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|
Attributes | |
ACN | 625745 |
Time | |
Date | 200407 |
Day | Sat |
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 | |
Operator | common carrier : air carrier |
Make Model Name | Dash 8-400 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 17 |
ASRS Report | 625745 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : company policies non adherence : far non adherence : published procedure |
Independent Detector | other other : 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : inspection performance deficiency : testing |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
By XA30 we had the plane in the hangar and went to break. After break, the avionics mechanics started working on their engineering order work. A mechanic started working the flap problem, another mechanic worked on the hydraulic lines on the l-hand main landing gear actuator, and another mechanic helped me with the daily. After completing the daily, I worked on the l-hand main landing gear door seal. The copied form of the deferred item for the l-hand main landing gear door seal mentioned that a part of the seal was hanging down and that the mechanic pulled the part that was hanging off the door and placed it on a deferred item due to no time to change it. After investigating the seals on the main landing gear door, I found only 1 seal that had a small piece about 2 1/2 - 3 inches long missing. After getting the correct bulb type seal that was needed to replace the old one (CVR49), I removed the attaching hardware (about 27 bolts, washers and nuts, along with the retainer, and the old seal) and then installed the new seal, and re-installed the attach hardware. When I completed the seal replacement, I went to the lead is office to get the paperwork to sign off the seal change. I didn't know exactly how to sign off the deferred item, so I asked my supervisor to help me. (I am new to working the line maintenance department (11 days). I worked on the heavy check the whole time I worked for air carrier X.) he helped me re-open the deferred item in the aircraft logbook. This was sort of hard since the company just revised the logbook. Then my supervisor left for some reason, not helping me fill out the signoff. From past experience of working on the dash 8-200, I believed there was no task reference for landing gear seals, so I used a clear and precise signoff just as stated at the beginning of this paragraph and then went to lunch. After lunch I checked with the mechanic that was working on the landing gear actuator lines. He showed me how they measure a specific gap on the fitting to make sure it is on the correct way. Then my lead came out to where we were and mentioned that there was a procedure for the seal change and thought it would need a fit and fare check, so I went to the manual and checked to see if there was a task for the procedure. Sure enough there was. I read it quickly. It said, everything that I had done when changing the seal, but said at the end of the procedure, steps that it needed an aerodynamic smoothness check per the srm. So, I went and looked that up and found that it mentioned that this was in an area that was known as a non-critical area and gave a gap dimension that was pretty large. I went back to the logbook and added the dash Q-400 air traffic area reference to my signoff. Since I had to perform an aerodynamic smoothness check, this meant that I needed to swing the gear. So another mechanic and I got the jacks we needed and also the hydraulic mule. When we got the aircraft ready to be jacked, I found out, by avionics, that we would have to wait until they were done with their engineering order work. The mechanic that worked the main landing gear actuator lines also needed to swing the gear in order to leak check the hydraulic lines. I then went on break. After break, my lead came over to the aircraft and mentioned to me that I should 'eie' (entered in error) my entire statement that I signed on the logbook. I thought this was strange because I did change the seal and followed the correct procedures and all I had left to do was to swing the gear, which I was ready to do. After a while, I checked on avionics to see how things were going. They were still hard at it. Later, my lead came over and mentioned that avionics was not going to be done tonight and that the plane was not going to make it up for the morning and also that I was going to be giving day shift the turn on the plane. Before I could figure anything else out, day shift showed up. So I gave them a complete (verbal) turnover on the plane. Avionics was working on some engineering orders and that the plane needed a gear swing to leak check the hydraulic lines on the l-hand main landing gear actuator and to do an aerodynamic smoothness check on the l-hand main landing gear forward door seal. Report listed above. They mentioned that I did not mark the rii box in the signoff and that I, myself, did not swing the gear. I told them that I didn't mark the signoff with an rii or the north rii box, and for the swinging of the gear, I turned that over to days, which I heard they did complete. The supervisors also mentioned that the gear swing was an rii item and that an inspector did not see the gear swing. The lead for this plane was the same lead I had on aircraft X. He told me that he was sorry because he dropped the ball on the paperwork for aircraft X. Later that night, around lunch time, the supervisor mentioned that the manager of quality control wanted to talk to me in the morning. I told him everything as mentioned in this report.
Original NASA ASRS Text
Title: A DHC8-400 WAS DISPATCHED IN NON COMPLIANCE WITH A MAIN LNDG GEAR SEAL REPLACED. ACFT WAS REQUIRED TO BE JACKED WITH INSPECTOR PRESENT TO SATISFY FAA CRITICAL ITEM INSPECTION.
Narrative: BY XA30 WE HAD THE PLANE IN THE HANGAR AND WENT TO BREAK. AFTER BREAK, THE AVIONICS MECHS STARTED WORKING ON THEIR ENGINEERING ORDER WORK. A MECH STARTED WORKING THE FLAP PROB, ANOTHER MECH WORKED ON THE HYD LINES ON THE L-HAND MAIN LNDG GEAR ACTUATOR, AND ANOTHER MECH HELPED ME WITH THE DAILY. AFTER COMPLETING THE DAILY, I WORKED ON THE L-HAND MAIN LNDG GEAR DOOR SEAL. THE COPIED FORM OF THE DEFERRED ITEM FOR THE L-HAND MAIN LNDG GEAR DOOR SEAL MENTIONED THAT A PART OF THE SEAL WAS HANGING DOWN AND THAT THE MECH PULLED THE PART THAT WAS HANGING OFF THE DOOR AND PLACED IT ON A DEFERRED ITEM DUE TO NO TIME TO CHANGE IT. AFTER INVESTIGATING THE SEALS ON THE MAIN LNDG GEAR DOOR, I FOUND ONLY 1 SEAL THAT HAD A SMALL PIECE ABOUT 2 1/2 - 3 INCHES LONG MISSING. AFTER GETTING THE CORRECT BULB TYPE SEAL THAT WAS NEEDED TO REPLACE THE OLD ONE (CVR49), I REMOVED THE ATTACHING HARDWARE (ABOUT 27 BOLTS, WASHERS AND NUTS, ALONG WITH THE RETAINER, AND THE OLD SEAL) AND THEN INSTALLED THE NEW SEAL, AND RE-INSTALLED THE ATTACH HARDWARE. WHEN I COMPLETED THE SEAL REPLACEMENT, I WENT TO THE LEAD IS OFFICE TO GET THE PAPERWORK TO SIGN OFF THE SEAL CHANGE. I DIDN'T KNOW EXACTLY HOW TO SIGN OFF THE DEFERRED ITEM, SO I ASKED MY SUPVR TO HELP ME. (I AM NEW TO WORKING THE LINE MAINT DEPT (11 DAYS). I WORKED ON THE HVY CHK THE WHOLE TIME I WORKED FOR ACR X.) HE HELPED ME RE-OPEN THE DEFERRED ITEM IN THE ACFT LOGBOOK. THIS WAS SORT OF HARD SINCE THE COMPANY JUST REVISED THE LOGBOOK. THEN MY SUPVR LEFT FOR SOME REASON, NOT HELPING ME FILL OUT THE SIGNOFF. FROM PAST EXPERIENCE OF WORKING ON THE DASH 8-200, I BELIEVED THERE WAS NO TASK REF FOR LNDG GEAR SEALS, SO I USED A CLR AND PRECISE SIGNOFF JUST AS STATED AT THE BEGINNING OF THIS PARAGRAPH AND THEN WENT TO LUNCH. AFTER LUNCH I CHKED WITH THE MECH THAT WAS WORKING ON THE LNDG GEAR ACTUATOR LINES. HE SHOWED ME HOW THEY MEASURE A SPECIFIC GAP ON THE FITTING TO MAKE SURE IT IS ON THE CORRECT WAY. THEN MY LEAD CAME OUT TO WHERE WE WERE AND MENTIONED THAT THERE WAS A PROC FOR THE SEAL CHANGE AND THOUGHT IT WOULD NEED A FIT AND FARE CHK, SO I WENT TO THE MANUAL AND CHKED TO SEE IF THERE WAS A TASK FOR THE PROC. SURE ENOUGH THERE WAS. I READ IT QUICKLY. IT SAID, EVERYTHING THAT I HAD DONE WHEN CHANGING THE SEAL, BUT SAID AT THE END OF THE PROC, STEPS THAT IT NEEDED AN AERODYNAMIC SMOOTHNESS CHK PER THE SRM. SO, I WENT AND LOOKED THAT UP AND FOUND THAT IT MENTIONED THAT THIS WAS IN AN AREA THAT WAS KNOWN AS A NON-CRITICAL AREA AND GAVE A GAP DIMENSION THAT WAS PRETTY LARGE. I WENT BACK TO THE LOGBOOK AND ADDED THE DASH Q-400 ATA REF TO MY SIGNOFF. SINCE I HAD TO PERFORM AN AERODYNAMIC SMOOTHNESS CHK, THIS MEANT THAT I NEEDED TO SWING THE GEAR. SO ANOTHER MECH AND I GOT THE JACKS WE NEEDED AND ALSO THE HYD MULE. WHEN WE GOT THE ACFT READY TO BE JACKED, I FOUND OUT, BY AVIONICS, THAT WE WOULD HAVE TO WAIT UNTIL THEY WERE DONE WITH THEIR ENGINEERING ORDER WORK. THE MECH THAT WORKED THE MAIN LNDG GEAR ACTUATOR LINES ALSO NEEDED TO SWING THE GEAR IN ORDER TO LEAK CHK THE HYD LINES. I THEN WENT ON BREAK. AFTER BREAK, MY LEAD CAME OVER TO THE ACFT AND MENTIONED TO ME THAT I SHOULD 'EIE' (ENTERED IN ERROR) MY ENTIRE STATEMENT THAT I SIGNED ON THE LOGBOOK. I THOUGHT THIS WAS STRANGE BECAUSE I DID CHANGE THE SEAL AND FOLLOWED THE CORRECT PROCS AND ALL I HAD LEFT TO DO WAS TO SWING THE GEAR, WHICH I WAS READY TO DO. AFTER A WHILE, I CHKED ON AVIONICS TO SEE HOW THINGS WERE GOING. THEY WERE STILL HARD AT IT. LATER, MY LEAD CAME OVER AND MENTIONED THAT AVIONICS WAS NOT GOING TO BE DONE TONIGHT AND THAT THE PLANE WAS NOT GOING TO MAKE IT UP FOR THE MORNING AND ALSO THAT I WAS GOING TO BE GIVING DAY SHIFT THE TURN ON THE PLANE. BEFORE I COULD FIGURE ANYTHING ELSE OUT, DAY SHIFT SHOWED UP. SO I GAVE THEM A COMPLETE (VERBAL) TURNOVER ON THE PLANE. AVIONICS WAS WORKING ON SOME ENGINEERING ORDERS AND THAT THE PLANE NEEDED A GEAR SWING TO LEAK CHK THE HYD LINES ON THE L-HAND MAIN LNDG GEAR ACTUATOR AND TO DO AN AERODYNAMIC SMOOTHNESS CHK ON THE L-HAND MAIN LNDG GEAR FORWARD DOOR SEAL. RPT LISTED ABOVE. THEY MENTIONED THAT I DID NOT MARK THE RII BOX IN THE SIGNOFF AND THAT I, MYSELF, DID NOT SWING THE GEAR. I TOLD THEM THAT I DIDN'T MARK THE SIGNOFF WITH AN RII OR THE N RII BOX, AND FOR THE SWINGING OF THE GEAR, I TURNED THAT OVER TO DAYS, WHICH I HEARD THEY DID COMPLETE. THE SUPVRS ALSO MENTIONED THAT THE GEAR SWING WAS AN RII ITEM AND THAT AN INSPECTOR DID NOT SEE THE GEAR SWING. THE LEAD FOR THIS PLANE WAS THE SAME LEAD I HAD ON ACFT X. HE TOLD ME THAT HE WAS SORRY BECAUSE HE DROPPED THE BALL ON THE PAPERWORK FOR ACFT X. LATER THAT NIGHT, AROUND LUNCH TIME, THE SUPVR MENTIONED THAT THE MGR OF QUALITY CTL WANTED TO TALK TO ME IN THE MORNING. I TOLD HIM EVERYTHING AS MENTIONED IN THIS RPT.
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.