37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 712131 |
Time | |
Date | 200610 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | SF 340A |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 712131 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : rt. duct leak warning other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other other |
Factors | |
Maintenance | contributing factor : engineering procedure contributing factor : manuals contributing factor : work cards performance deficiency : non compliance with legal requirements performance deficiency : repair performance deficiency : fault isolation |
Supplementary | |
Problem Areas | Environmental Factor Chart Or Publication Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | engineering order |
Narrative:
Aircraft had right engine bleed leak indication. Found right duct at wing root to fuselage leaking at top. A decision was made to change duct to correct leak. The duct in parts stores available is the new duct that requires the rubber orange elbow to be installed. This action required to perform engineering order that also needs to change the sensor loops. At first look of engineering order it's only complied with if desired or if replacement parts are not available. With the superseded parts available; the engineering order was incorrectly interpreted not to be needed. The aircraft was at the gate and was worked from XA00 to XI00. Incorrect interpretation of engineering order. First page stated 'this engineering order can be complied with if desired or if replacement parts are not available.' the aircraft ipc had the superseded parts available and did not associate the old part with new part to be part of this engineering order. Callback conversation with reporter revealed the following information: the reporter stated the decision to fix the pneumatic leak per the engineering order was predicated on having the superseded parts available. Reading the engineering order it appeared replacing only the duct was necessary and the remainder of the engineering order was optional. The duct was replaced and still indicated a duct leak and after reading the engineering order carefully it was discovered the sensing loop must be replaced and the left wing must have the engineering order also accomplished if the right wing is accomplished. The maintenance control must coordinate with engineering to eliminate the confusion that creeps in the service bulletins and engineering orders. The airplane was not flown until both wing to fuselage engineering orders were completed.
Original NASA ASRS Text
Title: A SAAB340 HAD A PNEUMATIC LEAK AT R WING ROOT TO FUSELAGE. PNEUMATIC DUCT REPLACED PER ENGINEERING ORDER. ENTIRE ENGINEERING ORDER NOT COMPLETED.
Narrative: ACFT HAD R ENG BLEED LEAK INDICATION. FOUND R DUCT AT WING ROOT TO FUSELAGE LEAKING AT TOP. A DECISION WAS MADE TO CHANGE DUCT TO CORRECT LEAK. THE DUCT IN PARTS STORES AVAILABLE IS THE NEW DUCT THAT REQUIRES THE RUBBER ORANGE ELBOW TO BE INSTALLED. THIS ACTION REQUIRED TO PERFORM ENGINEERING ORDER THAT ALSO NEEDS TO CHANGE THE SENSOR LOOPS. AT FIRST LOOK OF ENGINEERING ORDER IT'S ONLY COMPLIED WITH IF DESIRED OR IF REPLACEMENT PARTS ARE NOT AVAILABLE. WITH THE SUPERSEDED PARTS AVAILABLE; THE ENGINEERING ORDER WAS INCORRECTLY INTERPED NOT TO BE NEEDED. THE ACFT WAS AT THE GATE AND WAS WORKED FROM XA00 TO XI00. INCORRECT INTERP OF ENGINEERING ORDER. FIRST PAGE STATED 'THIS ENGINEERING ORDER CAN BE COMPLIED WITH IF DESIRED OR IF REPLACEMENT PARTS ARE NOT AVAILABLE.' THE ACFT IPC HAD THE SUPERSEDED PARTS AVAILABLE AND DID NOT ASSOCIATE THE OLD PART WITH NEW PART TO BE PART OF THIS ENGINEERING ORDER. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE DECISION TO FIX THE PNEUMATIC LEAK PER THE ENGINEERING ORDER WAS PREDICATED ON HAVING THE SUPERSEDED PARTS AVAILABLE. READING THE ENGINEERING ORDER IT APPEARED REPLACING ONLY THE DUCT WAS NECESSARY AND THE REMAINDER OF THE ENGINEERING ORDER WAS OPTIONAL. THE DUCT WAS REPLACED AND STILL INDICATED A DUCT LEAK AND AFTER READING THE ENGINEERING ORDER CAREFULLY IT WAS DISCOVERED THE SENSING LOOP MUST BE REPLACED AND THE L WING MUST HAVE THE ENGINEERING ORDER ALSO ACCOMPLISHED IF THE R WING IS ACCOMPLISHED. THE MAINT CTL MUST COORDINATE WITH ENGINEERING TO ELIMINATE THE CONFUSION THAT CREEPS IN THE SVC BULLETINS AND ENGINEERING ORDERS. THE AIRPLANE WAS NOT FLOWN UNTIL BOTH WING TO FUSELAGE ENGINEERING ORDERS WERE COMPLETED.
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.