37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 728063 |
Time | |
Date | 200702 |
Local Time Of Day | 1201 To 1800 |
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 8-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 4 maintenance technician : 17 |
ASRS Report | 728063 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 727314 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : work cards performance deficiency : inspection performance deficiency : testing performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance Chart Or Publication Environmental Factor |
Primary Problem | Chart Or Publication |
Narrative:
On feb/sat/07; at XA00 I was assigned to work aircraft X an airspeed indicator mismatch; and after finding that the first officer's airspeed indicator was reading 5 KTS higher than the captain's airspeed indicator; and the test box indicator I replaced the first officer's airspeed indicator in accordance with job X (airspeed indicator removal and installation and operation test task card). This task card then references me to use job Y (pitot/static system leak check) which the pitot/static system leak check was complied with but only the pitot part of the job sign for while the static part of the job was north/a reference log page. On feb/sat/07 the aircraft X was released for revenue service as flight X to ZZZ1 at which time a supervisor advise me that the static part of the pitot/static test was not complied with per the amm; and was going to have this pitot/static test complied with at the ZZZ1 maintenance base. Maintenance in ZZZ1 complied with the job Y (pitot/static leak check) with no defect noted and leak check good for both pitot and static system and the aircraft release for revenue service. I believe this could have been prevented if only the job X was more accurate in telling the maintenance mechanic what is actually required to be tested as the amm (if you installed the copilot's airspeed indicator; do the leak test of the copilot's pitot system) and do the leak test of the copilot's static system. The job X (airspeed indicator remove and install and operations test: perform the pitot/static leak check in accordance with job X) just references another task card to use; and job Y (pitot/static leak check) item states just check appropriate boxes for system to be check. #1 pitot system; #2 pitot system #1 static system #2 static system and alternate system. I believe this to be vague and should be more precise as the amm.
Original NASA ASRS Text
Title: A DHC8-200 HAD THE FO'S AIRSPD INDICATOR REPLACED PER THE JOB CARD. PERFORMED PITOT LEAKAGE TEST OK. ACFT DISPATCHED WITHOUT THE REQUIRED STATIC LEAKAGE TEST.
Narrative: ON FEB/SAT/07; AT XA00 I WAS ASSIGNED TO WORK ACFT X AN AIRSPD INDICATOR MISMATCH; AND AFTER FINDING THAT THE FO'S AIRSPD INDICATOR WAS READING 5 KTS HIGHER THAN THE CAPT'S AIRSPD INDICATOR; AND THE TEST BOX INDICATOR I REPLACED THE FO'S AIRSPD INDICATOR IN ACCORDANCE WITH JOB X (AIRSPD INDICATOR REMOVAL AND INSTALLATION AND OP TEST TASK CARD). THIS TASK CARD THEN REFS ME TO USE JOB Y (PITOT/STATIC SYS LEAK CHK) WHICH THE PITOT/STATIC SYS LEAK CHK WAS COMPLIED WITH BUT ONLY THE PITOT PART OF THE JOB SIGN FOR WHILE THE STATIC PART OF THE JOB WAS N/A REF LOG PAGE. ON FEB/SAT/07 THE ACFT X WAS RELEASED FOR REVENUE SVC AS FLT X TO ZZZ1 AT WHICH TIME A SUPVR ADVISE ME THAT THE STATIC PART OF THE PITOT/STATIC TEST WAS NOT COMPLIED WITH PER THE AMM; AND WAS GOING TO HAVE THIS PITOT/STATIC TEST COMPLIED WITH AT THE ZZZ1 MAINT BASE. MAINT IN ZZZ1 COMPLIED WITH THE JOB Y (PITOT/STATIC LEAK CHK) WITH NO DEFECT NOTED AND LEAK CHK GOOD FOR BOTH PITOT AND STATIC SYS AND THE ACFT RELEASE FOR REVENUE SVC. I BELIEVE THIS COULD HAVE BEEN PREVENTED IF ONLY THE JOB X WAS MORE ACCURATE IN TELLING THE MAINT MECH WHAT IS ACTUALLY REQUIRED TO BE TESTED AS THE AMM (IF YOU INSTALLED THE COPLT'S AIRSPD INDICATOR; DO THE LEAK TEST OF THE COPLT'S PITOT SYS) AND DO THE LEAK TEST OF THE COPLT'S STATIC SYS. THE JOB X (AIRSPD INDICATOR REMOVE AND INSTALL AND OPS TEST: PERFORM THE PITOT/STATIC LEAK CHK IN ACCORDANCE WITH JOB X) JUST REFS ANOTHER TASK CARD TO USE; AND JOB Y (PITOT/STATIC LEAK CHK) ITEM STATES JUST CHK APPROPRIATE BOXES FOR SYS TO BE CHK. #1 PITOT SYS; #2 PITOT SYS #1 STATIC SYS #2 STATIC SYS AND ALTERNATE SYS. I BELIEVE THIS TO BE VAGUE AND SHOULD BE MORE PRECISE AS THE AMM.
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.