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|
Attributes | |
ACN | 278440 |
Time | |
Date | 199407 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : hnl |
State Reference | HI |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B747 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
ASRS Report | 278440 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
ASRS Report | 278789 |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Air Traffic Incident | other |
Narrative:
I was assigned to an aircraft, for a maintenance opportunity visit of approximately 5 1/2 hours before its next scheduled departure, which was flight X on the evening of jul/xx/94. Myself and another mechanic were assigned the task of performing a change order authority/authorized (coa) to the left wing landing gear which involved removing the downlock actuator and replacing it with an improved actuator. Our lead mechanic gave us our necessary coa paperwork and we set up for the task. I ordered the part (actuator). Per the paperwork, we removed and replaced the actuator and performed the operational check which checked good. The actuator was a maintenance record part, so the maintenance record numbers were needed for the paperwork to sign off the job. While recording these numbers, I noticed that they were different, as did my partner, but did nothing to further investigate this because I thought since this was a coa, the part numbers were changing on purpose. As I was going back through the paperwork, I realized the paperwork that had been printed was for a body landing gear. I took this to my lead, and he relayed it to management, as they were responsible for this paperwork. (Printing it) the lead mechanic then went back himself and printed the correct coa paperwork. I then reviewed the correct coa paperwork, went through the removal and installation, and operations check procedures which were basically identical. I then signed off the paperwork for the coa. Aircraft north left honolulu at approximately XG15 and returned at approximately XH30 with landing gear problems. Upon further investigation, it was found that the wrong actuator had been installed which was not letting the gear retract fully. This was the actuator which was listed on the original incorrect paperwork. Both of the new and old actuator are identical in size and shape. Although I should have caught the error in paperwork, I feel the party in management was just as responsible because they printed it up, and that's what got the event started in the wrong direction.
Original NASA ASRS Text
Title: WRONG PART INSTALLED IN LNDG GEAR CAUSED A RETURN LAND.
Narrative: I WAS ASSIGNED TO AN ACFT, FOR A MAINT OPPORTUNITY VISIT OF APPROX 5 1/2 HRS BEFORE ITS NEXT SCHEDULED DEP, WHICH WAS FLT X ON THE EVENING OF JUL/XX/94. MYSELF AND ANOTHER MECH WERE ASSIGNED THE TASK OF PERFORMING A CHANGE ORDER AUTH (COA) TO THE L WING LNDG GEAR WHICH INVOLVED REMOVING THE DOWNLOCK ACTUATOR AND REPLACING IT WITH AN IMPROVED ACTUATOR. OUR LEAD MECH GAVE US OUR NECESSARY COA PAPERWORK AND WE SET UP FOR THE TASK. I ORDERED THE PART (ACTUATOR). PER THE PAPERWORK, WE REMOVED AND REPLACED THE ACTUATOR AND PERFORMED THE OPERATIONAL CHK WHICH CHKED GOOD. THE ACTUATOR WAS A MAINT RECORD PART, SO THE MAINT RECORD NUMBERS WERE NEEDED FOR THE PAPERWORK TO SIGN OFF THE JOB. WHILE RECORDING THESE NUMBERS, I NOTICED THAT THEY WERE DIFFERENT, AS DID MY PARTNER, BUT DID NOTHING TO FURTHER INVESTIGATE THIS BECAUSE I THOUGHT SINCE THIS WAS A COA, THE PART NUMBERS WERE CHANGING ON PURPOSE. AS I WAS GOING BACK THROUGH THE PAPERWORK, I REALIZED THE PAPERWORK THAT HAD BEEN PRINTED WAS FOR A BODY LNDG GEAR. I TOOK THIS TO MY LEAD, AND HE RELAYED IT TO MGMNT, AS THEY WERE RESPONSIBLE FOR THIS PAPERWORK. (PRINTING IT) THE LEAD MECH THEN WENT BACK HIMSELF AND PRINTED THE CORRECT COA PAPERWORK. I THEN REVIEWED THE CORRECT COA PAPERWORK, WENT THROUGH THE REMOVAL AND INSTALLATION, AND OPS CHK PROCS WHICH WERE BASICALLY IDENTICAL. I THEN SIGNED OFF THE PAPERWORK FOR THE COA. ACFT N LEFT HONOLULU AT APPROX XG15 AND RETURNED AT APPROX XH30 WITH LNDG GEAR PROBS. UPON FURTHER INVESTIGATION, IT WAS FOUND THAT THE WRONG ACTUATOR HAD BEEN INSTALLED WHICH WAS NOT LETTING THE GEAR RETRACT FULLY. THIS WAS THE ACTUATOR WHICH WAS LISTED ON THE ORIGINAL INCORRECT PAPERWORK. BOTH OF THE NEW AND OLD ACTUATOR ARE IDENTICAL IN SIZE AND SHAPE. ALTHOUGH I SHOULD HAVE CAUGHT THE ERROR IN PAPERWORK, I FEEL THE PARTY IN MGMNT WAS JUST AS RESPONSIBLE BECAUSE THEY PRINTED IT UP, AND THAT'S WHAT GOT THE EVENT STARTED IN THE WRONG DIRECTION.
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.