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A DHC8-300 had a write-up to replace the forward #1 air cycle machine. The unit was replaced and all paperwork was complete. It was discovered #1 air cycle machine is located aft. #2 air cycle machine is located forward. Unit installed in wrong position.
| Attributes | |
| ACN | 684642 |
| Time | |
| Date | 200601 |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | Dash 8-300 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : airframe technician : powerplant |
| Experience | maintenance technician : 19 |
| ASRS Report | 684642 |
| Events | |
| Anomaly | aircraft equipment problem : less severe maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
| Independent Detector | other other : 1 |
| Resolutory Action | none taken : detected after the fact |
| Factors | |
| Maintenance | contributing factor : manuals performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : logbook entry |
| Supplementary | |
| Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
| Primary Problem | Chart Or Publication |
Narrative:
On the start of my shift I was told the forward air cycle machine was being right&right'ed as a scheduled maintenance item. The work was completed and I audited the work package. I checked that the air cycle machine right&right (#1 position) was initialed as completed work on the scheduled maintenance tally sheet; the applicable work card was completed and the svcable tag was completed showing position #1. The problem occurred because per the maintenance program the #1 position air cycle machine is actually the aft air cycle machine. I could have caught the error by xchking the air cycle machine serial number between the rotable tag and tally sheet. Also; the maintenance program should be modified to indicate the position as forward and aft instead of #1 and #2.
Original NASA ASRS Text
Title: A DHC8-300 HAD A WRITE-UP TO REPLACE THE FORWARD #1 AIR CYCLE MACHINE. THE UNIT WAS REPLACED AND ALL PAPERWORK WAS COMPLETE. IT WAS DISCOVERED #1 AIR CYCLE MACHINE IS LOCATED AFT. #2 AIR CYCLE MACHINE IS LOCATED FORWARD. UNIT INSTALLED IN WRONG POS.
Narrative: ON THE START OF MY SHIFT I WAS TOLD THE FORWARD AIR CYCLE MACHINE WAS BEING R&R'ED AS A SCHEDULED MAINT ITEM. THE WORK WAS COMPLETED AND I AUDITED THE WORK PACKAGE. I CHKED THAT THE AIR CYCLE MACHINE R&R (#1 POS) WAS INITIALED AS COMPLETED WORK ON THE SCHEDULED MAINT TALLY SHEET; THE APPLICABLE WORK CARD WAS COMPLETED AND THE SVCABLE TAG WAS COMPLETED SHOWING POS #1. THE PROB OCCURRED BECAUSE PER THE MAINT PROGRAM THE #1 POS AIR CYCLE MACHINE IS ACTUALLY THE AFT AIR CYCLE MACHINE. I COULD HAVE CAUGHT THE ERROR BY XCHKING THE AIR CYCLE MACHINE SERIAL NUMBER BTWN THE ROTABLE TAG AND TALLY SHEET. ALSO; THE MAINT PROGRAM SHOULD BE MODIFIED TO INDICATE THE POS AS FORWARD AND AFT INSTEAD OF #1 AND #2.
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.