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Attributes | |
ACN | 486196 |
Time | |
Date | 200009 |
Day | Thu |
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 | |
Operator | common carrier : air carrier |
Make Model Name | Do 328 TP (Turboprop) |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician maintenance : inspector |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 8 |
ASRS Report | 486196 |
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 : far non adherence : company policies non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | other |
Consequence | other other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : installation performance deficiency : testing |
Supplementary | |
Problem Areas | Company Environmental Factor Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
On the night of 00/09/thu during scheduled inspection the pilot and copilot rudder cables were found to be worn beyond limits. The pilots rudder cables were replaced, inspected and operationally checked with no discrepancies noted. The coplts rudder cables were installed, found to be the wrong length. The cables were then removed, the position were swapped (rh inboard. Rh outboard) then reinstalled. The installation was then completed without any further problems. I performed the inspection of the cable runs for proper routing and safeties with no defects noted. I performed the operations check of the pilots system with no defects noted. The paperwork was then completed and the aircraft was closed up. The aircraft was then taken by crew from the hangar. As crew preflighted the aircraft they noticed that when the captain pushed the left rudder pedal the copilot right rudder pedal moved forward. Crew immediately returned aircraft to maintenance hangar, at which time it was discovered that copilot rudder cables were improperly routed in tail section of aircraft (rudder bellcrank). This problem was corrected immediately by maintenance personnel. Aircraft was then test flown without incident. There was no damage to aircraft and no injuries to crew, as the aircraft had not flown before the problem was corrected. Other factors: the fact the copilot cables can be improperly routed, connected normally and the pilots system still functions normally, indicates a potentially problematic design. However the maintenance manual covers this possibility by stating that an operations check of the affected system is required. Fatigue was a factor, the initial work was completed as I went into the 16TH hour of my shift. No operational check of the copilot system was performed. Summary: the procedure is intended to have a mechanic perform the operational check while the inspector (self), observes and verifies that the work was correctly performed. This failed to occur because I put too much trust in the ability of the mechanic and did not correctly read, interpret and apply the instructions in the aircraft maintenance manual or company maintenance manual. Callback conversation with reporter revealed the following information: the reporter stated the only inspection accomplished was from the left seat and everything checked ok. The reporter said the operational check was made in darkness and the first officer's rudder pedals were not observed. The reporter stated the right rudder pedals and rudder operational check were never checked from the right seat. The reporter said the maintenance manual did require a operational check from both seats with an inspector observing the actual rudder movement. The reporter said in fact no actual final check was made per the maintenance manual.
Original NASA ASRS Text
Title: A DORNIER 328 DURING CREW PRFLIGHT CHK WAS FOUND TO HAVE THE FO'S RUDDER CABLES CONNECTED AND RIGGED INCORRECTLY.
Narrative: ON THE NIGHT OF 00/09/THU DURING SCHEDULED INSPECTION THE PLT AND COPLT RUDDER CABLES WERE FOUND TO BE WORN BEYOND LIMITS. THE PLTS RUDDER CABLES WERE REPLACED, INSPECTED AND OPERATIONALLY CHKED WITH NO DISCREPANCIES NOTED. THE COPLTS RUDDER CABLES WERE INSTALLED, FOUND TO BE THE WRONG LENGTH. THE CABLES WERE THEN REMOVED, THE POS WERE SWAPPED (RH INBOARD. RH OUTBOARD) THEN REINSTALLED. THE INSTALLATION WAS THEN COMPLETED WITHOUT ANY FURTHER PROBS. I PERFORMED THE INSPECTION OF THE CABLE RUNS FOR PROPER ROUTING AND SAFETIES WITH NO DEFECTS NOTED. I PERFORMED THE OPS CHK OF THE PLTS SYS WITH NO DEFECTS NOTED. THE PAPERWORK WAS THEN COMPLETED AND THE ACFT WAS CLOSED UP. THE ACFT WAS THEN TAKEN BY CREW FROM THE HANGAR. AS CREW PREFLIGHTED THE ACFT THEY NOTICED THAT WHEN THE CAPT PUSHED THE L RUDDER PEDAL THE COPLT R RUDDER PEDAL MOVED FORWARD. CREW IMMEDIATELY RETURNED ACFT TO MAINT HANGAR, AT WHICH TIME IT WAS DISCOVERED THAT COPLT RUDDER CABLES WERE IMPROPERLY ROUTED IN TAIL SECTION OF ACFT (RUDDER BELLCRANK). THIS PROB WAS CORRECTED IMMEDIATELY BY MAINT PERSONNEL. ACFT WAS THEN TEST FLOWN WITHOUT INCIDENT. THERE WAS NO DAMAGE TO ACFT AND NO INJURIES TO CREW, AS THE ACFT HAD NOT FLOWN BEFORE THE PROB WAS CORRECTED. OTHER FACTORS: THE FACT THE COPLT CABLES CAN BE IMPROPERLY ROUTED, CONNECTED NORMALLY AND THE PLTS SYS STILL FUNCTIONS NORMALLY, INDICATES A POTENTIALLY PROBLEMATIC DESIGN. HOWEVER THE MAINT MANUAL COVERS THIS POSSIBILITY BY STATING THAT AN OPS CHK OF THE AFFECTED SYS IS REQUIRED. FATIGUE WAS A FACTOR, THE INITIAL WORK WAS COMPLETED AS I WENT INTO THE 16TH HR OF MY SHIFT. NO OPERATIONAL CHK OF THE COPLT SYS WAS PERFORMED. SUMMARY: THE PROC IS INTENDED TO HAVE A MECH PERFORM THE OPERATIONAL CHK WHILE THE INSPECTOR (SELF), OBSERVES AND VERIFIES THAT THE WORK WAS CORRECTLY PERFORMED. THIS FAILED TO OCCUR BECAUSE I PUT TOO MUCH TRUST IN THE ABILITY OF THE MECH AND DID NOT CORRECTLY READ, INTERPRET AND APPLY THE INSTRUCTIONS IN THE ACFT MAINT MANUAL OR COMPANY MAINT MANUAL. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE ONLY INSPECTION ACCOMPLISHED WAS FROM THE L SEAT AND EVERYTHING CHKED OK. THE RPTR SAID THE OPERATIONAL CHK WAS MADE IN DARKNESS AND THE FO'S RUDDER PEDALS WERE NOT OBSERVED. THE RPTR STATED THE R RUDDER PEDALS AND RUDDER OPERATIONAL CHK WERE NEVER CHKED FROM THE R SEAT. THE RPTR SAID THE MAINT MANUAL DID REQUIRE A OPERATIONAL CHK FROM BOTH SEATS WITH AN INSPECTOR OBSERVING THE ACTUAL RUDDER MOVEMENT. THE RPTR SAID IN FACT NO ACTUAL FINAL CHK WAS MADE PER THE MAINT MANUAL.
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.