuable field knowledge of the Model 250 engine. This information will beanalyzed by Rolls-Royce with an ultimate goal of improving the usefulness of the engine to the operato r.The Model 250 Report is designed for use by owners/operators, Authorized Maintenance Centers (AMCs),

Iand Rolls-Royce representa tives. Rolls-Rovce reauires that the Model 250 Reoort be DroDerlv comoletedand forward ed to Rolls-Rovce every time an enaine. module or comoonent is removed, installed. or involvedin an event.This revision of the Model 250 Report includes the following features or changes:

0 Each repot-l has a preprinted report number.0 The reports are in three parts: a green original (A), a white co py (B), and a yellow copy (C ).

0 The green o riginal is to be sent to Rolls-Royce at the following address:Rolls-Royce CorporationPost Office Box 420Indianapolis, IN 46206-0420Attention: Model 250 Data Center

Speed Code P47

I0 The white copy is to be sent to the repair/over haul facility. The repair/overhaul facility

AMC will complete this copy a nd send it to Rolls-Royce.0 The yellow copy is to be retained by the owner/operator.

I0 General instructions for completion of the report are printed on a cover sheet included with

each package of reports.When writing the Model 25 0 Report, it is necessary to press firmly us ing a black b allpoint pen to be sure thatthe white and yellow copies are legible.

February 20,1975Revision 6April 11, 2001

250X1 8 Series CSL 76250-C20 Series CSL 1036250-C28 Series CSL 2020250-C30 Series CSL 3016250-C20R Series CSL 4039

250-C40 Series CSL 500325O-C47 Series CSL 6003250-8 15 Series TP CSL 14250-B17 Series TP CSL 1018250-B17F Series TP CSL 2053Page 1 of 2

Rolls-Royce Proprietary Data Uncontrolled Printed Copy

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EXPORT CONTROLLED Rolls-RoyceCOMMERCIAL SERVICE LETTER

Forms are available from Aviall, Rolls-Royce or your AMC at no charge:Aviall

0 1 (800) AVIALLl (800-284-25 51) in North America0 1 (800) AVIALL3 (800-284 -2553) International

Rolls-RoyceModel 250 Customer Support0 1 (888) 255-4766 Ext 27200 1 (317) 230-3381 FAX

Attached is a Model 250 Report example and Model 250 Report Instructions.Also, a ttached is a Model 25 0 Field Parts Return form. It should be filled out in full and returned along withany parts being returned. Additional information regarding the Field Parts Return Form is included in CSL 201.

CUSTOMER SUPPORTROLLS-ROYCE

February 20, 1975Revision 6April 11, 2001

250-Cl8 Series CSL 76250-C20 Series CSL 1036250-C28 Series CSL 2020250-C30 Series CSL 3016250-C20R Series CSL 4039

25O-C40 Series CSL 5003250-C47 Series CSL 6003250-815 Series TP CSL 14250-617 Series TP CSL 1018250-B17F Series TP CSL 2053Page 2 of 2


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. Press down firmly when writing

.ClRolls-RoyceElma. Black ink required for legible copy machine reproduction

Model 250 report instructionsComplete a report each time an engine, major unit, control/assembly or component is removedor involved in an event.Also complete a report when an engine or major unit is installed.Forward copies as noted on each page. If copy is to be sent to Rolls--Royce Corporation, use thefollowing address:

Rolls-Royce CorporationP. 0. Box 420, SC P-47Indianapolis, IN46206-0420 USAAttention: Mode l 250 Data CenterSpeed Code P-47

. Green sheet (A) - Operator fills out and sends to Rolls-Royce Corporation.

. White sheet (B)- Send to repair facility along with hardware, or send toRolls-Royce Corporation if repair done by operator, or discard ifreporting installation.. Yellow sheet (C) - Operator copy. Reference report number in all correspondencewith Rolls-Royce Corporation.

. Start all entries in left side of field and round all time fields to the nearest wholenumber.

. Dates - Enter as day, month, and yearused for month). (2 digits o r 3 character abbrevia tion may be

. Aircraft manufacturer serial number - Record for all aircraft. For [MD 500: enteronly the last 3 or 4 numbers and suffix letter which denotes aircraft serial number.. Engine/major units on aircraft at times of event - Record serial nurnber and times(TSO and TSN) for the engine and each of the major units on the engine when theevent (symptoms/removal) occurred.. Check-off boxes -Check all boxes that apply in each group.NOTE: Any event resulting in an engine or major unit removal, regardlessof cause,is considered an eng/unit removal.. SiY mptoms/reason for removal - Give a description of symptoms or cause ,for reportcheck-off box entries are not sufficient.. Primary failed item (PFI) - Identify the specific part, accessory, or conditionthat caused the maintenance action.number, and time and cycles, if known. Also enter the Rolls-Royce part number, serial

CT-8117-lA(l101)


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._..........................---------El Rolls-Royce Corporation MODEL 250 REPORTt?O. Box 420, S C P-47Indianapolis, Indiana Rol Is-Royce CUSTOMER SUPPORT DEPT. AIRCRAFTTYPE- +TELEPHDNE 317-230-272046206-0420 USA HEUCDPTERSPHONE

CUSTOMER

1950 0 EURD COFTER P1952 0 EURDCOPT ER I0404 0 AGUsTA206(\/80442 0 AGUSTA 109 SE

REPORTINGREPAIWOVERHAULFACILITYID.

I I I I ,AKOPERATORAKOWNERLADDRESS

AccYlcDNlRoL-fEMDvAL DNLY-ROUSROYCE PART NUMBER SERIALNUMBER Tso TSN

SYhlPTOMSREMDNS FOR REMOVALCHECK ALL THAT APPLY----82s cl cEB/MoD/coN-vEr61oN0 F.O.D.163 q -FIAMEDU

___ ..-...: BZkWtNlWSPOMNG831 i GIL CDNSUMFllDN HIGH811 cl OILLEAr

Effi LocAnDN ATTlMEDFEVENTONAK-POSlllON

E 842

A 0 GRNDRVN/T~B 0 TAKEDFFlcuMBc clcRulsED q IIANDINGF q InspectionHOHDVERJ q IINFIJGHTt OOFWG q OTHER0 UNKNOWN

DPERAllONAL EFFECISCHECK AUTHAT APPLY----A q UNSCHWUTDOWNB q FIAMEOUTD q UNSCHIANDINGE q uNscHAuTDRDTK OVlBRATiONu q HAml.ANuNG; pFoHmNG+l&GT ET&27iifF-S q SUBMERGEDi! q ACaDENT

14470101012201200126012701 28 q BELLGEMINIST-T01290130OlAH0118 l BELLTH67OBELLUO

0119 OBELL4300202 0 HILLER FHllOO1414 OHILlERUH12-SDIDY0303 OMD500U3690331 q lMDSOOD0332 q IMDSOOE033503530339OS050707151517763297

2181 q PARTENAVlAAP6S2261 0 ER-NORMAN ISL2798 q CESSNAP-2101485 q CESSNA206-S1489 q CESSNA207-SOW1212 q NDMAD2.21224 q NDMAD241060 0 RFB 400/600I909 Cl SIAI-MARCHEllllOl9l9B2 0 SIAi-MARCHETll I984 0 SlAI-MARCHElTl 1094 q BDNANZAA-365 0 FUJI T-Sq VALMETUOTP0 OMER -SPECIFY

__. - ~-.169 0 PDWER FLUCTUA TKINBS2 q PDwERiDss/DRDP-!ii EF-BaosMoKTNG8% q sTAm-HUNG897 USTART-NONE890 omRT-smw/HAflDi% oomMc3DTNER-SPEaFY

iUDDEN

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tJ Rolls-Royce Corporation m - . ,----m-v-- P.O. Box 420 FZEI 1-v.1- ..- WVK Indianapolis, Indiana /46206-0420 USA MODEL 250 FMER SUPPORTDWT.IONE 317-230-2720DAY MONTH YR PHONE/ CUSTOMER -

REPORTlNGREPAIR/OVERHAULFACILITYAKOPERATORNC OWNER &ADDRESS

ID.

-J

11111

-I

SYMPTOMS/REASO NS FOR REMOVALCHECK ALL THAT APPLY---v825 g ~EE$OD/CONVER163 0 FiAMEOUTII09 q FUELLEAK602 0 INSPECllONlRUKTlON819 0 MAG UGHT/PLlJG821 0 METALON SCREEN/F ILTER930 0 Nl LOCKUPEl ElEy NTERNAURVBBINGTo7 0 -LOT.- !miti895 OSTART-HOT628 0 OlLBREATHINGmEwlNG83; ; t&uc&iUMPnDN HIGH836 0 olLPREssuRE - FLucrUAnNG83.3 0 OlLF% ssUFzE-Lowg ~&~&tIE-NONE911 0 OVERTEMP169 0 POWER FLUCIU ATWJ852 0 POWER LOSS/DROP-SUD DEN

8% OsrART-HurJGa97 0 5rART-NONE8% q sTARI-sLow~844 q TlhwcYaEL3M3T927 0 wun0rdq DTHER-SPECIFY

ENG LounoN ATTIME OF EVENToNAK-PosmoNL3: 8:

A 0 GRNDRUNITAXJB 0 TAKEOFFKUMBC 0 CRVlSED OLANDIMGF OINSPECiWNIi q tiovERJ OINFLKWt 00 !HeG OOlHER0 UNKNOWN

OPERATIDNAL EFFECTSCHECK AU THAT APPLY----

TAIL ROTOR mKEPfw5rmKESUBMEFIGEDACCIDENT

/,,,IIIIIIIII-1I

I;;2i;1c-C C3

IPORT AIRCRAFrTYPE-+HELKOPTERS19501952it2144701010122012001260127012801290130

0 EUROCOF%R 0 EUROCOPTER0 AGUSTA 206A0 AGUSTA 109 q BELL47-SOmY0 BELL 206 JET0 BELL 206L SEq BELL2220 BELL 206L-40 BEU 206LT -; ;zELl;Nl 0 BELL 23001 AH 0 BELLAHIP0118 q lBELL407D119 q BELL430Dm214143303Q331333233353353333915051707151s177632971999

0 HItiER FHllOOg ~~~lL-solmq MDSOOD0 MDWE%E~q MD6ooN0 KAWASAK I E i;RgOflE& 0 SIKORSKY 576DENSTROM0 s- 3

4RPLANEs -y: 8 ;;P~NAVVIAP~~-NoRMANlsL1796 0 CESSNAP-210148s q cEssNA206-SMa9 ocEssNAm7-SO1212 q NOhMD221224 q NOMAD241D60 q lRFB400/6wI909 0 SIAl-MARClElll l9B2 0 SIAI-MARCHE TI984 0 SIAI-MAlKHElll IO94 0 BONANZAA- ,D FUJI T-50 VALM ET L9MF0 OTHER-SPECIF

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. . . . .-. *. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .!I Roils-Royce Corporation---e----- P.O. Box 420K Indianapolis, Indiana Rolls-Royce46206-0420 USAREPORTINGREPAIWOVERHAULFACILITY

PHONECUSTOMERID.

I I I I ,AKOPERATOR I I I I I ,A/c OWNER &ADDRESS I I I I ,

1 ENGINE/M AJOR UNITASSEMBLY ATnME DF EbENT WHOLE HOURS ONLYi SERIAL NUMBER Tso T5N

SYMPTOMS/REASONS FOR REMOVALCHECKALLTHATAPPLY---m825 ; ~~EC?D/CoNMR5ION163 0 F-LAkiEDLlT809 q FUELW80.2 Cl INsPEcrl0~cnDN819 q MAG LIGHT/PLUG821 0 METALON SCREEN/FILTER930 0 Nl LOCKUP931 0 N2 LDCKUP950 q NOISLINTERNAVRVBBINGTo7 0 -CO-T.- HIGHB95 OSTART-tKYT828 0 OlLBftEATliING/SPEWWG~3; g OI~3I5WTIDN HlCH636 Cl OIL PRESSORE - FLUClUAnNGWB cl olLPRESsuRE-LDwf4&J EO?E-NONE111 q DVERTEW169 q PDWERFLLICnJAT)DN;5 00 ELO(IOXWVDRDP-SUWENz E FOW&~3WOTALis 8Z%-E; IxTAxTA~yD127 oblBRAllDN0 OIHER-SPECIFY

ENG LDCATION ATrlME DF EVENToNNc-Po5moN

,Ol03 XfOFFAKB q TESlSfANDii oo~N~uLE ODTHERF USPARES0 UNKNOWN

EmNToEscruPnoN-NAIUIATM

WHEN MSCDVEREDA 0 GRNDRUN/lAXlB 0 TAKEDFFKLIMBc q cmJl5E0 0 LANDINGF 0 INSFECIWNHOHDVERJ OINFLJGHTK 0 PRACTALfTtXUl5 05HlJTDawNG q DTHER0 UNKNOWN

OPERAlloNAL EFFEClSCHECK AU TH AT APPLY----A q UNSCHSHUTDDWNB OFLAMEOLITD 0 UN5CH LANDINGE OUNSCHAUTDROTK ~VlBRAllDNu 0liAFtDlANDlNGw 0 HA~~DLANC~NG+~OGR OMAlNRDTOR5WJlEi ET&!2%krnKE5 OSUBMERGED2 0rxaDwr

EPORT AIRCRAFTTYPE- +HEUCOPTERS-1950 0 EUROCOPTER A1952 0 EURDCOPTERA0404 q IAGUSTA206A/B0442 0 AGUSTA 109 SEW1447 0 BELL 47 - SOLOY0101 0 BELL 206 JET RAN0122 q BELL206LSERlES0120 Cl BELL 2220126 0 BELL 2061 d0127 0 BELL 2060126 q BEI0129 0 BELLTH670130 q BEU230OlAH 0 BELLAHIP0116 q BELL4070119 q BELL4300202 0 HIUER FHl 100114 OHlLLERUH12-SDWY203 q lMDSOOU3690331 q lMDS.ClOD0332 OMD5OO-ED335 OMD52OND353 0 Mb Sk+3339 OMD6OON0505 Cl KAWASAKI KH50010707 q EUROCDflERBOlO51515 ONARM HSOOCI776 0 SI KORSKY 5763297 0 ENSTROM 4802999 0 SCHWEUER 330mPuNE5 -2181 q PARTENAVIAAWBTFI261 o BR-NDRMAN ISLA1790 q CESSNAP-2101465 0 CESS NA206 - SOLMB9 0 CESSNA207 - SDL1212 0 NOMAD 22I224 0 NOMAD 241060 q RFB 400/600)909 0 SIAl-MARCHEllllOl9i962 q SIAI-MARCHEt-ll SI964 o SIAI-MARCHEITI S1094 OBONANZA A-365 Ci FUJI T-5q VALM~L9Cfl-P0 OTHER SPEQF Y

GTdlll-1 (1tWRolls-Royce Proprietary Data Uncontrolled Printed Copy

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FIELD PARTS RETURN FORM(NOT A SHIPPING DOCUMENT)

1. Part(s) Number Serial Number Nomenclature TSO/-TSN Qty- -- -- -

NOTE: A supplemental sheet may be added for additional quantities of returns.

ENGINE/MODULE Serial Number From Which Item Was Removed __ENGINE MODEL _ AIRFRAME SERIAL NUMBERREPAIR FACILITY RETURNING THE PART

Contact PersonContact Telephone No. (Include Country Code)Fax No. (Include Country Code)

2. Check All Appropriat e Blocks:Reason for return:q Accident Investigationq CEB/CSL UpdateCl Rolls-Royce Request0 RFSE Return0 Warranty (must include AFA #)individual at Rolls-Royce or Referen ce for part returnShiping Information (Waybill # etc.)

Cl Failure Investigation0 Field CampaignCl Non-conforming i Other.AFA # -

3. Disposition of Part(s) (Investiaative Partsk0 Return to Sender. (Please place your shipping address at the bottom of this page..)0 To be scrapped.

4. 3 Additional data attached.5. List Anv Additional Information Below:

NOTE; PLEASE INCLUDE A FILLED OUT COPY OF THIS FORM WITH THE RETURNED UNIT(S)AND FAX A COPY TO ROLLS-ROYCE AT 317-23 0-3381 .


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Csl 1036