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|
Attributes | |
ACN | 639410 |
Time | |
Date | 200412 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 1500 |
Environment | |
Flight Conditions | VMC |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | Dash 8-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 169.7 flight time total : 1081.8 flight time type : 724.8 |
ASRS Report | 639410 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : instrument pilot : atp pilot : multi engine |
Experience | flight time last 90 days : 150 flight time total : 10400 flight time type : 5000 |
ASRS Report | 640039 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | controller : provided flight assist none taken : detected after the fact |
Consequence | faa : investigated other other other |
Factors | |
Maintenance | contributing factor : briefing contributing factor : schedule pressure contributing factor : work cards performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : inspection performance deficiency : scheduled maintenance performance deficiency : training |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Company Maintenance Human Performance Environmental Factor |
Primary Problem | Maintenance Human Performance |
Narrative:
On takeoff out of ZZZ, the flight crew noticed a delay of performance and a buffeting similar to light turbulence on climb out. Upon agreement that this was not normal, we decided to return to the airport for landing. On final approach, the tower relayed to us that air carrier Y (#1 for landing) reported a large piece of FOD approximately 25 ft to the right of the centerline approximately 1000 ft from the threshold. Upon landing, we saw the FOD in question and avoided it for a safe landing. Upon shutdown and post flight walk around, we discussed that the FOD in question had in fact come from our aircraft. It was the leading edge of the inboard right wing. Callback conversation with reporter revealed the following information: the reporter stated the walk around check did not reveal any problem with the wing leading edge which was checked visually for dents and damaged deicer boots. The fact the deicer boot is black and the leading edge fasteners are also black would not help in noting any missing fasteners. On return to the field, the tower alerted us to FOD just off the centerline of the runway and this turned out to be the missing leading edge assembly. Callback conversation with reporter acn 639896 revealed the following information: the reporter was called to the airplane after the technicians had removed the leading edge assembly to accomplish a repetitive inspection on a crack in the right wing forward spar. The inspector checked for crack progression and found none and advised the technicians to reinstall the wing leading edge. The technicians fitted the leading edge assembly on the wing and put several fasteners in finger tight and went to lunch. After lunch, the two technicians were reassigned to another airplane in the hangar that was routed but was falling behind in the check. Neither the inspector nor the technicians who removed the right wing leading edge assembly wrote up cards describing the incomplete right wing leading installation. No documentation existed stating the actual condition of the right inboard leading edge assembly not being secured. The airplane was towed to the gate and dispatched.
Original NASA ASRS Text
Title: A DHC-8-200 ON TKOF CLB RETURNED AND LANDED DUE TO DECAY OF PERFORMANCE AND BUFFETING. ON GND DISCOVERED R WING INBOARD LEADING EDGE MISSING.
Narrative: ON TKOF OUT OF ZZZ, THE FLT CREW NOTICED A DELAY OF PERFORMANCE AND A BUFFETING SIMILAR TO LIGHT TURB ON CLB OUT. UPON AGREEMENT THAT THIS WAS NOT NORMAL, WE DECIDED TO RETURN TO THE ARPT FOR LNDG. ON FINAL APCH, THE TWR RELAYED TO US THAT ACR Y (#1 FOR LNDG) RPTED A LARGE PIECE OF FOD APPROX 25 FT TO THE R OF THE CTRLINE APPROX 1000 FT FROM THE THRESHOLD. UPON LNDG, WE SAW THE FOD IN QUESTION AND AVOIDED IT FOR A SAFE LNDG. UPON SHUTDOWN AND POST FLT WALK AROUND, WE DISCUSSED THAT THE FOD IN QUESTION HAD IN FACT COME FROM OUR ACFT. IT WAS THE LEADING EDGE OF THE INBOARD R WING. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE WALK AROUND CHECK DID NOT REVEAL ANY PROB WITH THE WING LEADING EDGE WHICH WAS CHECKED VISUALLY FOR DENTS AND DAMAGED DEICER BOOTS. THE FACT THE DEICER BOOT IS BLACK AND THE LEADING EDGE FASTENERS ARE ALSO BLACK WOULD NOT HELP IN NOTING ANY MISSING FASTENERS. ON RETURN TO THE FIELD, THE TWR ALERTED US TO FOD JUST OFF THE CTRLINE OF THE RWY AND THIS TURNED OUT TO BE THE MISSING LEADING EDGE ASSEMBLY. CALLBACK CONVERSATION WITH RPTR ACN 639896 REVEALED THE FOLLOWING INFO: THE RPTR WAS CALLED TO THE AIRPLANE AFTER THE TECHNICIANS HAD REMOVED THE LEADING EDGE ASSEMBLY TO ACCOMPLISH A REPETITIVE INSPECTION ON A CRACK IN THE R WING FORWARD SPAR. THE INSPECTOR CHECKED FOR CRACK PROGRESSION AND FOUND NONE AND ADVISED THE TECHNICIANS TO REINSTALL THE WING LEADING EDGE. THE TECHNICIANS FITTED THE LEADING EDGE ASSEMBLY ON THE WING AND PUT SEVERAL FASTENERS IN FINGER TIGHT AND WENT TO LUNCH. AFTER LUNCH, THE TWO TECHNICIANS WERE REASSIGNED TO ANOTHER AIRPLANE IN THE HANGAR THAT WAS ROUTED BUT WAS FALLING BEHIND IN THE CHECK. NEITHER THE INSPECTOR NOR THE TECHNICIANS WHO REMOVED THE R WING LEADING EDGE ASSEMBLY WROTE UP CARDS DESCRIBING THE INCOMPLETE R WING LEADING INSTALLATION. NO DOCUMENTATION EXISTED STATING THE ACTUAL CONDITION OF THE R INBOARD LEADING EDGE ASSEMBLY NOT BEING SECURED. THE AIRPLANE WAS TOWED TO THE GATE AND DISPATCHED.
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.