37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 491056 |
Time | |
Date | 200011 |
Day | Sun |
Local Time Of Day | 0001 To 0600 |
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 8-200 |
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 : powerplant technician : airframe |
ASRS Report | 491056 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : person 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : work cards performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Chart Or Publication |
Narrative:
DHC8-200, aircraft xyz was grounded at ZZZ for an emergency engine removal and replacement. During inspection and disassembly it was found that 2 propeller blades on this engine had non-allowable defects. The propeller blades were removed and replaced myself and another mechanic. During re-assembly, a teflon backup ring was improperly installed under the main rubber oil seal on each blade. Maintenance instructions for this procedure refer to the ring by different names in the removal and installation paperwork. I had been on duty approximately 15 hours on this engine change and the other mechanic had worked 18 hours. He had questioned later on, the ring replacement, and called our supervisor. Made 1 non-revenue flight from ZZZ to zza. It was stopped shortly before revenue departure from zza, and repaired there. Major repair to an aircraft under conditions. Confusing dual terminology in maintenance instructions. Excessive duty time required to get job complete. Blade removal and replacement not an inspection item on this aircraft at this airline.
Original NASA ASRS Text
Title: A DHC8-200 WAS DISPATCHED ON A MAINT FERRY WITH 2 PROP BLADES WITH NYLON SEAL BACKUP RINGS INSTALLED INCORRECTLY.
Narrative: DHC8-200, ACFT XYZ WAS GROUNDED AT ZZZ FOR AN EMER ENG REMOVAL AND REPLACEMENT. DURING INSPECTION AND DISASSEMBLY IT WAS FOUND THAT 2 PROP BLADES ON THIS ENG HAD NON-ALLOWABLE DEFECTS. THE PROP BLADES WERE REMOVED AND REPLACED MYSELF AND ANOTHER MECH. DURING RE-ASSEMBLY, A TEFLON BACKUP RING WAS IMPROPERLY INSTALLED UNDER THE MAIN RUBBER OIL SEAL ON EACH BLADE. MAINT INSTRUCTIONS FOR THIS PROC REFER TO THE RING BY DIFFERENT NAMES IN THE REMOVAL AND INSTALLATION PAPERWORK. I HAD BEEN ON DUTY APPROX 15 HRS ON THIS ENG CHANGE AND THE OTHER MECH HAD WORKED 18 HRS. HE HAD QUESTIONED LATER ON, THE RING REPLACEMENT, AND CALLED OUR SUPVR. MADE 1 NON-REVENUE FLT FROM ZZZ TO ZZA. IT WAS STOPPED SHORTLY BEFORE REVENUE DEP FROM ZZA, AND REPAIRED THERE. MAJOR REPAIR TO AN ACFT UNDER CONDITIONS. CONFUSING DUAL TERMINOLOGY IN MAINT INSTRUCTIONS. EXCESSIVE DUTY TIME REQUIRED TO GET JOB COMPLETE. BLADE REMOVAL AND REPLACEMENT NOT AN INSPECTION ITEM ON THIS ACFT AT THIS AIRLINE.
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.