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|
Attributes | |
ACN | 160557 |
Time | |
Date | 199010 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : stl |
State Reference | MO |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | climbout : takeoff ground : preflight landing other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
ASRS Report | 160557 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical |
Independent Detector | other flight crewa |
Resolutory Action | none taken : unable |
Consequence | faa : investigated other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | other |
Narrative:
I was asked to reinstall the left augmentation valve on medium large transport as it was removed by mistake. It was explained that the valve was not completely removed and all I had to do was put a clamp on and secure it and hook all the lines up. The cables were not disconnected. When I asked about the paperwork involved, I was told it would be taken care of. After installation, I checked the system using APU air and the system checked normal. The aircraft was returned to service. The aircraft was scheduled for an am flight to bna from stl. After takeoff, it was reported that there were fumes and smoke in the cabin and the aircraft returned to stl. Investigation revealed that the outboard clamp on the augmentation valve was installed but not secured and when supplied with 13TH stage air the augmentation valve leaked, subsequently melting insulation and generator lines. The generator lines arced across a hydraulic line causing it to lose fluid which caused the smoke and fumes in the cabin. When the aircraft returned they either had the anti-skid off or it failed because all 4 main tires skidded and had to be changed. Even though the augmentation valve was removed by mistake, I feel I should have been given a complete set of paperwork explaining what was done and what was required to reinstall properly and not just 'put it back in and I'll take care of the paperwork.' accidents do happen in regard to removing the wrong component from an aircraft, but if proper procedures and correct instructions are provided, problems like this could be avoided. This is my first incident of this nature as a mechanic and it will be my last. If need be, I will find the paperwork myself and reinstall a unit as if it were new.
Original NASA ASRS Text
Title: IMPROPER MAINTENANCE CAUSES MLG TO RETURN LAND AFTER TKOF.
Narrative: I WAS ASKED TO REINSTALL THE LEFT AUGMENTATION VALVE ON MLG AS IT WAS REMOVED BY MISTAKE. IT WAS EXPLAINED THAT THE VALVE WAS NOT COMPLETELY REMOVED AND ALL I HAD TO DO WAS PUT A CLAMP ON AND SECURE IT AND HOOK ALL THE LINES UP. THE CABLES WERE NOT DISCONNECTED. WHEN I ASKED ABOUT THE PAPERWORK INVOLVED, I WAS TOLD IT WOULD BE TAKEN CARE OF. AFTER INSTALLATION, I CHKED THE SYS USING APU AIR AND THE SYS CHKED NORMAL. THE ACFT WAS RETURNED TO SVC. THE ACFT WAS SCHEDULED FOR AN AM FLT TO BNA FROM STL. AFTER TKOF, IT WAS RPTED THAT THERE WERE FUMES AND SMOKE IN THE CABIN AND THE ACFT RETURNED TO STL. INVESTIGATION REVEALED THAT THE OUTBOARD CLAMP ON THE AUGMENTATION VALVE WAS INSTALLED BUT NOT SECURED AND WHEN SUPPLIED WITH 13TH STAGE AIR THE AUGMENTATION VALVE LEAKED, SUBSEQUENTLY MELTING INSULATION AND GENERATOR LINES. THE GENERATOR LINES ARCED ACROSS A HYD LINE CAUSING IT TO LOSE FLUID WHICH CAUSED THE SMOKE AND FUMES IN THE CABIN. WHEN THE ACFT RETURNED THEY EITHER HAD THE ANTI-SKID OFF OR IT FAILED BECAUSE ALL 4 MAIN TIRES SKIDDED AND HAD TO BE CHANGED. EVEN THOUGH THE AUGMENTATION VALVE WAS REMOVED BY MISTAKE, I FEEL I SHOULD HAVE BEEN GIVEN A COMPLETE SET OF PAPERWORK EXPLAINING WHAT WAS DONE AND WHAT WAS REQUIRED TO REINSTALL PROPERLY AND NOT JUST 'PUT IT BACK IN AND I'LL TAKE CARE OF THE PAPERWORK.' ACCIDENTS DO HAPPEN IN REGARD TO REMOVING THE WRONG COMPONENT FROM AN ACFT, BUT IF PROPER PROCS AND CORRECT INSTRUCTIONS ARE PROVIDED, PROBS LIKE THIS COULD BE AVOIDED. THIS IS MY FIRST INCIDENT OF THIS NATURE AS A MECH AND IT WILL BE MY LAST. IF NEED BE, I WILL FIND THE PAPERWORK MYSELF AND REINSTALL A UNIT AS IF IT WERE NEW.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.