37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 687093 |
Time | |
Date | 200602 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tower : vny.tower |
Operator | general aviation : personal |
Make Model Name | PA-28 Cherokee Arrow IV |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | other |
Function | maintenance : inspector |
Qualification | technician : powerplant technician : inspection authority technician : fcc technician : airframe |
Experience | maintenance lead technician : 9 maintenance technician : 11 |
ASRS Report | 687093 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Factors | |
Maintenance | contributing factor : manuals performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : logbook entry performance deficiency : inspection |
Supplementary | |
Problem Areas | FAA Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft engine was started and shut down after a few seconds. Then wouldn't restart. Inspection discovered the r-hand magneto impulse coupling came apart. Preliminary inspections of the damage cannot determine the extent of the damage. The engine will be removed and tore down for a complete inspection. Research of logbooks proved that the impulse coupling had approximately 400 hours on it since its last inspection for compliance to airworthiness directive 99-04-04. I was the inspector who performed the last annual inspection 8 months prior and failed to identify the airworthiness directive was due for compliance. Looking through the previous airworthiness directive search from 4 yrs ago found that the mechanic who signed off the annual had stated the airworthiness directive did not apply because of the 'model number.' at that time the airworthiness directive was not due (inspection due every 250 hours). The next 3 annuals including the last one which I signed off the airworthiness directive was due for inspection and was not idented as such. The human factor that led to my oversight was the assumption that the previous airworthiness directive search was correct and the airworthiness directive did not apply. I have learned that it is very important to perform an airworthiness directive search from the beginning and not to refer to other mechanic's statement regarding applicability. Factor that contributes to the quality of performance would be the amount of time needed to perform a complete airworthiness directive search and the inability to charge a customer for the time while still providing a competitive price for the complete inspection. More defined rules and a standard outline for procedures/documentation of airworthiness directives from the FAA would greatly reduce the occurrence of this type of oversight in the industry as a whole.
Original NASA ASRS Text
Title: A PA28-235 ENG WAS STARTED THEN AFTER A FEW SECONDS SHUTDOWN. NO RESTART. FOUND R MAGNETO IMPULSE COUPLER FAILED. RPTR FAILED TO IDENT IMPULSE COUPLER AIRWORTHINESS DIRECTIVE WAS OVERDUE FOR COMPLIANCE.
Narrative: ACFT ENG WAS STARTED AND SHUT DOWN AFTER A FEW SECONDS. THEN WOULDN'T RESTART. INSPECTION DISCOVERED THE R-HAND MAGNETO IMPULSE COUPLING CAME APART. PRELIMINARY INSPECTIONS OF THE DAMAGE CANNOT DETERMINE THE EXTENT OF THE DAMAGE. THE ENG WILL BE REMOVED AND TORE DOWN FOR A COMPLETE INSPECTION. RESEARCH OF LOGBOOKS PROVED THAT THE IMPULSE COUPLING HAD APPROX 400 HRS ON IT SINCE ITS LAST INSPECTION FOR COMPLIANCE TO AIRWORTHINESS DIRECTIVE 99-04-04. I WAS THE INSPECTOR WHO PERFORMED THE LAST ANNUAL INSPECTION 8 MONTHS PRIOR AND FAILED TO IDENT THE AIRWORTHINESS DIRECTIVE WAS DUE FOR COMPLIANCE. LOOKING THROUGH THE PREVIOUS AIRWORTHINESS DIRECTIVE SEARCH FROM 4 YRS AGO FOUND THAT THE MECH WHO SIGNED OFF THE ANNUAL HAD STATED THE AIRWORTHINESS DIRECTIVE DID NOT APPLY BECAUSE OF THE 'MODEL NUMBER.' AT THAT TIME THE AIRWORTHINESS DIRECTIVE WAS NOT DUE (INSPECTION DUE EVERY 250 HRS). THE NEXT 3 ANNUALS INCLUDING THE LAST ONE WHICH I SIGNED OFF THE AIRWORTHINESS DIRECTIVE WAS DUE FOR INSPECTION AND WAS NOT IDENTED AS SUCH. THE HUMAN FACTOR THAT LED TO MY OVERSIGHT WAS THE ASSUMPTION THAT THE PREVIOUS AIRWORTHINESS DIRECTIVE SEARCH WAS CORRECT AND THE AIRWORTHINESS DIRECTIVE DID NOT APPLY. I HAVE LEARNED THAT IT IS VERY IMPORTANT TO PERFORM AN AIRWORTHINESS DIRECTIVE SEARCH FROM THE BEGINNING AND NOT TO REFER TO OTHER MECH'S STATEMENT REGARDING APPLICABILITY. FACTOR THAT CONTRIBUTES TO THE QUALITY OF PERFORMANCE WOULD BE THE AMOUNT OF TIME NEEDED TO PERFORM A COMPLETE AIRWORTHINESS DIRECTIVE SEARCH AND THE INABILITY TO CHARGE A CUSTOMER FOR THE TIME WHILE STILL PROVIDING A COMPETITIVE PRICE FOR THE COMPLETE INSPECTION. MORE DEFINED RULES AND A STANDARD OUTLINE FOR PROCS/DOCUMENTATION OF AIRWORTHINESS DIRECTIVES FROM THE FAA WOULD GREATLY REDUCE THE OCCURRENCE OF THIS TYPE OF OVERSIGHT IN THE INDUSTRY AS A WHOLE.
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.