37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 766759 |
Time | |
Date | 200712 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | general aviation : personal |
Make Model Name | M-20 TN Acclaim |
Operating Under FAR Part | Part 91 |
Person 1 | |
Affiliation | other |
Function | maintenance : technician |
Qualification | technician : airframe technician : fcc technician : powerplant |
Experience | maintenance technician : 21 |
ASRS Report | 766759 |
Person 2 | |
Affiliation | other |
Function | flight crew : single pilot |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other flight crewa other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : briefing performance deficiency : installation performance deficiency : inspection performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
After troubleshooting the airspeed gear safety switch/hobbs meter system on a mooney M20TN; the left aft tail cone compartment access panel was installed but not secured properly. Aircraft owner reported that the panel was missing after his arrival at his destination. Factors that contributed to this event were; a personal oversight; and distrs from other tasks being performed that day. I feel that what needs to be done to prevent this type of event from happening in the future is personal due diligence to the task at hand and including following our process of additional personnel to be involved in the final inspection process before the aircraft is returned to service. Callback conversation with reporter revealed the following information: reporter states his company's procedures includes double checking by other maintenance personnel for a final on outgoing aircraft. Although 80 % of the panel's cam-localizer fasteners were secured; the two fasteners at the panel's fwd edge were not. As a result; the wind caught that unsecured edge; lifted; rattled and then tore the metal panel off from the fuselage; leaving all the secured fasteners in the fuselage; except for the two loose cam-locs which departed with the panel skin. Reporter also states he was distracted as a result of a phone call and with everyone rushing to get the aircraft ready for flight; the double check procedure was not accomplished and the pilot's walkaround did not catch the unsecured fasteners. The aft left access panel was removed so he could complete a service bulletin (south/B) to replace a diode in the external power receptacle in the aft section of the aircraft. Reporter adds this aircraft is brand new with G-1000 glass cockpit and very fast.
Original NASA ASRS Text
Title: A NEW MOONEY M20TN ACCLAIM ACFT LEFT AFT TAIL CONE COMPARTMENT ACCESS PANEL WAS RE-INSTALLED BUT NOT PROPERLY SECURED. ACFT OWNER REPORTED THAT PANEL WAS MISSING AFTER ARRIVAL AT HIS DESTINATION.
Narrative: AFTER TROUBLESHOOTING THE AIRSPD GEAR SAFETY SWITCH/HOBBS METER SYS ON A MOONEY M20TN; THE L AFT TAIL CONE COMPARTMENT ACCESS PANEL WAS INSTALLED BUT NOT SECURED PROPERLY. ACFT OWNER RPTED THAT THE PANEL WAS MISSING AFTER HIS ARR AT HIS DEST. FACTORS THAT CONTRIBUTED TO THIS EVENT WERE; A PERSONAL OVERSIGHT; AND DISTRS FROM OTHER TASKS BEING PERFORMED THAT DAY. I FEEL THAT WHAT NEEDS TO BE DONE TO PREVENT THIS TYPE OF EVENT FROM HAPPENING IN THE FUTURE IS PERSONAL DUE DILIGENCE TO THE TASK AT HAND AND INCLUDING FOLLOWING OUR PROCESS OF ADDITIONAL PERSONNEL TO BE INVOLVED IN THE FINAL INSPECTION PROCESS BEFORE THE ACFT IS RETURNED TO SVC. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATES HIS COMPANY'S PROCEDURES INCLUDES DOUBLE CHECKING BY OTHER MAINT PERSONNEL FOR A FINAL ON OUTGOING ACFT. ALTHOUGH 80 % OF THE PANEL'S CAM-LOC FASTENERS WERE SECURED; THE TWO FASTENERS AT THE PANEL'S FWD EDGE WERE NOT. AS A RESULT; THE WIND CAUGHT THAT UNSECURED EDGE; LIFTED; RATTLED AND THEN TORE THE METAL PANEL OFF FROM THE FUSELAGE; LEAVING ALL THE SECURED FASTENERS IN THE FUSELAGE; EXCEPT FOR THE TWO LOOSE CAM-LOCS WHICH DEPARTED WITH THE PANEL SKIN. REPORTER ALSO STATES HE WAS DISTRACTED AS A RESULT OF A PHONE CALL AND WITH EVERYONE RUSHING TO GET THE ACFT READY FOR FLIGHT; THE DOUBLE CHECK PROCEDURE WAS NOT ACCOMPLISHED AND THE PILOT'S WALKAROUND DID NOT CATCH THE UNSECURED FASTENERS. THE AFT LEFT ACCESS PANEL WAS REMOVED SO HE COULD COMPLETE A SERVICE BULLETIN (S/B) TO REPLACE A DIODE IN THE EXTERNAL POWER RECEPTACLE IN THE AFT SECTION OF THE ACFT. REPORTER ADDS THIS ACFT IS BRAND NEW WITH G-1000 GLASS COCKPIT AND VERY FAST.
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.