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Attributes | |
ACN | 519457 |
Time | |
Date | 200107 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier other |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 15 |
ASRS Report | 519457 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician oversight : supervisor |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other other : person #1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : briefing performance deficiency : scheduled maintenance performance deficiency : installation |
Supplementary | |
Problem Areas | Maintenance Human Performance Company Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
I work for a major airline that provides receipt/dispatch as well as contract maintenance for international carriers. The gate I was assigned had an overweight A320 from an international carrier, with a leaking hydraulic line on the r-hand main gear. Using my company's ipc, I idented the line as the r-hand inboard lock stay actuator flex line. I contacted the other carrier's line maintenance and confirmed that our ipc part number matched theirs. I obtained the new line and began installing it on the aircraft. I noticed that the manufacturer's number on the removed line did not match the line I was installing. I also noticed that the new line swiveled in the opposite direction as those already installed on the aircraft. I then checked all 4 lines (2 each gear) for part number in reference to the ipc. I found that all 4 lines didn't match the ipc and were installed with l-hand line part numbers on right gear and r-hand line part numbers installed on l-hand gear. I contacted the international carrier's line maintenance again and they as well as I couldn't believe that all 4 lines could be installed in the wrong position and that the ipc must be incorrect. In agreement with their line maintenance I installed the same part number line that I took off, accomplished the required leak/operations checks and the logbook was signed off and aircraft released for service. Several days later, I checked the lines installed on several of my company's A320's and found that they matched the ipc. I contacted the other carrier's line maintenance and informed them of my findings. They were researching a possible ipc problem. A callout was made to rechk the line installation and replace as necessary on the aircraft in question. The fact that this was the first trip of day (XA00), that the airplane was on the gate, and pressure from gate agents for on time departure all added to installing the wrong line. I also couldn't believe that someone else could install all 4 lines in the wrong position. Callback conversation with reporter revealed the following information: the reporter stated that after discovering the left main gear hose installed on the right main gear the foreign carrier's maintenance controller was advised of the condition. The reporter said the controller was advised to check the carrier's ipc to verify the incorrect installation. The reporter said the maintenance controller affirmed the incorrect installation and advised the reporter to replace the flexible line with the same part number removed. The airplane was dispatched with the left actuator hoses on the right landing gear and the right hoses on the left gear. The reporter said the difference in hoses is the swivel fitting built on the hoses which will not turn in the correct direction distorting and kinking the hoses.
Original NASA ASRS Text
Title: AN AIRBUS 320 WAS DISPATCHED IN NON COMPLIANCE WITH THE INCORRECT MAIN LNDG GEAR LOCK STAY ACTUATOR FLEXIBLE HYD LINES INSTALLED.
Narrative: I WORK FOR A MAJOR AIRLINE THAT PROVIDES RECEIPT/DISPATCH AS WELL AS CONTRACT MAINT FOR INTL CARRIERS. THE GATE I WAS ASSIGNED HAD AN OVERWT A320 FROM AN INTL CARRIER, WITH A LEAKING HYD LINE ON THE R-HAND MAIN GEAR. USING MY COMPANY'S IPC, I IDENTED THE LINE AS THE R-HAND INBOARD LOCK STAY ACTUATOR FLEX LINE. I CONTACTED THE OTHER CARRIER'S LINE MAINT AND CONFIRMED THAT OUR IPC PART NUMBER MATCHED THEIRS. I OBTAINED THE NEW LINE AND BEGAN INSTALLING IT ON THE ACFT. I NOTICED THAT THE MANUFACTURER'S NUMBER ON THE REMOVED LINE DID NOT MATCH THE LINE I WAS INSTALLING. I ALSO NOTICED THAT THE NEW LINE SWIVELED IN THE OPPOSITE DIRECTION AS THOSE ALREADY INSTALLED ON THE ACFT. I THEN CHKED ALL 4 LINES (2 EACH GEAR) FOR PART NUMBER IN REF TO THE IPC. I FOUND THAT ALL 4 LINES DIDN'T MATCH THE IPC AND WERE INSTALLED WITH L-HAND LINE PART NUMBERS ON R GEAR AND R-HAND LINE PART NUMBERS INSTALLED ON L-HAND GEAR. I CONTACTED THE INTL CARRIER'S LINE MAINT AGAIN AND THEY AS WELL AS I COULDN'T BELIEVE THAT ALL 4 LINES COULD BE INSTALLED IN THE WRONG POS AND THAT THE IPC MUST BE INCORRECT. IN AGREEMENT WITH THEIR LINE MAINT I INSTALLED THE SAME PART NUMBER LINE THAT I TOOK OFF, ACCOMPLISHED THE REQUIRED LEAK/OPS CHKS AND THE LOGBOOK WAS SIGNED OFF AND ACFT RELEASED FOR SVC. SEVERAL DAYS LATER, I CHKED THE LINES INSTALLED ON SEVERAL OF MY COMPANY'S A320'S AND FOUND THAT THEY MATCHED THE IPC. I CONTACTED THE OTHER CARRIER'S LINE MAINT AND INFORMED THEM OF MY FINDINGS. THEY WERE RESEARCHING A POSSIBLE IPC PROB. A CALLOUT WAS MADE TO RECHK THE LINE INSTALLATION AND REPLACE AS NECESSARY ON THE ACFT IN QUESTION. THE FACT THAT THIS WAS THE FIRST TRIP OF DAY (XA00), THAT THE AIRPLANE WAS ON THE GATE, AND PRESSURE FROM GATE AGENTS FOR ON TIME DEP ALL ADDED TO INSTALLING THE WRONG LINE. I ALSO COULDN'T BELIEVE THAT SOMEONE ELSE COULD INSTALL ALL 4 LINES IN THE WRONG POS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THAT AFTER DISCOVERING THE L MAIN GEAR HOSE INSTALLED ON THE R MAIN GEAR THE FOREIGN CARRIER'S MAINT CTLR WAS ADVISED OF THE CONDITION. THE RPTR SAID THE CTLR WAS ADVISED TO CHK THE CARRIER'S IPC TO VERIFY THE INCORRECT INSTALLATION. THE RPTR SAID THE MAINT CTLR AFFIRMED THE INCORRECT INSTALLATION AND ADVISED THE RPTR TO REPLACE THE FLEXIBLE LINE WITH THE SAME PART NUMBER REMOVED. THE AIRPLANE WAS DISPATCHED WITH THE L ACTUATOR HOSES ON THE R LNDG GEAR AND THE R HOSES ON THE L GEAR. THE RPTR SAID THE DIFFERENCE IN HOSES IS THE SWIVEL FITTING BUILT ON THE HOSES WHICH WILL NOT TURN IN THE CORRECT DIRECTION DISTORTING AND KINKING THE HOSES.
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.