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|
Attributes | |
ACN | 616780 |
Time | |
Date | 200405 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | general aviation : instructional |
Make Model Name | PA-28 Cherokee/Archer II/Dakota/Pillan/Warrior |
Operating Under FAR Part | Part 91 |
Flight Phase | ground : parked |
Person 1 | |
Affiliation | other |
Function | maintenance : inspector maintenance : technician |
Qualification | technician : powerplant technician : airframe technician : inspection authority |
Experience | maintenance lead technician : 16 maintenance technician : 5 |
ASRS Report | 616780 |
Person 2 | |
Affiliation | other |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : person 1 |
Resolutory Action | none taken : detected after the fact other |
Consequence | other other Other |
Factors | |
Maintenance | contributing factor : non availability of parts performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : logbook entry performance deficiency : inspection performance deficiency : installation |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance FAA Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Airworthiness Directive |
Narrative:
Discovered oversight during routine phase inspection of company aircraft that airworthiness directive 95-26-13, oil cooler hose inspection/replacement was overdue. Further investigation revealed that 2 other company aircraft were also overdue. All 3 aircraft are currently grounded and are awaiting replacement of oil cooler hose assemblies conforming to tso-C53A, type D, which when installed, terminates the repetitive inspection/replacement requirements of the airworthiness directive. During the most recent engine change on each of the affected aircraft, the oil cooler hose assemblies were replaced with tso-C53A, type C hoses, which requires repetitive inspections at 100 hour intervals and replacement at each 1000 hour interval or 8 yrs, whichever is first. Records show that no inspections or replacements took place after the hose assemblies were installed and that each aircraft are overdue for hose replacement. 1) airworthiness directive 95-26-13 was previously complied with by installation to tso-C53A, type D hose assemblies and were signed off in all 3 affected aircraft logbooks as 'no further action required' and the airworthiness directive then listed as a non-recurring airworthiness directive. 2) during the most recent engine change, the type D hoses were sent out as samples for fabrication by an outside hose shop and type C hoses were substituted and returned. 3) failure to recognize substitution of hose type prior to installation of hose assemblies and that repetitive inspection/replacement of the type C hoses were now required.
Original NASA ASRS Text
Title: 3 PA28 ACFT WERE OPERATED IN NON COMPLIANCE OF AN AIRWORTHINESS DIRECTIVE WHEN NON CONFORMING OIL COOLER HOSES WERE INSTALLED.
Narrative: DISCOVERED OVERSIGHT DURING ROUTINE PHASE INSPECTION OF COMPANY ACFT THAT AIRWORTHINESS DIRECTIVE 95-26-13, OIL COOLER HOSE INSPECTION/REPLACEMENT WAS OVERDUE. FURTHER INVESTIGATION REVEALED THAT 2 OTHER COMPANY ACFT WERE ALSO OVERDUE. ALL 3 ACFT ARE CURRENTLY GNDED AND ARE AWAITING REPLACEMENT OF OIL COOLER HOSE ASSEMBLIES CONFORMING TO TSO-C53A, TYPE D, WHICH WHEN INSTALLED, TERMINATES THE REPETITIVE INSPECTION/REPLACEMENT REQUIREMENTS OF THE AIRWORTHINESS DIRECTIVE. DURING THE MOST RECENT ENG CHANGE ON EACH OF THE AFFECTED ACFT, THE OIL COOLER HOSE ASSEMBLIES WERE REPLACED WITH TSO-C53A, TYPE C HOSES, WHICH REQUIRES REPETITIVE INSPECTIONS AT 100 HR INTERVALS AND REPLACEMENT AT EACH 1000 HR INTERVAL OR 8 YRS, WHICHEVER IS FIRST. RECORDS SHOW THAT NO INSPECTIONS OR REPLACEMENTS TOOK PLACE AFTER THE HOSE ASSEMBLIES WERE INSTALLED AND THAT EACH ACFT ARE OVERDUE FOR HOSE REPLACEMENT. 1) AIRWORTHINESS DIRECTIVE 95-26-13 WAS PREVIOUSLY COMPLIED WITH BY INSTALLATION TO TSO-C53A, TYPE D HOSE ASSEMBLIES AND WERE SIGNED OFF IN ALL 3 AFFECTED ACFT LOGBOOKS AS 'NO FURTHER ACTION REQUIRED' AND THE AIRWORTHINESS DIRECTIVE THEN LISTED AS A NON-RECURRING AIRWORTHINESS DIRECTIVE. 2) DURING THE MOST RECENT ENG CHANGE, THE TYPE D HOSES WERE SENT OUT AS SAMPLES FOR FABRICATION BY AN OUTSIDE HOSE SHOP AND TYPE C HOSES WERE SUBSTITUTED AND RETURNED. 3) FAILURE TO RECOGNIZE SUBSTITUTION OF HOSE TYPE PRIOR TO INSTALLATION OF HOSE ASSEMBLIES AND THAT REPETITIVE INSPECTION/REPLACEMENT OF THE TYPE C HOSES WERE NOW REQUIRED.
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.