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Attributes | |
ACN | 522513 |
Time | |
Date | 200010 |
Day | Thu |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tower : mmun.tower |
Operator | general aviation : personal |
Make Model Name | PA-32 Cherokee Six/Lance/Saratoga |
Operating Under FAR Part | Part 91 |
Person 1 | |
Affiliation | other |
Function | maintenance : inspector |
Qualification | technician : powerplant technician : inspection authority technician : airframe |
Experience | maintenance technician : 14 |
ASRS Report | 522513 |
Person 2 | |
Affiliation | other |
Function | flight crew : single pilot |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : oil press indicator other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Environmental Factor Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Chart Or Publication |
Narrative:
This report is being made to identify missing compliance with ad 2000-18-53R/textran lycoming SB543A. During 10-200 annual inspection, signed aircraft for return to service and all ads complied with. However, textran/lycoming SB543A supplement 1 was forthcoming and parts on order. Bottom line is that parts/procedures were not installed as confusion existed as to impact of SB543A supplement 1 and FAA ad 2000-18-53R's 'pending update.' intent was to comply with revised ad/service bulletin supplement 1 once 'settled' and parts available. Textran/lycoming/FAA notification to owner was to 'trigger reminder' for next oil change. Owner does not recollect receiving such notification and parts were never installed resulting in non compliance with ad 2000-18-53A, engine failure and aircraft damage. Contributing factors were confusion on compliance methods, judgement to comply 'once settled and parts available,' and subsequent oversight of compliance with subsequent oil changes. Callback conversation with reporter revealed the following information: the reporter stated that when the annual inspection was completed the ad 2000-18-53R was in a pending update state. The reporter said the parts required were unavailable. The reporter stated the ad required the owner to replace the oil filter every 50 hours and use a new type oil seal not yet available. The reporter said the problem is the way the directive was written prior to later revision would require an inspector after each oil filter replacement. The reporter stated that much later it was decided the owner would replace the seal and filter without inspection. The reporter said this engine failed and the problem may be the owner did not use the new type seal. The reporter stated the FAA has not made contact with the reporter.
Original NASA ASRS Text
Title: A PIPER PA32 ANNUAL INSPECTION WAS COMPLETED AND ALL ADS WERE SIGNED OFF. ONE AD WAS IN REVISION AND NO PARTS WERE AVAILABLE. OWNER AND TECHNICIAN AGREED TO SIGN OFF.
Narrative: THIS RPT IS BEING MADE TO IDENT MISSING COMPLIANCE WITH AD 2000-18-53R/TEXTRAN LYCOMING SB543A. DURING 10-200 ANNUAL INSPECTION, SIGNED ACFT FOR RETURN TO SVC AND ALL ADS COMPLIED WITH. HOWEVER, TEXTRAN/LYCOMING SB543A SUPPLEMENT 1 WAS FORTHCOMING AND PARTS ON ORDER. BOTTOM LINE IS THAT PARTS/PROCS WERE NOT INSTALLED AS CONFUSION EXISTED AS TO IMPACT OF SB543A SUPPLEMENT 1 AND FAA AD 2000-18-53R'S 'PENDING UPDATE.' INTENT WAS TO COMPLY WITH REVISED AD/SVC BULLETIN SUPPLEMENT 1 ONCE 'SETTLED' AND PARTS AVAILABLE. TEXTRAN/LYCOMING/FAA NOTIFICATION TO OWNER WAS TO 'TRIGGER REMINDER' FOR NEXT OIL CHANGE. OWNER DOES NOT RECOLLECT RECEIVING SUCH NOTIFICATION AND PARTS WERE NEVER INSTALLED RESULTING IN NON COMPLIANCE WITH AD 2000-18-53A, ENG FAILURE AND ACFT DAMAGE. CONTRIBUTING FACTORS WERE CONFUSION ON COMPLIANCE METHODS, JUDGEMENT TO COMPLY 'ONCE SETTLED AND PARTS AVAILABLE,' AND SUBSEQUENT OVERSIGHT OF COMPLIANCE WITH SUBSEQUENT OIL CHANGES. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THAT WHEN THE ANNUAL INSPECTION WAS COMPLETED THE AD 2000-18-53R WAS IN A PENDING UPDATE STATE. THE RPTR SAID THE PARTS REQUIRED WERE UNAVAILABLE. THE RPTR STATED THE AD REQUIRED THE OWNER TO REPLACE THE OIL FILTER EVERY 50 HRS AND USE A NEW TYPE OIL SEAL NOT YET AVAILABLE. THE RPTR SAID THE PROB IS THE WAY THE DIRECTIVE WAS WRITTEN PRIOR TO LATER REVISION WOULD REQUIRE AN INSPECTOR AFTER EACH OIL FILTER REPLACEMENT. THE RPTR STATED THAT MUCH LATER IT WAS DECIDED THE OWNER WOULD REPLACE THE SEAL AND FILTER WITHOUT INSPECTION. THE RPTR SAID THIS ENG FAILED AND THE PROB MAY BE THE OWNER DID NOT USE THE NEW TYPE SEAL. THE RPTR STATED THE FAA HAS NOT MADE CONTACT WITH THE RPTR.
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.