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|
Attributes | |
ACN | 492087 |
Time | |
Date | 200011 |
Day | Mon |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Dash 8 Series Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 210 flight time total : 9300 flight time type : 6200 |
ASRS Report | 492087 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : multi engine pilot : commercial |
Events | |
Anomaly | maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : person 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : inspection |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
We flew the aircraft 4 legs. The first officer preflted the aircraft before dawn and did 3 subsequent postflt walkarounds in daylight. When we turned over the plane to the next crew, after our flying was over, the incoming first officer did a preflight. The incoming first officer came onto the aircraft and advised me that it appeared our underwing emergency exit was damaged. I looked at the exit, and then walked around to the other underwing emergency exit, and observed that the emergency exits were each on the wrong side. The mechanics installed them incorrectly during the last maintenance inspection. I was about the 3RD or 4TH crew to fly that aircraft and nobody noticed this. It had flown 2 days in this confign. I don't know how the first officer missed this on 4 separate walkarounds other than complacency. I, as captain, also could have done at least 1 walkaround as a check but did not.
Original NASA ASRS Text
Title: A DHC8 DURING A PREFLT CHK WAS FOUND TO HAVE THE UNDERWING EMER EXIT DOORS INSTALLED INCORRECTLY SWAPPED.
Narrative: WE FLEW THE ACFT 4 LEGS. THE FO PREFLTED THE ACFT BEFORE DAWN AND DID 3 SUBSEQUENT POSTFLT WALKAROUNDS IN DAYLIGHT. WHEN WE TURNED OVER THE PLANE TO THE NEXT CREW, AFTER OUR FLYING WAS OVER, THE INCOMING FO DID A PREFLT. THE INCOMING FO CAME ONTO THE ACFT AND ADVISED ME THAT IT APPEARED OUR UNDERWING EMER EXIT WAS DAMAGED. I LOOKED AT THE EXIT, AND THEN WALKED AROUND TO THE OTHER UNDERWING EMER EXIT, AND OBSERVED THAT THE EMER EXITS WERE EACH ON THE WRONG SIDE. THE MECHS INSTALLED THEM INCORRECTLY DURING THE LAST MAINT INSPECTION. I WAS ABOUT THE 3RD OR 4TH CREW TO FLY THAT ACFT AND NOBODY NOTICED THIS. IT HAD FLOWN 2 DAYS IN THIS CONFIGN. I DON'T KNOW HOW THE FO MISSED THIS ON 4 SEPARATE WALKAROUNDS OTHER THAN COMPLACENCY. I, AS CAPT, ALSO COULD HAVE DONE AT LEAST 1 WALKAROUND AS A CHK BUT DID NOT.
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.