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Attributes | |
ACN | 484560 |
Time | |
Date | 200009 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | general aviation : instructional |
Make Model Name | PA-28 Cherokee/Archer II/Dakota/Pillan/Warrior |
Operating Under FAR Part | Part 91 |
Flight Phase | landing : roll |
Person 1 | |
Affiliation | other |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 484560 |
Person 2 | |
Affiliation | other |
Function | maintenance : inspector maintenance : technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 484561 |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : company policies non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : declared emergency flight crew : landed in emergency condition none taken : unable |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : engineering procedure contributing factor : work cards performance deficiency : inspection performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : testing performance deficiency : repair |
Supplementary | |
Problem Areas | Maintenance Human Performance Company Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
A pa28r200 was modified by our company by the removal of the automatic gear extension system in accordance with piper kit 765-303. Subsequently, the gear motor failed which resulted in the pilot landing gear up. It was later discovered that our mechanic misinterpreted the kit instructions since there was no textual description as to where to install a bolt which is only refered to as '402 780 bolt'. The instructions say to refer to 'figure 3' during the 'bolt' installation. Figure 3 does not directly show the relationship between the bolt and the emergency gear lever. At the point when the bolt was installed it made no sense to install the bolt above the lever since a spring would cause the lever to be pulled down thereby preventing the gear from retracting. Step 2.9 says to install the bolt, later the spring was changed in step 3.5 to load the emergency gear lever in the up position. Section 5.0 completion says, 'with the aircraft on jacks, turn on master switch and ensure that landing gear operates correctly.' nowhere was there specific mention of using an emergency extension system. We misinterpreted that the alternate means of lowering the gear was by pulling the 'pullable' gear motor circuit breaker which the kit had us install. We feel that the kit should be clarified as to how the emergency gear extension is supposed to work. Also, we feel that our existing company inspection procedures should be reviewed and discussed with all inspectors and mechanics to prevent a future occurrence of this nature. Callback conversation with reporter revealed the following information: this was the first stc kit of this nature the maintenance shop had installed. The reporter was confused and did not understand the manufacturer's stc paperwork. He was of the opinion that it needs to be much more clearly written. Also there is need to require operation of the gear free fall system. This would have disclosed the incorrect installation of the free fall lever bolt.
Original NASA ASRS Text
Title: PA-28 PLT HAD A GEAR UP LNDG AT ZZZ.
Narrative: A PA28R200 WAS MODIFIED BY OUR COMPANY BY THE REMOVAL OF THE AUTO GEAR EXTENSION SYSTEM IN ACCORDANCE WITH PIPER KIT 765-303. SUBSEQUENTLY, THE GEAR MOTOR FAILED WHICH RESULTED IN THE PILOT LNDG GEAR UP. IT WAS LATER DISCOVERED THAT OUR MECH MISINTERPRETED THE KIT INSTRUCTIONS SINCE THERE WAS NO TEXTUAL DESCRIPTION AS TO WHERE TO INSTALL A BOLT WHICH IS ONLY REFERED TO AS '402 780 BOLT'. THE INSTRUCTIONS SAY TO REFER TO 'FIGURE 3' DURING THE 'BOLT' INSTALLATION. FIGURE 3 DOES NOT DIRECTLY SHOW THE RELATIONSHIP BTWN THE BOLT AND THE EMERGENCY GEAR LEVER. AT THE POINT WHEN THE BOLT WAS INSTALLED IT MADE NO SENSE TO INSTALL THE BOLT ABOVE THE LEVER SINCE A SPRING WOULD CAUSE THE LEVER TO BE PULLED DOWN THEREBY PREVENTING THE GEAR FROM RETRACTING. STEP 2.9 SAYS TO INSTALL THE BOLT, LATER THE SPRING WAS CHANGED IN STEP 3.5 TO LOAD THE EMERGENCY GEAR LEVER IN THE UP POSITION. SECTION 5.0 COMPLETION SAYS, 'WITH THE ACFT ON JACKS, TURN ON MASTER SWITCH AND ENSURE THAT LNDG GEAR OPERATES CORRECTLY.' NOWHERE WAS THERE SPECIFIC MENTION OF USING AN EMERGENCY EXTENSION SYSTEM. WE MISINTERPRETED THAT THE ALTERNATE MEANS OF LOWERING THE GEAR WAS BY PULLING THE 'PULLABLE' GEAR MOTOR CIRCUIT BREAKER WHICH THE KIT HAD US INSTALL. WE FEEL THAT THE KIT SHOULD BE CLARIFIED AS TO HOW THE EMERGENCY GEAR EXTENSION IS SUPPOSED TO WORK. ALSO, WE FEEL THAT OUR EXISTING COMPANY INSPECTION PROCEDURES SHOULD BE REVIEWED AND DISCUSSED WITH ALL INSPECTORS AND MECHANICS TO PREVENT A FUTURE OCCURRENCE OF THIS NATURE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THIS WAS THE FIRST STC KIT OF THIS NATURE THE MAINT SHOP HAD INSTALLED. THE REPORTER WAS CONFUSED AND DID NOT UNDERSTAND THE MANUFACTURER'S STC PAPERWORK. HE WAS OF THE OPINION THAT IT NEEDS TO BE MUCH MORE CLEARLY WRITTEN. ALSO THERE IS NEED TO REQUIRE OPERATION OF THE GEAR FREE FALL SYSTEM. THIS WOULD HAVE DISCLOSED THE INCORRECT INSTALLATION OF THE FREE FALL LEVER BOLT.
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.