37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 670679 |
Time | |
Date | 200509 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tracon : zzz.tracon |
Operator | common carrier : air carrier |
Make Model Name | Caravan 1 208A |
Operating Under FAR Part | Part 91 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance repairman : 4.5 |
ASRS Report | 670679 |
Person 2 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
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 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : inspection performance deficiency : installation performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On sep/fri/05 at approximately XA00; I was charged with the task of replacing the pilot's upper console light on a C208 caravan which requires removal of the upper console and standby flap switch covers (2 each). With my supervisor with me; I removed the upper console and replaced the lamp. I then reinstalled the upper console and standby switch covers (2 each). Due to this being the first time performing this task; I inadvertently switched the standby switch covers upon reinstallation. However; the covers still closed and I was able to safety wire the covers. They both appeared to be positioned properly and due to the lighting in the cockpit; I did not visually see a difference in the covers. After completing the task; I applied power to the aircraft and everything appeared to function normally. The following morning the aircraft took off for its morning cargo run without incident. Shortly after takeoff; the pilot apparently bumped the standby flap switch covers which repositioned the switches due to the difference in the covers. This; in turn; caused a runaway flap condition. The pilot was able to rectify the situation and completed the cargo run without further incident. After arriving at his destination; maintenance personnel were notified and the switch covers were removed and reinstalled in their proper position. All appropriate paperwork was completed and the aircraft returned home that evening without incident. Callback conversation with reporter revealed the following information: the reporter stated this was a last min deal and did not take the time to note the position of the switch guards. After reassembling the panel and switches; they looked right.
Original NASA ASRS Text
Title: C208 WAS DISPATCHED WITH THE STANDBY FLAP SWITCH GUARDS INSTALLED INCORRECTLY. PLT INADVERTENTLY BUMPED SWITCH GUARD AND DEPLOYED FLAPS INFLT.
Narrative: ON SEP/FRI/05 AT APPROX XA00; I WAS CHARGED WITH THE TASK OF REPLACING THE PLT'S UPPER CONSOLE LIGHT ON A C208 CARAVAN WHICH REQUIRES REMOVAL OF THE UPPER CONSOLE AND STANDBY FLAP SWITCH COVERS (2 EACH). WITH MY SUPVR WITH ME; I REMOVED THE UPPER CONSOLE AND REPLACED THE LAMP. I THEN REINSTALLED THE UPPER CONSOLE AND STANDBY SWITCH COVERS (2 EACH). DUE TO THIS BEING THE FIRST TIME PERFORMING THIS TASK; I INADVERTENTLY SWITCHED THE STANDBY SWITCH COVERS UPON REINSTALLATION. HOWEVER; THE COVERS STILL CLOSED AND I WAS ABLE TO SAFETY WIRE THE COVERS. THEY BOTH APPEARED TO BE POSITIONED PROPERLY AND DUE TO THE LIGHTING IN THE COCKPIT; I DID NOT VISUALLY SEE A DIFFERENCE IN THE COVERS. AFTER COMPLETING THE TASK; I APPLIED PWR TO THE ACFT AND EVERYTHING APPEARED TO FUNCTION NORMALLY. THE FOLLOWING MORNING THE ACFT TOOK OFF FOR ITS MORNING CARGO RUN WITHOUT INCIDENT. SHORTLY AFTER TKOF; THE PLT APPARENTLY BUMPED THE STANDBY FLAP SWITCH COVERS WHICH REPOSITIONED THE SWITCHES DUE TO THE DIFFERENCE IN THE COVERS. THIS; IN TURN; CAUSED A RUNAWAY FLAP CONDITION. THE PLT WAS ABLE TO RECTIFY THE SIT AND COMPLETED THE CARGO RUN WITHOUT FURTHER INCIDENT. AFTER ARRIVING AT HIS DEST; MAINT PERSONNEL WERE NOTIFIED AND THE SWITCH COVERS WERE REMOVED AND REINSTALLED IN THEIR PROPER POS. ALL APPROPRIATE PAPERWORK WAS COMPLETED AND THE ACFT RETURNED HOME THAT EVENING WITHOUT INCIDENT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THIS WAS A LAST MIN DEAL AND DID NOT TAKE THE TIME TO NOTE THE POS OF THE SWITCH GUARDS. AFTER REASSEMBLING THE PANEL AND SWITCHES; THEY LOOKED RIGHT.
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.