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|
Attributes | |
ACN | 743020 |
Time | |
Date | 200706 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zzzz.artcc |
Operator | other |
Make Model Name | Sabreliner 265 |
Operating Under FAR Part | Part 91 |
Flight Phase | ground : taxi |
Person 1 | |
Affiliation | other |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 743020 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : 1 |
Resolutory Action | other |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : briefing performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : training performance deficiency : testing performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
The aircraft involved is a military sabreliner that our company has a maintenance contract to do aircraft condition inspections on. This involves disassembly of the aircraft with a complete wing demate; system overhaul and structural overhaul. I was given the assignment to reinstall hydraulic lines that were removed for access for major structural work that had been completed. The ends of each hydraulic line had been capped and tagged with an identify tag marking it to its proper port. I had attached each line to its proper port and double-checked each one before removing the tags. The sabreliner maintenance manual does not clearly show which line goes to which port. 4 months later the aircraft had completed its overhaul and reassembly and had gone through all of its post operational checks and had completed its taxi test. The aircraft was turned over to the military test pilots for light test. On the third test flight during the landing rollout the brakes were found to be operating in reverse; meaning the right brake pedal operated the left brake and the left brake pedal operated the right brake. The aircraft landed and returned to our maintenance facility undamaged. From the time I installed the hydraulic lines in question; I was assigned to another aircraft and the aircraft in question continued through 4 months of maintenance; overhaul and reassembly. There is the possibility that these lines had been tagged incorrectly and the possibility that these lines had been disconnected and reconnected for other maintenance after I had installed them. It is our company policy before hydraulic lines are disconnected that each end be tagged with a metal identify tag to properly identify what port it goes to. Aircraft maintenance is something that I take very seriously and I know that I had checked and double-checked to make sure that these lines were connected to the proper ports as they had been tagged. It's hard to believe that after all the final post operational checks and through several taxi test this problem was not detected until the aircraft returned for landing on its third test flight. I feel the sabreliner maintenance manual needs to be updated to clearly show identify of hydraulic lines and proper ports. Also operational checks need to be called out for testing the brakes for proper operation. These checks need to be reviewed to see why this problem wasn't detected.
Original NASA ASRS Text
Title: A MIL SABRELINER-40 (T39B/D) ACFT BRAKE LINES WERE RE-INSTALLED IN REVERSE (CROSSED). LEFT PEDAL OPERATED R BRAKE AND R OPERATED LEFT BRAKE.
Narrative: THE ACFT INVOLVED IS A MIL SABRELINER THAT OUR COMPANY HAS A MAINT CONTRACT TO DO ACFT CONDITION INSPECTIONS ON. THIS INVOLVES DISASSEMBLY OF THE ACFT WITH A COMPLETE WING DEMATE; SYS OVERHAUL AND STRUCTURAL OVERHAUL. I WAS GIVEN THE ASSIGNMENT TO REINSTALL HYD LINES THAT WERE REMOVED FOR ACCESS FOR MAJOR STRUCTURAL WORK THAT HAD BEEN COMPLETED. THE ENDS OF EACH HYD LINE HAD BEEN CAPPED AND TAGGED WITH AN IDENT TAG MARKING IT TO ITS PROPER PORT. I HAD ATTACHED EACH LINE TO ITS PROPER PORT AND DOUBLE-CHKED EACH ONE BEFORE REMOVING THE TAGS. THE SABRELINER MAINT MANUAL DOES NOT CLRLY SHOW WHICH LINE GOES TO WHICH PORT. 4 MONTHS LATER THE ACFT HAD COMPLETED ITS OVERHAUL AND REASSEMBLY AND HAD GONE THROUGH ALL OF ITS POST OPERATIONAL CHKS AND HAD COMPLETED ITS TAXI TEST. THE ACFT WAS TURNED OVER TO THE MIL TEST PLTS FOR LIGHT TEST. ON THE THIRD TEST FLT DURING THE LNDG ROLLOUT THE BRAKES WERE FOUND TO BE OPERATING IN REVERSE; MEANING THE R BRAKE PEDAL OPERATED THE L BRAKE AND THE L BRAKE PEDAL OPERATED THE R BRAKE. THE ACFT LANDED AND RETURNED TO OUR MAINT FACILITY UNDAMAGED. FROM THE TIME I INSTALLED THE HYD LINES IN QUESTION; I WAS ASSIGNED TO ANOTHER ACFT AND THE ACFT IN QUESTION CONTINUED THROUGH 4 MONTHS OF MAINT; OVERHAUL AND REASSEMBLY. THERE IS THE POSSIBILITY THAT THESE LINES HAD BEEN TAGGED INCORRECTLY AND THE POSSIBILITY THAT THESE LINES HAD BEEN DISCONNECTED AND RECONNECTED FOR OTHER MAINT AFTER I HAD INSTALLED THEM. IT IS OUR COMPANY POLICY BEFORE HYD LINES ARE DISCONNECTED THAT EACH END BE TAGGED WITH A METAL IDENT TAG TO PROPERLY IDENT WHAT PORT IT GOES TO. ACFT MAINT IS SOMETHING THAT I TAKE VERY SERIOUSLY AND I KNOW THAT I HAD CHKED AND DOUBLE-CHKED TO MAKE SURE THAT THESE LINES WERE CONNECTED TO THE PROPER PORTS AS THEY HAD BEEN TAGGED. IT'S HARD TO BELIEVE THAT AFTER ALL THE FINAL POST OPERATIONAL CHKS AND THROUGH SEVERAL TAXI TEST THIS PROB WAS NOT DETECTED UNTIL THE ACFT RETURNED FOR LNDG ON ITS THIRD TEST FLT. I FEEL THE SABRELINER MAINT MANUAL NEEDS TO BE UPDATED TO CLRLY SHOW IDENT OF HYD LINES AND PROPER PORTS. ALSO OPERATIONAL CHKS NEED TO BE CALLED OUT FOR TESTING THE BRAKES FOR PROPER OP. THESE CHKS NEED TO BE REVIEWED TO SEE WHY THIS PROB WASN'T DETECTED.
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.