37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 494774 |
Time | |
Date | 200012 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
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 | DC-9 50 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 14 |
ASRS Report | 494774 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals performance deficiency : repair |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication Company |
Primary Problem | Chart Or Publication |
Situations | |
Publication | MAINT MANUAL WIRE DIAGRAMS |
Narrative:
Pilot write-up: spoiler/flap extended light and master caution light were illuminating on touchdown with wheel spin-up. Based on our current wiring diagrams and maintenance manual for this aircraft, I believed the system to be operating normally. I released the aircraft for flight on these log page numbers: ybxy, ybxz. Due to pilot concern the following day, engineering found this aircraft had been modified by the previous carrier and an applicable maintenance manual was found. Upon receiving this maintenance manual, I discovered that I misinterped the wiring diagrams and the system was indeed faulty. The same day, I found the faulty wire and repaired as required. The system was tested operational per this applicable maintenance manual. To prevent future problems, the previous carrier manuals should be incorporated into our current set of maintenance manuals. Callback conversation with reporter revealed the following information: the reporter stated the wire diagrams and maintenance manual references were not idented as to the effectivity of the document to fleet hull numbers. The reporter said he used the wire diagrams and maintenance manual procedures to troubleshoot the spoiler system and found no discrepancy. The reporter said he then signed off the report and released the airplane for service. The reporter stated the airplane came back with a repeat report of spoiler and spoiler indication problems. The reporter said engineering was advised and it was discovered the reporter had used the wrong documentation. The reporter stated the correct effectivity documentation had not been incorporated into the maintenance manual and wire diagrams.
Original NASA ASRS Text
Title: A DC9-50 RPTED SPOILER PROB WAS GND TESTED OK AND RELEASED, BUT WHEN PROB WAS RPTED AGAIN IT WAS FOUND THE REPAIR WAS DONE WITH THE WRONG MANUALS.
Narrative: PLT WRITE-UP: SPOILER/FLAP EXTENDED LIGHT AND MASTER CAUTION LIGHT WERE ILLUMINATING ON TOUCHDOWN WITH WHEEL SPIN-UP. BASED ON OUR CURRENT WIRING DIAGRAMS AND MAINT MANUAL FOR THIS ACFT, I BELIEVED THE SYS TO BE OPERATING NORMALLY. I RELEASED THE ACFT FOR FLT ON THESE LOG PAGE NUMBERS: YBXY, YBXZ. DUE TO PLT CONCERN THE FOLLOWING DAY, ENGINEERING FOUND THIS ACFT HAD BEEN MODIFIED BY THE PREVIOUS CARRIER AND AN APPLICABLE MAINT MANUAL WAS FOUND. UPON RECEIVING THIS MAINT MANUAL, I DISCOVERED THAT I MISINTERPED THE WIRING DIAGRAMS AND THE SYS WAS INDEED FAULTY. THE SAME DAY, I FOUND THE FAULTY WIRE AND REPAIRED AS REQUIRED. THE SYS WAS TESTED OPERATIONAL PER THIS APPLICABLE MAINT MANUAL. TO PREVENT FUTURE PROBS, THE PREVIOUS CARRIER MANUALS SHOULD BE INCORPORATED INTO OUR CURRENT SET OF MAINT MANUALS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE WIRE DIAGRAMS AND MAINT MANUAL REFS WERE NOT IDENTED AS TO THE EFFECTIVITY OF THE DOCUMENT TO FLEET HULL NUMBERS. THE RPTR SAID HE USED THE WIRE DIAGRAMS AND MAINT MANUAL PROCS TO TROUBLESHOOT THE SPOILER SYS AND FOUND NO DISCREPANCY. THE RPTR SAID HE THEN SIGNED OFF THE RPT AND RELEASED THE AIRPLANE FOR SVC. THE RPTR STATED THE AIRPLANE CAME BACK WITH A REPEAT RPT OF SPOILER AND SPOILER INDICATION PROBS. THE RPTR SAID ENGINEERING WAS ADVISED AND IT WAS DISCOVERED THE RPTR HAD USED THE WRONG DOCUMENTATION. THE RPTR STATED THE CORRECT EFFECTIVITY DOCUMENTATION HAD NOT BEEN INCORPORATED INTO THE MAINT MANUAL AND WIRE DIAGRAMS.
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.