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|
Attributes | |
ACN | 452226 |
Time | |
Date | 199910 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : pvd.tower |
Operator | common carrier : air carrier |
Make Model Name | DC-9 30 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | None |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 16 |
ASRS Report | 452226 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 15 |
ASRS Report | 452223 |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure |
Independent Detector | other other : maintenance |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : work cards performance deficiency : repair performance deficiency : scheduled maintenance performance deficiency : installation |
Supplementary | |
Problem Areas | Company Maintenance Human Performance Chart Or Publication Aircraft |
Primary Problem | Chart Or Publication |
Situations | |
Publication | Illustrated Parts Catalog |
Narrative:
On oct/xa/99 the heat exchanger assemblies were changed on aircraft xyz and the wrong heat exchangers were installed. The following is a summary of the things we feel that led to the installation of the wrong heat exchanger assemblies. The manufacturer's part number that corresponds with the assembly number is not in the illustrated parts catalog. The only reference to the part number is on the air carrier job card #WX-XXX, which was not issued to the aircraft. Also, the mssd screen shows conflicting information for the air carrier effectivity for the heat exchangers assemblies. The event has been self-disclosed by air carrier quality assurance and they are correcting the problem. Callback conversation with reporter revealed the following information: the reporter stated the only document that had the correct part number of the heat exchangers was the job card and this was not issued. The reporter said the manufacturer's and air carrier's illustrated parts catalog did not list the correct part number. The reporter said the mssd (a computer display listing the parts effectivity for aircraft type and model) was also in error. The reporter stated the carrier has brought the documents up-to-date and has allowed MD80 heat exchangers to be used on the DC9 aircraft.
Original NASA ASRS Text
Title: A DC9-30 WAS DISPATCHED IN NON COMPLIANCE WITH THE INCORRECT L AND R PACK HEAT EXCHANGERS INSTALLED CAUSED BY IMPROPER PARTS DOCUMENTATION.
Narrative: ON OCT/XA/99 THE HEAT EXCHANGER ASSEMBLIES WERE CHANGED ON ACFT XYZ AND THE WRONG HEAT EXCHANGERS WERE INSTALLED. THE FOLLOWING IS A SUMMARY OF THE THINGS WE FEEL THAT LED TO THE INSTALLATION OF THE WRONG HEAT EXCHANGER ASSEMBLIES. THE MANUFACTURER'S PART NUMBER THAT CORRESPONDS WITH THE ASSEMBLY NUMBER IS NOT IN THE ILLUSTRATED PARTS CATALOG. THE ONLY REF TO THE PART NUMBER IS ON THE ACR JOB CARD #WX-XXX, WHICH WAS NOT ISSUED TO THE ACFT. ALSO, THE MSSD SCREEN SHOWS CONFLICTING INFO FOR THE ACR EFFECTIVITY FOR THE HEAT EXCHANGERS ASSEMBLIES. THE EVENT HAS BEEN SELF-DISCLOSED BY ACR QUALITY ASSURANCE AND THEY ARE CORRECTING THE PROB. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE ONLY DOCUMENT THAT HAD THE CORRECT PART NUMBER OF THE HEAT EXCHANGERS WAS THE JOB CARD AND THIS WAS NOT ISSUED. THE RPTR SAID THE MANUFACTURER'S AND ACR'S ILLUSTRATED PARTS CATALOG DID NOT LIST THE CORRECT PART NUMBER. THE RPTR SAID THE MSSD (A COMPUTER DISPLAY LISTING THE PARTS EFFECTIVITY FOR ACFT TYPE AND MODEL) WAS ALSO IN ERROR. THE RPTR STATED THE CARRIER HAS BROUGHT THE DOCUMENTS UP-TO-DATE AND HAS ALLOWED MD80 HEAT EXCHANGERS TO BE USED ON THE DC9 ACFT.
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.