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Attributes | |
ACN | 561705 |
Time | |
Date | 200209 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Dash 8-400 |
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 pilot : multi engine |
Experience | flight time last 90 days : 200 flight time total : 12750 flight time type : 1100 |
ASRS Report | 561705 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
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 : flap drive warning light other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other other other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : fault isolation performance deficiency : inspection performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Maintenance Human Performance Flight Crew Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | MAINT PROCS |
Narrative:
Upon entry into the airport environment, I selected flaps 5 degrees for landing, flaps 15 degree landing checklist. At this point, on the caution advisory panel, there was an advisory light for 'flap drive' -- noted flaps at approximately 10 degrees. Reset landing bugs for a flaps 10 degree landing, continued the approach and landing. Landing was uneventful. Upon taxiing into ZZZ, contacted company's maintenance control via cell call. Reported 'flap drive' caution light and that we were parking in ZZZ. After engine shutdown and passenger deplaned, company maintenance arrived, noted the 'flap drive' caution light and flaps 10 degrees. Observed maintenance proceeding to correct 'flap drive' caution light by resetting circuit breakers. Maintenance proceeded to check the arcdu. Aircraft was cleared of discrepancy and passenger boarded the aircraft for departure to ZZZ1. Prior to departure, maintenance came back with the maintenance logbook signed off. The mechanic provided a service letter of sorts explaining pilot induced causes for 'flap power' caution light (specific write-up in the logbook was for 'flap drive' caution light). We were puzzled as to the relevance to the 'flap drive' light. My comment to my first officer prior to the engine start and pushback was 'I don't think this is going to work' due to the fact that maintenance never ran the aircraft to reset the flaps after we shut the aircraft down. After pushback, flaps were selected at 15 degrees. Immediately with flap selection, we received a 'flap drive' caution light. We proceeded back to the gate, shut down and asked for maintenance. The same maintenance personnel arrived at the aircraft and this time they reset the circuit breaker and 'flap drive' caution light was extinguished. To verify fault, they had us start #2 engine, selected flaps 35 degrees with the standby pump on. Flaps were extending to flaps 35 degrees, but this time very slowly. They had us start #1 engine, and selected flaps to 0 degrees after 35 degrees -- trying to recreate the 'flap drive' caution problem. This scenario continued for 4-6 cycles. The 'flap drive' caution light would extinguish any time the flaps were anything more than approximately 5 degrees and would extend normally. Only upon retraction at flaps 5 degrees would we get the 'flap drive' caution light. The 'flap drive' caution light would extinguish without resetting any circuit breakers -- simply by flaps setting being more than 5 degrees the light would extinguish. At this point, maintenance had us deplane the aircraft and subsequently this flight was canceled. Maintenance continued their work. Approximately 1.5 hours later, we were informed that we were to ferry the aircraft to ZZZ2 maintenance facility. We received a logbook with a ferry permit. We were instructed to fly the aircraft at flaps 5 degrees for the duration of the flight. They also stated that if additional flaps were required, we were not to retract flaps to less than 5 degrees after use. During the flight we did not exceed 160 KTS. We maintained flaps 5 degrees for the duration of the flight with the 'flap drive' caution light illuminated. As the captain, I endorsed to land flaps 35 degrees. During the approach and landing, we selected flaps 5-15 degrees. As soon as we were out of the flaps 5 degree detent, the caution light was extinguished. From 15-35 degrees, no other caution lights were illuminated and the landing was uneventful. During taxi in, flaps were selected to 5 degrees. As soon as flaps retracted to 5 degrees, the 'flap drive' caution light illuminated once again. Upon parking, I inspected wing flaps and noted them to be approximately 5 degrees. We were misled by maintenance personnel to use something other than flaps 5 degrees for landing. More importantly, additional information is being revealed by hearsay from other maintenance personnel, that our maintenance management has disregarded a service bulletin received about flap drive mechanisms coming loose in the Q400 series aircraft. The decision to ferry this aircraft by maintenance personnel, assuming that it was some sort of software or microswitch problem, in fact jeopardized our lives. It is unknown to me whether or not the maintenance in ZZZ, who signed off for us to ferry this aircraft, were aware of the service bulletin. In actuality, it was an internal worm drive failure which caused major damage to the internal part of the aircraft wing. Callback conversation with reporter revealed the following information: the reporter stated that at the termination of the maintenance ferry, the airplane was inspected and it was discovered the flap drive mechanism failure caused major damage to the aircraft wing. The reporter said the Q400 dash 8 is a new airplane and the service bulletin reporting on the flap drive unit coming loose was going to be inspected at the next heavy maintenance check and corrected as needed. The reporter stated when this airplane was found to have flap drive unit failure with wing damage, an immediate inspection was initiated on the fleet where several other flap drive unit failures were discovered. The reporter said the technicians at the smaller stations should have been aware of the service bulletin and if not, a flap drive visual inspection was required for safe flight.
Original NASA ASRS Text
Title: AN AVRO RJ85 WAS DISPATCHED ON A MAINT FERRY IN NON COMPLIANCE WITH THE FLC GIVEN INADEQUATE AND ERRONEOUS ACFT FAULT INFO.
Narrative: UPON ENTRY INTO THE ARPT ENVIRONMENT, I SELECTED FLAPS 5 DEGS FOR LNDG, FLAPS 15 DEG LNDG CHKLIST. AT THIS POINT, ON THE CAUTION ADVISORY PANEL, THERE WAS AN ADVISORY LIGHT FOR 'FLAP DRIVE' -- NOTED FLAPS AT APPROX 10 DEGS. RESET LNDG BUGS FOR A FLAPS 10 DEG LNDG, CONTINUED THE APCH AND LNDG. LNDG WAS UNEVENTFUL. UPON TAXIING INTO ZZZ, CONTACTED COMPANY'S MAINT CTL VIA CELL CALL. RPTED 'FLAP DRIVE' CAUTION LIGHT AND THAT WE WERE PARKING IN ZZZ. AFTER ENG SHUTDOWN AND PAX DEPLANED, COMPANY MAINT ARRIVED, NOTED THE 'FLAP DRIVE' CAUTION LIGHT AND FLAPS 10 DEGS. OBSERVED MAINT PROCEEDING TO CORRECT 'FLAP DRIVE' CAUTION LIGHT BY RESETTING CIRCUIT BREAKERS. MAINT PROCEEDED TO CHK THE ARCDU. ACFT WAS CLRED OF DISCREPANCY AND PAX BOARDED THE ACFT FOR DEP TO ZZZ1. PRIOR TO DEP, MAINT CAME BACK WITH THE MAINT LOGBOOK SIGNED OFF. THE MECH PROVIDED A SVC LETTER OF SORTS EXPLAINING PLT INDUCED CAUSES FOR 'FLAP PWR' CAUTION LIGHT (SPECIFIC WRITE-UP IN THE LOGBOOK WAS FOR 'FLAP DRIVE' CAUTION LIGHT). WE WERE PUZZLED AS TO THE RELEVANCE TO THE 'FLAP DRIVE' LIGHT. MY COMMENT TO MY FO PRIOR TO THE ENG START AND PUSHBACK WAS 'I DON'T THINK THIS IS GOING TO WORK' DUE TO THE FACT THAT MAINT NEVER RAN THE ACFT TO RESET THE FLAPS AFTER WE SHUT THE ACFT DOWN. AFTER PUSHBACK, FLAPS WERE SELECTED AT 15 DEGS. IMMEDIATELY WITH FLAP SELECTION, WE RECEIVED A 'FLAP DRIVE' CAUTION LIGHT. WE PROCEEDED BACK TO THE GATE, SHUT DOWN AND ASKED FOR MAINT. THE SAME MAINT PERSONNEL ARRIVED AT THE ACFT AND THIS TIME THEY RESET THE CIRCUIT BREAKER AND 'FLAP DRIVE' CAUTION LIGHT WAS EXTINGUISHED. TO VERIFY FAULT, THEY HAD US START #2 ENG, SELECTED FLAPS 35 DEGS WITH THE STANDBY PUMP ON. FLAPS WERE EXTENDING TO FLAPS 35 DEGS, BUT THIS TIME VERY SLOWLY. THEY HAD US START #1 ENG, AND SELECTED FLAPS TO 0 DEGS AFTER 35 DEGS -- TRYING TO RECREATE THE 'FLAP DRIVE' CAUTION PROB. THIS SCENARIO CONTINUED FOR 4-6 CYCLES. THE 'FLAP DRIVE' CAUTION LIGHT WOULD EXTINGUISH ANY TIME THE FLAPS WERE ANYTHING MORE THAN APPROX 5 DEGS AND WOULD EXTEND NORMALLY. ONLY UPON RETRACTION AT FLAPS 5 DEGS WOULD WE GET THE 'FLAP DRIVE' CAUTION LIGHT. THE 'FLAP DRIVE' CAUTION LIGHT WOULD EXTINGUISH WITHOUT RESETTING ANY CIRCUIT BREAKERS -- SIMPLY BY FLAPS SETTING BEING MORE THAN 5 DEGS THE LIGHT WOULD EXTINGUISH. AT THIS POINT, MAINT HAD US DEPLANE THE ACFT AND SUBSEQUENTLY THIS FLT WAS CANCELED. MAINT CONTINUED THEIR WORK. APPROX 1.5 HRS LATER, WE WERE INFORMED THAT WE WERE TO FERRY THE ACFT TO ZZZ2 MAINT FACILITY. WE RECEIVED A LOGBOOK WITH A FERRY PERMIT. WE WERE INSTRUCTED TO FLY THE ACFT AT FLAPS 5 DEGS FOR THE DURATION OF THE FLT. THEY ALSO STATED THAT IF ADDITIONAL FLAPS WERE REQUIRED, WE WERE NOT TO RETRACT FLAPS TO LESS THAN 5 DEGS AFTER USE. DURING THE FLT WE DID NOT EXCEED 160 KTS. WE MAINTAINED FLAPS 5 DEGS FOR THE DURATION OF THE FLT WITH THE 'FLAP DRIVE' CAUTION LIGHT ILLUMINATED. AS THE CAPT, I ENDORSED TO LAND FLAPS 35 DEGS. DURING THE APCH AND LNDG, WE SELECTED FLAPS 5-15 DEGS. AS SOON AS WE WERE OUT OF THE FLAPS 5 DEG DETENT, THE CAUTION LIGHT WAS EXTINGUISHED. FROM 15-35 DEGS, NO OTHER CAUTION LIGHTS WERE ILLUMINATED AND THE LNDG WAS UNEVENTFUL. DURING TAXI IN, FLAPS WERE SELECTED TO 5 DEGS. AS SOON AS FLAPS RETRACTED TO 5 DEGS, THE 'FLAP DRIVE' CAUTION LIGHT ILLUMINATED ONCE AGAIN. UPON PARKING, I INSPECTED WING FLAPS AND NOTED THEM TO BE APPROX 5 DEGS. WE WERE MISLED BY MAINT PERSONNEL TO USE SOMETHING OTHER THAN FLAPS 5 DEGS FOR LNDG. MORE IMPORTANTLY, ADDITIONAL INFO IS BEING REVEALED BY HEARSAY FROM OTHER MAINT PERSONNEL, THAT OUR MAINT MGMNT HAS DISREGARDED A SVC BULLETIN RECEIVED ABOUT FLAP DRIVE MECHANISMS COMING LOOSE IN THE Q400 SERIES ACFT. THE DECISION TO FERRY THIS ACFT BY MAINT PERSONNEL, ASSUMING THAT IT WAS SOME SORT OF SOFTWARE OR MICROSWITCH PROB, IN FACT JEOPARDIZED OUR LIVES. IT IS UNKNOWN TO ME WHETHER OR NOT THE MAINT IN ZZZ, WHO SIGNED OFF FOR US TO FERRY THIS ACFT, WERE AWARE OF THE SVC BULLETIN. IN ACTUALITY, IT WAS AN INTERNAL WORM DRIVE FAILURE WHICH CAUSED MAJOR DAMAGE TO THE INTERNAL PART OF THE ACFT WING. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THAT AT THE TERMINATION OF THE MAINT FERRY, THE AIRPLANE WAS INSPECTED AND IT WAS DISCOVERED THE FLAP DRIVE MECHANISM FAILURE CAUSED MAJOR DAMAGE TO THE ACFT WING. THE RPTR SAID THE Q400 DASH 8 IS A NEW AIRPLANE AND THE SVC BULLETIN RPTING ON THE FLAP DRIVE UNIT COMING LOOSE WAS GOING TO BE INSPECTED AT THE NEXT HVY MAINT CHK AND CORRECTED AS NEEDED. THE RPTR STATED WHEN THIS AIRPLANE WAS FOUND TO HAVE FLAP DRIVE UNIT FAILURE WITH WING DAMAGE, AN IMMEDIATE INSPECTION WAS INITIATED ON THE FLEET WHERE SEVERAL OTHER FLAP DRIVE UNIT FAILURES WERE DISCOVERED. THE RPTR SAID THE TECHNICIANS AT THE SMALLER STATIONS SHOULD HAVE BEEN AWARE OF THE SVC BULLETIN AND IF NOT, A FLAP DRIVE VISUAL INSPECTION WAS REQUIRED FOR SAFE FLT.
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.