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An A320 avionics cooling fan became inoperative at an outstation. The airline employed contract maintenance to MEL the cooling system. The mechanic wired the improper door closed while complying with the MEL causing an in-flight ruptured duct. Pressurization and other system problems developed. Flight diverted.
| Attributes | |
| ACN | 632505 |
| Time | |
| Date | 200410 |
| Day | Mon |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tower : sfo.tower |
| Operator | common carrier : air carrier |
| Make Model Name | Airbus Industrie Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 50 flight time total : 25000 flight time type : 5000 |
| ASRS Report | 632505 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Events | |
| Anomaly | maintenance problem : improper maintenance maintenance problem : improper documentation maintenance problem : non compliance with mel |
| Independent Detector | aircraft equipment other aircraft equipment : press., ecam, airconditioning |
| Resolutory Action | flight crew : declared emergency flight crew : diverted to alternate |
| Factors | |
| Maintenance | performance deficiency : training performance deficiency : repair performance deficiency : unqualified personnel performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Aircraft Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
Numerous system warnings on ECAM. Followed procedures on checklist. Pressurization erratic. Divert to ZZZ1. Callback conversation with reporter revealed the following information: the reporter stated that because his air carrier has reduced the number of outstations with maintenance, the FBO mechanics being employed may or may not have specific aircraft type experience. In this case the mechanic had never performed maintenance of any kind on any airbus product. The captain and first officer both asked him if he was confident of the procedures he was performing. His reply that yes he was because he had the instructions faxed to him and he was talking with the air carrier's maintenance. What happened in reality was the contract mechanic wired the incorrect avionics cooling door closed allowing the system to pressurize in-flight, thereby rupturing an air conditioning duct. The aircraft would not pressurize properly after the duct ruptured and the crew received numerous ECAM warnings. The crew diverted to a maintenance station.
Original NASA ASRS Text
Title: AN A320 AVIONICS COOLING FAN BECAME INOP AT AN OUTSTATION. THE AIRLINE EMPLOYED CONTRACT MAINT TO MEL THE COOLING SYS. THE MECH WIRED THE IMPROPER DOOR CLOSED WHILE COMPLYING WITH THE MEL CAUSING AN INFLT RUPTURED DUCT. PRESSURIZATION AND OTHER SYS PROBS DEVELOPED. FLT DIVERTED.
Narrative: NUMEROUS SYS WARNINGS ON ECAM. FOLLOWED PROCS ON CHKLIST. PRESSURIZATION ERRATIC. DIVERT TO ZZZ1. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THAT BECAUSE HIS ACR HAS REDUCED THE NUMBER OF OUTSTATIONS WITH MAINT, THE FBO MECHS BEING EMPLOYED MAY OR MAY NOT HAVE SPECIFIC ACFT TYPE EXPERIENCE. IN THIS CASE THE MECH HAD NEVER PERFORMED MAINT OF ANY KIND ON ANY AIRBUS PRODUCT. THE CAPT AND FO BOTH ASKED HIM IF HE WAS CONFIDENT OF THE PROCS HE WAS PERFORMING. HIS REPLY THAT YES HE WAS BECAUSE HE HAD THE INSTRUCTIONS FAXED TO HIM AND HE WAS TALKING WITH THE ACR'S MAINT. WHAT HAPPENED IN REALITY WAS THE CONTRACT MECH WIRED THE INCORRECT AVIONICS COOLING DOOR CLOSED ALLOWING THE SYS TO PRESSURIZE INFLT, THEREBY RUPTURING AN AIR CONDITIONING DUCT. THE ACFT WOULD NOT PRESSURIZE PROPERLY AFTER THE DUCT RUPTURED AND THE CREW RECEIVED NUMEROUS ECAM WARNINGS. THE CREW DIVERTED TO A MAINT STATION.
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.