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|
Attributes | |
ACN | 452813 |
Time | |
Date | 199909 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Dash 8-100 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance lead technician : 1 maintenance technician : 9 |
ASRS Report | 452813 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : company policies |
Independent Detector | aircraft equipment other aircraft equipment : hydraulic pressure indication |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | performance deficiency : repair performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : inspection performance deficiency : testing |
Supplementary | |
Problem Areas | Aircraft Company Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
During a scheduled line check, the caution light modules #8 and #9 had unreadable legends. The modules were removed and replaced with the wrong part number modules, thus changing the segment confign. The aircraft was modified with a rudder isolation valve and part of the modification is to change a 'filter' in the caution panel module and inscribe a new part number on the side of the module, the old number is to be crossed out. When I removed the discrepant modules I used the part number on the side of the module (which should have been crossed out and a new one installed). This failure to change the number, and my neglect in consulting the ipc (illustrated parts catalog) resulted in the wrong module being installed in position #8 and #9. The aircraft was released for passenger service and flew for several days, until the aircraft encountered a loss of hydraulic pressure on the #1 system. This resulted in the 'rudder isolation valve' being activated. The caution light was illuminated, and instead of the 'rudder isolation valve' caution light being illuminated it was a blank (only a lighted dash in the segment).
Original NASA ASRS Text
Title: A DHC8-100 WAS DISPATCHED IN NON COMPLIANCE WITH THE INCORRECT MASTER CAUTION ANNUNCIATOR PANEL INSTALLED CAUSED BY A SHOP PART NUMBER ERROR.
Narrative: DURING A SCHEDULED LINE CHK, THE CAUTION LIGHT MODULES #8 AND #9 HAD UNREADABLE LEGENDS. THE MODULES WERE REMOVED AND REPLACED WITH THE WRONG PART NUMBER MODULES, THUS CHANGING THE SEGMENT CONFIGN. THE ACFT WAS MODIFIED WITH A RUDDER ISOLATION VALVE AND PART OF THE MODIFICATION IS TO CHANGE A 'FILTER' IN THE CAUTION PANEL MODULE AND INSCRIBE A NEW PART NUMBER ON THE SIDE OF THE MODULE, THE OLD NUMBER IS TO BE CROSSED OUT. WHEN I REMOVED THE DISCREPANT MODULES I USED THE PART NUMBER ON THE SIDE OF THE MODULE (WHICH SHOULD HAVE BEEN CROSSED OUT AND A NEW ONE INSTALLED). THIS FAILURE TO CHANGE THE NUMBER, AND MY NEGLECT IN CONSULTING THE IPC (ILLUSTRATED PARTS CATALOG) RESULTED IN THE WRONG MODULE BEING INSTALLED IN POS #8 AND #9. THE ACFT WAS RELEASED FOR PAX SVC AND FLEW FOR SEVERAL DAYS, UNTIL THE ACFT ENCOUNTERED A LOSS OF HYD PRESSURE ON THE #1 SYS. THIS RESULTED IN THE 'RUDDER ISOLATION VALVE' BEING ACTIVATED. THE CAUTION LIGHT WAS ILLUMINATED, AND INSTEAD OF THE 'RUDDER ISOLATION VALVE' CAUTION LIGHT BEING ILLUMINATED IT WAS A BLANK (ONLY A LIGHTED DASH IN THE SEGMENT).
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.