37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 503911 |
Time | |
Date | 200103 |
Day | Thu |
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 | common carrier : air carrier |
Make Model Name | DC-9 30 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 120 flight time total : 12000 |
ASRS Report | 503911 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Independent Detector | other other : 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : installation |
Supplementary | |
Problem Areas | Company Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
I was informed on mar/sat/01 that I flew aircraft xyz on mar/thu/01 with the wrong ram air temperature EPR gauge installed. Aircraft is equipped with JT8D-7 engines. The gauge installed was a JT8D-9 gauge. The preflight of aircraft was very hectic -- late inbound, copilot was late (I did entire preflight/set-up), maintenance on board dealing with electrical problem, numerous flight attendant requests, flight release amendments, on and on. When things settled down I noticed ram air temperature/EPR gauge was reading erroneously high (+28 degrees C with outside air temperature at +4 degrees C). This of course gets maintenance back on board to change out gauge. That completed, we pushed off gate. I simply didn't notice that maintenance installed a -9 ram air temperature/EPR gauge. The differences between a -9 and -7 gauge are very subtle, compounded by the fact only 3 of our DC9-30's have -7 engines -- it is very common to see the higher EPR settings of the -9. No where in any of our manuals and no time during training is it stressed to verify the proper ram air temperature/EPR gauge is installed.
Original NASA ASRS Text
Title: A DC9-30 WAS DISPATCHED IN NON COMPLIANCE WITH THE WRONG ENG RAM AIR TEMP ENG PRESSURE RATIO INDICATOR INSTALLED IN #1 ENG POS.
Narrative: I WAS INFORMED ON MAR/SAT/01 THAT I FLEW ACFT XYZ ON MAR/THU/01 WITH THE WRONG RAM AIR TEMP EPR GAUGE INSTALLED. ACFT IS EQUIPPED WITH JT8D-7 ENGS. THE GAUGE INSTALLED WAS A JT8D-9 GAUGE. THE PREFLT OF ACFT WAS VERY HECTIC -- LATE INBOUND, COPLT WAS LATE (I DID ENTIRE PREFLT/SET-UP), MAINT ON BOARD DEALING WITH ELECTRICAL PROB, NUMEROUS FLT ATTENDANT REQUESTS, FLT RELEASE AMENDMENTS, ON AND ON. WHEN THINGS SETTLED DOWN I NOTICED RAM AIR TEMP/EPR GAUGE WAS READING ERRONEOUSLY HIGH (+28 DEGS C WITH OUTSIDE AIR TEMP AT +4 DEGS C). THIS OF COURSE GETS MAINT BACK ON BOARD TO CHANGE OUT GAUGE. THAT COMPLETED, WE PUSHED OFF GATE. I SIMPLY DIDN'T NOTICE THAT MAINT INSTALLED A -9 RAM AIR TEMP/EPR GAUGE. THE DIFFERENCES BTWN A -9 AND -7 GAUGE ARE VERY SUBTLE, COMPOUNDED BY THE FACT ONLY 3 OF OUR DC9-30'S HAVE -7 ENGS -- IT IS VERY COMMON TO SEE THE HIGHER EPR SETTINGS OF THE -9. NO WHERE IN ANY OF OUR MANUALS AND NO TIME DURING TRAINING IS IT STRESSED TO VERIFY THE PROPER RAM AIR TEMP/EPR GAUGE IS INSTALLED.
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.