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|
Attributes | |
ACN | 403262 |
Time | |
Date | 199805 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz |
State Reference | US |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Dash 8-100 |
Operating Under FAR Part | Part 121 |
Flight Phase | other |
Flight Plan | None |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
ASRS Report | 403262 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight attendant : on duty oversight : supervisor |
Qualification | other other : other |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : published procedure other anomaly other |
Independent Detector | other other : unspecified |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | other |
Narrative:
I work line maintenance for air carrier. On may/xa/98 I was told that aircraft xyz had caution light panel problems. Maintenance control gave me a class control number for a new caution panel in parts room. I was told to go to the gate at XX35 and remove and replace it. The aircraft had a down time of only 20 mins, so I had to work fast. When the plane arrived, I looked at the logbook and there was no open write-up, so I made the write-up that the caution panel needed to be replaced. Once I installed the new caution panel, I started to remove the old caution panel modules one by one and install them on the new panel. When I got to module #9, I noticed the pins that hold it in place were broken. So instead of ignoring the problem like the mechanic before me by duct taping it in, I looked at the part number on it and called maintenance control to order me a new module. When I received the new part, I looked at the rotatable tag to make sure the part numbers matched, installed the module on the caution panel, and made sure the lights worked. I finished the job, signed off the jobs 1) installing the panel and 2) installing the module. On may/xb/98, it was brought to my attention by quality control that I installed the wrong module. The one I installed had a blank filter, but should have had a caution light for the #2 hydraulic isolation valve. I found the old part and rotatable tag and showed them to my chief inspector. The part I removed had the pre-mod part number, but should have had the post mod number. I felt I did my job correctly. On the line you don't have time to go to the shop and look up part numbers. I relied on the part number that came off the old caution light module, and it fit correctly. If I had any reason to doubt that I was doing something wrong, I would have stopped what I was doing. The company has to disclose to the FAA the situation.
Original NASA ASRS Text
Title: A DHC-8 WAS DISPATCHED WITH AN INCORRECT WARNING LIGHT MODULE INSTALLED ON THE MASTER CAUTION LIGHT PANEL.
Narrative: I WORK LINE MAINT FOR ACR. ON MAY/XA/98 I WAS TOLD THAT ACFT XYZ HAD CAUTION LIGHT PANEL PROBS. MAINT CTL GAVE ME A CLASS CTL NUMBER FOR A NEW CAUTION PANEL IN PARTS ROOM. I WAS TOLD TO GO TO THE GATE AT XX35 AND REMOVE AND REPLACE IT. THE ACFT HAD A DOWN TIME OF ONLY 20 MINS, SO I HAD TO WORK FAST. WHEN THE PLANE ARRIVED, I LOOKED AT THE LOGBOOK AND THERE WAS NO OPEN WRITE-UP, SO I MADE THE WRITE-UP THAT THE CAUTION PANEL NEEDED TO BE REPLACED. ONCE I INSTALLED THE NEW CAUTION PANEL, I STARTED TO REMOVE THE OLD CAUTION PANEL MODULES ONE BY ONE AND INSTALL THEM ON THE NEW PANEL. WHEN I GOT TO MODULE #9, I NOTICED THE PINS THAT HOLD IT IN PLACE WERE BROKEN. SO INSTEAD OF IGNORING THE PROB LIKE THE MECH BEFORE ME BY DUCT TAPING IT IN, I LOOKED AT THE PART NUMBER ON IT AND CALLED MAINT CTL TO ORDER ME A NEW MODULE. WHEN I RECEIVED THE NEW PART, I LOOKED AT THE ROTATABLE TAG TO MAKE SURE THE PART NUMBERS MATCHED, INSTALLED THE MODULE ON THE CAUTION PANEL, AND MADE SURE THE LIGHTS WORKED. I FINISHED THE JOB, SIGNED OFF THE JOBS 1) INSTALLING THE PANEL AND 2) INSTALLING THE MODULE. ON MAY/XB/98, IT WAS BROUGHT TO MY ATTN BY QUALITY CTL THAT I INSTALLED THE WRONG MODULE. THE ONE I INSTALLED HAD A BLANK FILTER, BUT SHOULD HAVE HAD A CAUTION LIGHT FOR THE #2 HYD ISOLATION VALVE. I FOUND THE OLD PART AND ROTATABLE TAG AND SHOWED THEM TO MY CHIEF INSPECTOR. THE PART I REMOVED HAD THE PRE-MOD PART NUMBER, BUT SHOULD HAVE HAD THE POST MOD NUMBER. I FELT I DID MY JOB CORRECTLY. ON THE LINE YOU DON'T HAVE TIME TO GO TO THE SHOP AND LOOK UP PART NUMBERS. I RELIED ON THE PART NUMBER THAT CAME OFF THE OLD CAUTION LIGHT MODULE, AND IT FIT CORRECTLY. IF I HAD ANY REASON TO DOUBT THAT I WAS DOING SOMETHING WRONG, I WOULD HAVE STOPPED WHAT I WAS DOING. THE COMPANY HAS TO DISCLOSE TO THE FAA THE SIT.
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.