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A bell 407 helicopter was dispatched in non compliance with the engine driven hydraulic pump installed incorrectly.
| Attributes | |
| ACN | 528357 |
| Time | |
| Date | 200110 |
| Day | Fri |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | tower : dbq.tower |
| Operator | general aviation : corporate |
| Make Model Name | Kiowa Warrior |
| Operating Under FAR Part | Part 91 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : corporate |
| Function | maintenance : lead technician |
| Qualification | technician : airframe technician : powerplant technician : inspection authority |
| Experience | maintenance lead technician : 18 maintenance technician : 24 |
| ASRS Report | 528357 |
| Person 2 | |
| Affiliation | company : corporate |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| Experience | maintenance technician : 10 |
| ASRS Report | 528093 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : manuals performance deficiency : installation performance deficiency : training performance deficiency : testing performance deficiency : inspection |
| Supplementary | |
| Problem Areas | Chart Or Publication Aircraft Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
I inspected and returned to service an aircraft that had a hydraulic pump installed incorrectly. The a&P mechanic that did the work had installed the pump 180 degrees out or upside down. The case drain line was installed on the wrong port. The aircraft was run up, leak checked and test flown with no problems or leaks. I returned the aircraft to service. After 2 hours of flying, the pump started to leak and drained the hydraulic system. The aircraft was landed safely and a loaner pump installed. The maintenance manual is not as clear as it could be, and the pump design could be improved, to keep the pump from being installed with the case drain hooked to the wrong port. I missed the case drain line hooked up wrong, which allowed fluid to leak out of the pump.
Original NASA ASRS Text
Title: A BELL 407 HELI WAS DISPATCHED IN NON COMPLIANCE WITH THE ENG DRIVEN HYD PUMP INSTALLED INCORRECTLY.
Narrative: I INSPECTED AND RETURNED TO SVC AN ACFT THAT HAD A HYD PUMP INSTALLED INCORRECTLY. THE A&P MECH THAT DID THE WORK HAD INSTALLED THE PUMP 180 DEGS OUT OR UPSIDE DOWN. THE CASE DRAIN LINE WAS INSTALLED ON THE WRONG PORT. THE ACFT WAS RUN UP, LEAK CHKED AND TEST FLOWN WITH NO PROBS OR LEAKS. I RETURNED THE ACFT TO SVC. AFTER 2 HRS OF FLYING, THE PUMP STARTED TO LEAK AND DRAINED THE HYD SYS. THE ACFT WAS LANDED SAFELY AND A LOANER PUMP INSTALLED. THE MAINT MANUAL IS NOT AS CLR AS IT COULD BE, AND THE PUMP DESIGN COULD BE IMPROVED, TO KEEP THE PUMP FROM BEING INSTALLED WITH THE CASE DRAIN HOOKED TO THE WRONG PORT. I MISSED THE CASE DRAIN LINE HOOKED UP WRONG, WHICH ALLOWED FLUID TO LEAK OUT OF THE PUMP.
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.