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|
Attributes | |
ACN | 660635 |
Time | |
Date | 200506 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | general aviation : instructional |
Make Model Name | Bonanza 33 |
Operating Under FAR Part | Part 91 |
Aircraft 2 | |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | other |
Function | maintenance : inspector |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 14 |
ASRS Report | 660635 |
Person 2 | |
Affiliation | other |
Function | flight crew : single pilot |
Qualification | pilot : cfi pilot : instrument pilot : multi engine pilot : commercial |
Experience | flight time last 90 days : 130 flight time total : 5420 flight time type : 3400 |
ASRS Report | 660636 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : unqualified personnel performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : installation |
Supplementary | |
Problem Areas | Chart Or Publication Company Environmental Factor Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Upon aircraft return from being painted; our shop at ZZZ performed a routine inspection and found that the ailerons were installed incorrectly. The left aileron was installed on the right wing; and the right aileron was installed on the left wing using incorrect hardware. Before further flight; we installed the correct hardware and placement of the ailerons in their correct location. The cause of this problem was the paint shop removed and installed the flight control surfaces instead of the contracted repair station hired by the paint shop. To prevent recurrence is for the paint shop to have technicians from the certified repair station use the correct maintenance manuals to remove these control surfaces and reinstall the control surfaces after being painted and balance checked; as they stated in their logbook entry. Callback conversation with reporter revealed the following information: the reporter stated this paint shop just wanted to save a few bucks by using paint shop people to install the ailerons instead of calling the local certified repair shop that removed the ailerons and rudder. The reporter stated the airplane was flown to their base shop where they were troubleshooting the pilot's report of airplane entering a shallow left bank when the controls were released. Rptedly after several inspections and tests of the ailerons; it was noted by a technician the location of the static wicks were wrong. The static wicks were attached to the top surface of both ailerons and should be mounted on the lower surface. Reporter stated this made it obvious the ailerons were installed wrong; both were upside down in the wrong place. The reporter stated this paint shop has been known to cut corners and the certified shop that removed the ailerons is also suspect for performing poor maintenance. Callback conversation with reporter acn 660636 revealed the following information: the reporter stated the airplane was preflight checked twice; once after the rudder was removed for balancing and when the rudder was installed after balancing. The airplane was flown back to home base. One report was written up on the performance; a shallow left bank was experienced when the controls were released. Supplemental information from acn 660636: the flight school was having aircraft X painted in ZZZ1. Two pilots took two aircraft from ZZZ to ZZZ1 to be painted and pick up aircraft X. Our chief of maintenance went along to inspect aircraft X. During inspection; it was found that the rudder needed to be removed to be balanced; which was not done during; before; or after being painted. So before the flight back from ZZZ1 to ZZZ the rudder needed to be balanced before flight. This was on tues/jun/2005. This is where I got involved. On wed/jun/2005 after the rudder was balanced and reinstalled on the aircraft; I preflighted the aircraft and flew it back from ZZZ1 to ZZZ; 2:10 flight. I looked at this aircraft 2 days in a row; preflighted it twice; our chief of maintenance walked around it and another ip from the flight school also walked around it and none of us realized that the ailerons were installed incorrectly. Right aileron was installed on the left wing upside down. Left aileron was installed on right wing upside down. This was not discovered until the aircraft was back at ZZZ on wed/jun/2005 by our maintenance personnel. The only problem with the flight was that the aircraft wanted to make a shallow left bank when the controls were released. I wrote up this problem in the aircraft technical logbook along with a problem with the flaps and several lights inoperative. I did not believe you could install the ailerons incorrectly and still be able to control the aircraft correctly in-flight. I am just glad the flight was uneventful in my favor.
Original NASA ASRS Text
Title: A BE33 WAS RELEASED FOR SVC FROM A CONTRACT PAINT SHOP AND FLOWN TO A BASE SHOP WHEN THE PLT RPTED THAT THE ACFT ENTERED A SHALLOW L BANK WHEN CTLS WERE RELEASED. AILERONS WERE FOUND TO BE INSTALLED INCORRECTLY.
Narrative: UPON ACFT RETURN FROM BEING PAINTED; OUR SHOP AT ZZZ PERFORMED A ROUTINE INSPECTION AND FOUND THAT THE AILERONS WERE INSTALLED INCORRECTLY. THE L AILERON WAS INSTALLED ON THE R WING; AND THE R AILERON WAS INSTALLED ON THE L WING USING INCORRECT HARDWARE. BEFORE FURTHER FLT; WE INSTALLED THE CORRECT HARDWARE AND PLACEMENT OF THE AILERONS IN THEIR CORRECT LOCATION. THE CAUSE OF THIS PROB WAS THE PAINT SHOP REMOVED AND INSTALLED THE FLT CTL SURFACES INSTEAD OF THE CONTRACTED REPAIR STATION HIRED BY THE PAINT SHOP. TO PREVENT RECURRENCE IS FOR THE PAINT SHOP TO HAVE TECHNICIANS FROM THE CERTIFIED REPAIR STATION USE THE CORRECT MAINT MANUALS TO REMOVE THESE CTL SURFACES AND REINSTALL THE CTL SURFACES AFTER BEING PAINTED AND BALANCE CHKED; AS THEY STATED IN THEIR LOGBOOK ENTRY. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THIS PAINT SHOP JUST WANTED TO SAVE A FEW BUCKS BY USING PAINT SHOP PEOPLE TO INSTALL THE AILERONS INSTEAD OF CALLING THE LOCAL CERTIFIED REPAIR SHOP THAT REMOVED THE AILERONS AND RUDDER. THE RPTR STATED THE AIRPLANE WAS FLOWN TO THEIR BASE SHOP WHERE THEY WERE TROUBLESHOOTING THE PLT'S RPT OF AIRPLANE ENTERING A SHALLOW L BANK WHEN THE CTLS WERE RELEASED. RPTEDLY AFTER SEVERAL INSPECTIONS AND TESTS OF THE AILERONS; IT WAS NOTED BY A TECHNICIAN THE LOCATION OF THE STATIC WICKS WERE WRONG. THE STATIC WICKS WERE ATTACHED TO THE TOP SURFACE OF BOTH AILERONS AND SHOULD BE MOUNTED ON THE LOWER SURFACE. RPTR STATED THIS MADE IT OBVIOUS THE AILERONS WERE INSTALLED WRONG; BOTH WERE UPSIDE DOWN IN THE WRONG PLACE. THE RPTR STATED THIS PAINT SHOP HAS BEEN KNOWN TO CUT CORNERS AND THE CERTIFIED SHOP THAT REMOVED THE AILERONS IS ALSO SUSPECT FOR PERFORMING POOR MAINT. CALLBACK CONVERSATION WITH RPTR ACN 660636 REVEALED THE FOLLOWING INFO: THE RPTR STATED THE AIRPLANE WAS PREFLT CHKED TWICE; ONCE AFTER THE RUDDER WAS REMOVED FOR BALANCING AND WHEN THE RUDDER WAS INSTALLED AFTER BALANCING. THE AIRPLANE WAS FLOWN BACK TO HOME BASE. ONE RPT WAS WRITTEN UP ON THE PERFORMANCE; A SHALLOW LEFT BANK WAS EXPERIENCED WHEN THE CTLS WERE RELEASED. SUPPLEMENTAL INFO FROM ACN 660636: THE FLT SCHOOL WAS HAVING ACFT X PAINTED IN ZZZ1. TWO PLTS TOOK TWO ACFT FROM ZZZ TO ZZZ1 TO BE PAINTED AND PICK UP ACFT X. OUR CHIEF OF MAINT WENT ALONG TO INSPECT ACFT X. DURING INSPECTION; IT WAS FOUND THAT THE RUDDER NEEDED TO BE REMOVED TO BE BALANCED; WHICH WAS NOT DONE DURING; BEFORE; OR AFTER BEING PAINTED. SO BEFORE THE FLT BACK FROM ZZZ1 TO ZZZ THE RUDDER NEEDED TO BE BALANCED BEFORE FLT. THIS WAS ON TUES/JUN/2005. THIS IS WHERE I GOT INVOLVED. ON WED/JUN/2005 AFTER THE RUDDER WAS BALANCED AND REINSTALLED ON THE ACFT; I PREFLIGHTED THE ACFT AND FLEW IT BACK FROM ZZZ1 TO ZZZ; 2:10 FLT. I LOOKED AT THIS ACFT 2 DAYS IN A ROW; PREFLIGHTED IT TWICE; OUR CHIEF OF MAINT WALKED AROUND IT AND ANOTHER IP FROM THE FLT SCHOOL ALSO WALKED AROUND IT AND NONE OF US REALIZED THAT THE AILERONS WERE INSTALLED INCORRECTLY. R AILERON WAS INSTALLED ON THE L WING UPSIDE DOWN. L AILERON WAS INSTALLED ON R WING UPSIDE DOWN. THIS WAS NOT DISCOVERED UNTIL THE ACFT WAS BACK AT ZZZ ON WED/JUN/2005 BY OUR MAINT PERSONNEL. THE ONLY PROB WITH THE FLT WAS THAT THE ACFT WANTED TO MAKE A SHALLOW L BANK WHEN THE CTLS WERE RELEASED. I WROTE UP THIS PROB IN THE ACFT TECHNICAL LOGBOOK ALONG WITH A PROB WITH THE FLAPS AND SEVERAL LIGHTS INOP. I DID NOT BELIEVE YOU COULD INSTALL THE AILERONS INCORRECTLY AND STILL BE ABLE TO CTL THE ACFT CORRECTLY INFLT. I AM JUST GLAD THE FLT WAS UNEVENTFUL IN MY FAVOR.
Data retrieved from NASA's ASRS site as of January 2009 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.