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|
Attributes | |
ACN | 640401 |
Time | |
Date | 200412 |
Day | Tue |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tower : smo.tower |
Operator | common carrier : air carrier |
Make Model Name | Dash 8-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 2.5 |
ASRS Report | 640401 |
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 : published procedure non adherence : far non adherence : company policies |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other other other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : work cards performance deficiency : training performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : installation |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
On the evening of 12/mon/04 I was temporarily assigned to prepare aircraft X for a borescope. This included opening the cowling and removing the igniter. After this was accomplished, I was immediately reassigned to other aircraft and was not involved in completing the task. I assume that there was proper documentation for completing it. Personnel involved in the borescope completed company document job card revision date 11/mon/04. This document does not include procedures for opening and closing the cowling or removing or reinstalling the igniter. On 12/wed/04 I was contacted by company personnel and informed that the aircraft, on a routine inspection, was found to be damaged in ZZZ1. This included burnt cowling, engine mount and wiring on the #2 engine. When they opened the cowl, they discovered the outboard igniter laying in plain sight in the lower cowl. Currently the engine, affected cowling, engine strut, and wiring are being replaced on the #2 engine. This could have been prevented by proper documentation for this task. The work cards need to be expanded to include additional steps for performance of this task. Callback conversation with reporter revealed the following information: the reporter stated the borescope inspection job card did not have procedures and signoff blocks for opening and closing of the cowling. The inspector doing the borescope normally removes the igniter, but in this case the reporter removed the plug. After opening the cowling and removing the outboard igniter plug, the reporter was reassigned to another airplane and no non routine card was written to cover the status of the airplane. The reporter never returned to the airplane. Damage was incurred to cowling, engine strut, wiring, and the engine was replaced. The engine was a P & west 123.
Original NASA ASRS Text
Title: A DHC-8-200 WAS DISPATCHED AFTER #2 ENG BORESCOPE INSPECTION AND OPERATED WITH THE OUTBOARD IGNITER PLUG NOT INSTALLED.
Narrative: ON THE EVENING OF 12/MON/04 I WAS TEMPORARILY ASSIGNED TO PREPARE ACFT X FOR A BORESCOPE. THIS INCLUDED OPENING THE COWLING AND REMOVING THE IGNITER. AFTER THIS WAS ACCOMPLISHED, I WAS IMMEDIATELY REASSIGNED TO OTHER ACFT AND WAS NOT INVOLVED IN COMPLETING THE TASK. I ASSUME THAT THERE WAS PROPER DOCUMENTATION FOR COMPLETING IT. PERSONNEL INVOLVED IN THE BORESCOPE COMPLETED COMPANY DOCUMENT JOB CARD REVISION DATE 11/MON/04. THIS DOCUMENT DOES NOT INCLUDE PROCEDURES FOR OPENING AND CLOSING THE COWLING OR REMOVING OR REINSTALLING THE IGNITER. ON 12/WED/04 I WAS CONTACTED BY COMPANY PERSONNEL AND INFORMED THAT THE ACFT, ON A ROUTINE INSPECTION, WAS FOUND TO BE DAMAGED IN ZZZ1. THIS INCLUDED BURNT COWLING, ENG MOUNT AND WIRING ON THE #2 ENG. WHEN THEY OPENED THE COWL, THEY DISCOVERED THE OUTBOARD IGNITER LAYING IN PLAIN SIGHT IN THE LOWER COWL. CURRENTLY THE ENG, AFFECTED COWLING, ENG STRUT, AND WIRING ARE BEING REPLACED ON THE #2 ENG. THIS COULD HAVE BEEN PREVENTED BY PROPER DOCUMENTATION FOR THIS TASK. THE WORK CARDS NEED TO BE EXPANDED TO INCLUDE ADDITIONAL STEPS FOR PERFORMANCE OF THIS TASK. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE BORESCOPE INSPECTION JOB CARD DID NOT HAVE PROCEDURES AND SIGNOFF BLOCKS FOR OPENING AND CLOSING OF THE COWLING. THE INSPECTOR DOING THE BORESCOPE NORMALLY REMOVES THE IGNITER, BUT IN THIS CASE THE RPTR REMOVED THE PLUG. AFTER OPENING THE COWLING AND REMOVING THE OUTBOARD IGNITER PLUG, THE RPTR WAS REASSIGNED TO ANOTHER AIRPLANE AND NO NON ROUTINE CARD WAS WRITTEN TO COVER THE STATUS OF THE AIRPLANE. THE RPTR NEVER RETURNED TO THE AIRPLANE. DAMAGE WAS INCURRED TO COWLING, ENG STRUT, WIRING, AND THE ENG WAS REPLACED. THE ENG WAS A P & W 123.
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.