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An L1011-500 was operated in non compliance with the incorrect #2 engine fire loop installed caused by the illustrated parts catalog listing loop effectivity is vague and does not clearly list engine model.
| Attributes | |
| ACN | 443387 |
| Time | |
| Date | 199907 |
| Day | Thu |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Daylight |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | L-1011-500 Series |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance ground : parked |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| Experience | maintenance technician : 15 |
| ASRS Report | 443387 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : manuals performance deficiency : installation |
| Supplementary | |
| Problem Areas | Chart Or Publication Company Maintenance Human Performance Aircraft |
| Primary Problem | Chart Or Publication |
| Situations | |
| Publication | Illustrated Parts Catalog |
Narrative:
On jul/thu/99, an engine was removed from the #2 position of an air carrier L1011 (aircraft xyz) due to a history of false fire warning indication. 2 days later shop personnel discovered a fire detector loop installed on the engine was not the proper effectivity for an RB211-524. Records revealed that I had installed the incorrect part on that engine on jul/xy/98. 2 factors contributed to this error, the ipc is vague and the incorrect part number was listed on the ongoing maintenance report. The L1011 ipc 26-11-26, figure 1, page 2, item 500, lists multiple part numbers for the fire loop. The effectivity column to the right of the part numbers doesn't clearly list the engine model number for the part number given. The aircraft discrepancy was troubleshot 2 days earlier at another station. The repair was deferred due to lack of parts. The incorrect part number was listed in the ongoing maintenance report. That number was used when ordering the part. I have researched aircraft records and have idented at least 4 other aircraft in the air carrier L1011 that have had the same incorrect part installed within the past yr. To correct this recurring problem the ipc must be clarified to identify the effectivity by engine model. Increased vigilance should also be given when a part number is given in the ongoing maintenance report.
Original NASA ASRS Text
Title: AN L1011-500 WAS OPERATED IN NON COMPLIANCE WITH THE INCORRECT #2 ENG FIRE LOOP INSTALLED CAUSED BY THE ILLUSTRATED PARTS CATALOG LISTING LOOP EFFECTIVITY IS VAGUE AND DOES NOT CLEARLY LIST ENG MODEL.
Narrative: ON JUL/THU/99, AN ENG WAS REMOVED FROM THE #2 POS OF AN ACR L1011 (ACFT XYZ) DUE TO A HISTORY OF FALSE FIRE WARNING INDICATION. 2 DAYS LATER SHOP PERSONNEL DISCOVERED A FIRE DETECTOR LOOP INSTALLED ON THE ENG WAS NOT THE PROPER EFFECTIVITY FOR AN RB211-524. RECORDS REVEALED THAT I HAD INSTALLED THE INCORRECT PART ON THAT ENG ON JUL/XY/98. 2 FACTORS CONTRIBUTED TO THIS ERROR, THE IPC IS VAGUE AND THE INCORRECT PART NUMBER WAS LISTED ON THE ONGOING MAINT RPT. THE L1011 IPC 26-11-26, FIGURE 1, PAGE 2, ITEM 500, LISTS MULTIPLE PART NUMBERS FOR THE FIRE LOOP. THE EFFECTIVITY COLUMN TO THE R OF THE PART NUMBERS DOESN'T CLRLY LIST THE ENG MODEL NUMBER FOR THE PART NUMBER GIVEN. THE ACFT DISCREPANCY WAS TROUBLESHOT 2 DAYS EARLIER AT ANOTHER STATION. THE REPAIR WAS DEFERRED DUE TO LACK OF PARTS. THE INCORRECT PART NUMBER WAS LISTED IN THE ONGOING MAINT RPT. THAT NUMBER WAS USED WHEN ORDERING THE PART. I HAVE RESEARCHED ACFT RECORDS AND HAVE IDENTED AT LEAST 4 OTHER ACFT IN THE ACR L1011 THAT HAVE HAD THE SAME INCORRECT PART INSTALLED WITHIN THE PAST YR. TO CORRECT THIS RECURRING PROB THE IPC MUST BE CLARIFIED TO IDENT THE EFFECTIVITY BY ENG MODEL. INCREASED VIGILANCE SHOULD ALSO BE GIVEN WHEN A PART NUMBER IS GIVEN IN THE ONGOING MAINT RPT.
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.