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|
Attributes | |
ACN | 540214 |
Time | |
Date | 200203 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Super King Air 200 HDC |
Operating Under FAR Part | Part 121 |
Person 1 | |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 5 |
ASRS Report | 540214 |
Person 2 | |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : elevator trim wheel missing other flight crewa other flight crewb |
Resolutory Action | flight crew : diverted to another airport |
Consequence | other |
Factors | |
Maintenance | contributing factor : briefing contributing factor : engineering procedure contributing factor : lighting performance deficiency : testing performance deficiency : unqualified personnel performance deficiency : inspection performance deficiency : installation |
Supplementary | |
Problem Areas | Aircraft Environmental Factor Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
The pilot on a ferry flight returned to the airport due to 'trim problems' for the elevator. It was discovered on inspection that the trim gear wheel was not installed on the bar which holds the throttle levers/condition levers/propeller controls. The condition levers had been removed 2 months prior for another aircraft and the aircraft was left disassembled for that period of time. 2 days prior to this incident, I was asked to reinstall the condition levers due to the fact the aircraft was to be ferried to another facility. (The engines and propellers were installed by another visiting crew!) the condition levers were installed and with no battery installed, a test of the system was not possible at the time of installation. No post installation inspection was carried out, and no system check carried out at this time by myself. At the time the condition levers were removed, the aircraft was stored in an unlighted hangar. Lighting was poor to non existent and the pilot's side kick panel on the control pedestal was not removed. It was not removed at the time of installation either. After the visiting crew completed their work, the aircraft was inspected by them and released for the one time ferry flight. A request was made by one of their technicians to inspect the tail area, and I offered them a hydraulic stairs to complete their inspection. This was declined. All the parts that were removed from the aircraft were reinstalled and copies of the 8130's were given to the visiting crew. No questions about how, why, where, when, what were asked by the visiting crew to myself, so I did not give them specific details on the parts installed. Failure to install the parts in the pedestal correctly, and failure to inspect, test, and check the system correctly were considerations. Failure to communicate the sequence of parts removed to the visiting crew were contributing factors that led to this event. The time lapse from removal to installation were considerations, as was the lighting in the storage hangar at the time of removal. The aircraft was to be salvaged or scrapped 1 week prior to its ferry flight due to economic costs of repair from a gear up landing it was not to be returned to service. All work carried out by the visiting crew was completed by them and offers of our help were declined.
Original NASA ASRS Text
Title: A BEECH KING AIR 200 WAS DISPATCHED ON A FERRY FLT IN NON COMPLIANCE WITH FAR'S WITH THE ELEVATOR TRIM WHEEL MISSING FROM THE CTR PEDESTAL.
Narrative: THE PLT ON A FERRY FLT RETURNED TO THE ARPT DUE TO 'TRIM PROBS' FOR THE ELEVATOR. IT WAS DISCOVERED ON INSPECTION THAT THE TRIM GEAR WHEEL WAS NOT INSTALLED ON THE BAR WHICH HOLDS THE THROTTLE LEVERS/CONDITION LEVERS/PROP CTLS. THE CONDITION LEVERS HAD BEEN REMOVED 2 MONTHS PRIOR FOR ANOTHER ACFT AND THE ACFT WAS LEFT DISASSEMBLED FOR THAT PERIOD OF TIME. 2 DAYS PRIOR TO THIS INCIDENT, I WAS ASKED TO REINSTALL THE CONDITION LEVERS DUE TO THE FACT THE ACFT WAS TO BE FERRIED TO ANOTHER FACILITY. (THE ENGS AND PROPS WERE INSTALLED BY ANOTHER VISITING CREW!) THE CONDITION LEVERS WERE INSTALLED AND WITH NO BATTERY INSTALLED, A TEST OF THE SYS WAS NOT POSSIBLE AT THE TIME OF INSTALLATION. NO POST INSTALLATION INSPECTION WAS CARRIED OUT, AND NO SYS CHK CARRIED OUT AT THIS TIME BY MYSELF. AT THE TIME THE CONDITION LEVERS WERE REMOVED, THE ACFT WAS STORED IN AN UNLIGHTED HANGAR. LIGHTING WAS POOR TO NON EXISTENT AND THE PLT'S SIDE KICK PANEL ON THE CTL PEDESTAL WAS NOT REMOVED. IT WAS NOT REMOVED AT THE TIME OF INSTALLATION EITHER. AFTER THE VISITING CREW COMPLETED THEIR WORK, THE ACFT WAS INSPECTED BY THEM AND RELEASED FOR THE ONE TIME FERRY FLT. A REQUEST WAS MADE BY ONE OF THEIR TECHNICIANS TO INSPECT THE TAIL AREA, AND I OFFERED THEM A HYD STAIRS TO COMPLETE THEIR INSPECTION. THIS WAS DECLINED. ALL THE PARTS THAT WERE REMOVED FROM THE ACFT WERE REINSTALLED AND COPIES OF THE 8130'S WERE GIVEN TO THE VISITING CREW. NO QUESTIONS ABOUT HOW, WHY, WHERE, WHEN, WHAT WERE ASKED BY THE VISITING CREW TO MYSELF, SO I DID NOT GIVE THEM SPECIFIC DETAILS ON THE PARTS INSTALLED. FAILURE TO INSTALL THE PARTS IN THE PEDESTAL CORRECTLY, AND FAILURE TO INSPECT, TEST, AND CHK THE SYS CORRECTLY WERE CONSIDERATIONS. FAILURE TO COMMUNICATE THE SEQUENCE OF PARTS REMOVED TO THE VISITING CREW WERE CONTRIBUTING FACTORS THAT LED TO THIS EVENT. THE TIME LAPSE FROM REMOVAL TO INSTALLATION WERE CONSIDERATIONS, AS WAS THE LIGHTING IN THE STORAGE HANGAR AT THE TIME OF REMOVAL. THE ACFT WAS TO BE SALVAGED OR SCRAPPED 1 WK PRIOR TO ITS FERRY FLT DUE TO ECONOMIC COSTS OF REPAIR FROM A GEAR UP LNDG IT WAS NOT TO BE RETURNED TO SVC. ALL WORK CARRIED OUT BY THE VISITING CREW WAS COMPLETED BY THEM AND OFFERS OF OUR HELP WERE DECLINED.
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.