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Attributes | |
ACN | 775514 |
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 | common carrier : air carrier |
Make Model Name | Dash 8-400 |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 775514 |
Events | |
Anomaly | maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : engineering procedure contributing factor : manuals contributing factor : weather performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : repair |
Supplementary | |
Problem Areas | Aircraft Weather Maintenance Human Performance Company Chart Or Publication |
Primary Problem | Chart Or Publication |
Narrative:
I started my field work assignment in ZZZ1. Being from the hangar; and knowing about the special inspections that the Q400 propeller blades were going through; I informed fellow mechanics and lead supervisors of this new inspection card. However; on this end; I was not doing the initial inspection on the blades; or reinspection of the blades. I was using a different card to reapply repairs to propeller blades that had previously been repaired and was on the special inspection program per our company's contracted maintenance compliance system. By going into the maintenance compliance system to view the blade serial number that had a repair that was damaged; or delamination on the nickel sheath; I would look for this special inspection card. If I saw that this task was listed below the serial number blade; I would re-apply the repair per that portion of the task card; and previously completed with the rest of the steps; due to it already being in the system; and being tracked. The adhesive that is used in this repair is different than the clamping method repair used in the maintenance manual. This task card tells the mechanic to apply an overlap of the material by an inch to try and keep water from ingressing into the blade. The repairs that I redid seemed to be very 'thick' and about half it would be cracked off and missing. Due to the previous mechanic performing the repair putting the material on so thick; when the blade would flex; it would crack apart at the seam line of the nickel sheath and the blade itself. All of these re-repairs were done outside on the ramp in ZZZ1 where the WX was wet and windy. To dry out the propeller blade I would use a heat gun; and if it was raining hard; I would use a hazmat bag (or similar) to tape above the tip of the blade to divert water away from the tip of the blade. I would use the heat gun to dry out the tip; and then use alcohol to clean the area the best that I could and then re-dry the area again with the heat gun. Then after this; I could apply the repair in accordance with this already attached card in the maintenance compliance system per the steps. Being that the propeller blade was showing; I would sign off the logbook per this card. When I first arrived at the ZZZ1 station; I was informed that we didn't use work orders for things such as tire/brake changes. We did all of this off of electronic publications; and hand wrote everything in. I thought no different about this; because this task card was showing in the maintenance compliance system as already being assigned to that applicable propeller blade. I was informed by another mechanic that he went to ZZZ2 to inspect a blade that I had signed off per this inspection; and was informed by maintenance control; to sign it off per the repair manual. I do not recall if that blade was removed from service or not. That blade was also signed off the same way that the previous blades were. Showing the special inspection card assigned to it; using the method above to find it. On feb/xa; mr X needed to talk to me about work and brought up the fact that 'I had been doing illegal blade repairs.' during this time; I told him; and showed him in the maintenance compliance system; how I came to the conclusion that the blades were already on the special inspection; being that it was beneath that serial number in the maintenance compliance system. In doing so; I would reapply the repair; or in I think 2 of the cases; apply a repair. The records department or a special audit is how they found out these were 'signed off' improperly. The maintenance compliance system attached engineering changes that were no longer effective to part number/serial number. If this blade had this engineering change still attached; and I reapplied the repair; that was already on a 500 hour life limit; the maintenance compliance system should have already been counting time; due to the maintenance compliance system survey questions being answered; from the other initial inspection card; putting it on the this card. If the blades were no longer under this; then the maintenance compliance system shouldn't have shown that it still was. These repairs were repaired in the method as described in this special inspection. The overlap is different than the permanent repair per the maintenance manual. The maintenance compliance system will let you do things sometimes that it shouldn't. With this being said; it also will not let you attach a power assurance run twice to the same work order; even though sometimes you need to perform the task twice or more to correct the issue at hand. I looked into the only history/records program that we have and used the information that it provided me. As a mechanic; I need documentation to perform any maintenance on the aircraft. The maintenance compliance system showed that these special inspection cards were already attached to the part number/serial number applicable blades in question; so I previously complied with the steps; except for the one that was for applying the repair to the blade. The blades in question; one which I attached in the maintenance compliance system (which unknowingly to me was out of the timeframe) was still allowed by the maintenance compliance system to attach it to the propeller blade. If the maintenance compliance system is wrong here; where else is it wrong? The paper method and old tracking system was much easier; and less confusing; as a mechanic; to operate. I would be much happier if the air carrier would come up with a better system. Paper only would be nice! We have to enter in information several times for doing the same job. We have to sign off a log page; enter it into the maintenance compliance system; and then if it is a maximum hours since repair MEL; we have to sign the non routine card with the work order as well. So for doing my job; I have to sign for it 3 different times. Just this past week I went to remove a brake from aircraft X and the maintenance compliance system would not let me attached a part number/engineering change specific task card because the task was not applicable to the brake installed on the #3 position. We only have 1 task card for removing a Q200 brake; and the maintenance compliance system said that it was wrong and my lead ended up writing in the information across the top of the card; due to the infamous 'maintenance compliance system glitch and/or sometimes having a mind of its own.' I do not trust the maintenance compliance system one bit; and now my job is in limbo because of using the information the air carrier and this maintenance compliance system has provided me as a mechanic. Callback conversation with reporter revealed the following information: reporter stated the dowty Q-400 propellers are made of carbon fiber material utilizing a nickel sheath leading edge that has been prone to delamination and separation; mostly from water or moisture ingress. When searching for the required inspection task card for the specific propeller needing a leading edge or blade tip repair; the mechanic uses the maintenance compliance system. However; the type of repair the system tells the mechanic to follow has been found to be assigning the wrong repair task cards to an incorrect serial numbered propeller. The numerous inaccuracies of their system also conflicts with the propeller manufacturer; dowty's maintenance manual procedures.
Original NASA ASRS Text
Title: A DEHAVILLAND DHC-8-400 MECHANIC EXPLAINS THE MULTIPLE PROBLEMS WITH HIS CARRIERS MAINT COMPLIANCE SYSTEM FOR REPAIRING THE Q-400 PROP BLADES FOR DELAMINATION AND SEPARATION OF THE PROP LEADING EDGE NICKEL SHEATH.
Narrative: I STARTED MY FIELD WORK ASSIGNMENT IN ZZZ1. BEING FROM THE HANGAR; AND KNOWING ABOUT THE SPECIAL INSPECTIONS THAT THE Q400 PROP BLADES WERE GOING THROUGH; I INFORMED FELLOW MECHS AND LEAD SUPVRS OF THIS NEW INSPECTION CARD. HOWEVER; ON THIS END; I WAS NOT DOING THE INITIAL INSPECTION ON THE BLADES; OR REINSPECTION OF THE BLADES. I WAS USING A DIFFERENT CARD TO REAPPLY REPAIRS TO PROP BLADES THAT HAD PREVIOUSLY BEEN REPAIRED AND WAS ON THE SPECIAL INSPECTION PROGRAM PER OUR COMPANY'S CONTRACTED MAINT COMPLIANCE SYS. BY GOING INTO THE MAINT COMPLIANCE SYS TO VIEW THE BLADE SERIAL NUMBER THAT HAD A REPAIR THAT WAS DAMAGED; OR DELAMINATION ON THE NICKEL SHEATH; I WOULD LOOK FOR THIS SPECIAL INSPECTION CARD. IF I SAW THAT THIS TASK WAS LISTED BELOW THE SERIAL NUMBER BLADE; I WOULD RE-APPLY THE REPAIR PER THAT PORTION OF THE TASK CARD; AND PREVIOUSLY COMPLETED WITH THE REST OF THE STEPS; DUE TO IT ALREADY BEING IN THE SYSTEM; AND BEING TRACKED. THE ADHESIVE THAT IS USED IN THIS REPAIR IS DIFFERENT THAN THE CLAMPING METHOD REPAIR USED IN THE MAINT MANUAL. THIS TASK CARD TELLS THE MECH TO APPLY AN OVERLAP OF THE MATERIAL BY AN INCH TO TRY AND KEEP WATER FROM INGRESSING INTO THE BLADE. THE REPAIRS THAT I REDID SEEMED TO BE VERY 'THICK' AND ABOUT HALF IT WOULD BE CRACKED OFF AND MISSING. DUE TO THE PREVIOUS MECH PERFORMING THE REPAIR PUTTING THE MATERIAL ON SO THICK; WHEN THE BLADE WOULD FLEX; IT WOULD CRACK APART AT THE SEAM LINE OF THE NICKEL SHEATH AND THE BLADE ITSELF. ALL OF THESE RE-REPAIRS WERE DONE OUTSIDE ON THE RAMP IN ZZZ1 WHERE THE WX WAS WET AND WINDY. TO DRY OUT THE PROP BLADE I WOULD USE A HEAT GUN; AND IF IT WAS RAINING HARD; I WOULD USE A HAZMAT BAG (OR SIMILAR) TO TAPE ABOVE THE TIP OF THE BLADE TO DIVERT WATER AWAY FROM THE TIP OF THE BLADE. I WOULD USE THE HEAT GUN TO DRY OUT THE TIP; AND THEN USE ALCOHOL TO CLEAN THE AREA THE BEST THAT I COULD AND THEN RE-DRY THE AREA AGAIN WITH THE HEAT GUN. THEN AFTER THIS; I COULD APPLY THE REPAIR IN ACCORDANCE WITH THIS ALREADY ATTACHED CARD IN THE MAINT COMPLIANCE SYS PER THE STEPS. BEING THAT THE PROP BLADE WAS SHOWING; I WOULD SIGN OFF THE LOGBOOK PER THIS CARD. WHEN I FIRST ARRIVED AT THE ZZZ1 STATION; I WAS INFORMED THAT WE DIDN'T USE WORK ORDERS FOR THINGS SUCH AS TIRE/BRAKE CHANGES. WE DID ALL OF THIS OFF OF ELECTRONIC PUBLICATIONS; AND HAND WROTE EVERYTHING IN. I THOUGHT NO DIFFERENT ABOUT THIS; BECAUSE THIS TASK CARD WAS SHOWING IN THE MAINT COMPLIANCE SYS AS ALREADY BEING ASSIGNED TO THAT APPLICABLE PROP BLADE. I WAS INFORMED BY ANOTHER MECH THAT HE WENT TO ZZZ2 TO INSPECT A BLADE THAT I HAD SIGNED OFF PER THIS INSPECTION; AND WAS INFORMED BY MAINT CTL; TO SIGN IT OFF PER THE REPAIR MANUAL. I DO NOT RECALL IF THAT BLADE WAS REMOVED FROM SVC OR NOT. THAT BLADE WAS ALSO SIGNED OFF THE SAME WAY THAT THE PREVIOUS BLADES WERE. SHOWING THE SPECIAL INSPECTION CARD ASSIGNED TO IT; USING THE METHOD ABOVE TO FIND IT. ON FEB/XA; MR X NEEDED TO TALK TO ME ABOUT WORK AND BROUGHT UP THE FACT THAT 'I HAD BEEN DOING ILLEGAL BLADE REPAIRS.' DURING THIS TIME; I TOLD HIM; AND SHOWED HIM IN THE MAINT COMPLIANCE SYS; HOW I CAME TO THE CONCLUSION THAT THE BLADES WERE ALREADY ON THE SPECIAL INSPECTION; BEING THAT IT WAS BENEATH THAT SERIAL NUMBER IN THE MAINT COMPLIANCE SYS. IN DOING SO; I WOULD REAPPLY THE REPAIR; OR IN I THINK 2 OF THE CASES; APPLY A REPAIR. THE RECORDS DEPT OR A SPECIAL AUDIT IS HOW THEY FOUND OUT THESE WERE 'SIGNED OFF' IMPROPERLY. THE MAINT COMPLIANCE SYS ATTACHED ENGINEERING CHANGES THAT WERE NO LONGER EFFECTIVE TO PART NUMBER/SERIAL NUMBER. IF THIS BLADE HAD THIS ENGINEERING CHANGE STILL ATTACHED; AND I REAPPLIED THE REPAIR; THAT WAS ALREADY ON A 500 HR LIFE LIMIT; THE MAINT COMPLIANCE SYS SHOULD HAVE ALREADY BEEN COUNTING TIME; DUE TO THE MAINT COMPLIANCE SYS SURVEY QUESTIONS BEING ANSWERED; FROM THE OTHER INITIAL INSPECTION CARD; PUTTING IT ON THE THIS CARD. IF THE BLADES WERE NO LONGER UNDER THIS; THEN THE MAINT COMPLIANCE SYS SHOULDN'T HAVE SHOWN THAT IT STILL WAS. THESE REPAIRS WERE REPAIRED IN THE METHOD AS DESCRIBED IN THIS SPECIAL INSPECTION. THE OVERLAP IS DIFFERENT THAN THE PERMANENT REPAIR PER THE MAINT MANUAL. THE MAINT COMPLIANCE SYS WILL LET YOU DO THINGS SOMETIMES THAT IT SHOULDN'T. WITH THIS BEING SAID; IT ALSO WILL NOT LET YOU ATTACH A PWR ASSURANCE RUN TWICE TO THE SAME WORK ORDER; EVEN THOUGH SOMETIMES YOU NEED TO PERFORM THE TASK TWICE OR MORE TO CORRECT THE ISSUE AT HAND. I LOOKED INTO THE ONLY HISTORY/RECORDS PROGRAM THAT WE HAVE AND USED THE INFO THAT IT PROVIDED ME. AS A MECH; I NEED DOCUMENTATION TO PERFORM ANY MAINT ON THE ACFT. THE MAINT COMPLIANCE SYS SHOWED THAT THESE SPECIAL INSPECTION CARDS WERE ALREADY ATTACHED TO THE PART NUMBER/SERIAL NUMBER APPLICABLE BLADES IN QUESTION; SO I PREVIOUSLY COMPLIED WITH THE STEPS; EXCEPT FOR THE ONE THAT WAS FOR APPLYING THE REPAIR TO THE BLADE. THE BLADES IN QUESTION; ONE WHICH I ATTACHED IN THE MAINT COMPLIANCE SYS (WHICH UNKNOWINGLY TO ME WAS OUT OF THE TIMEFRAME) WAS STILL ALLOWED BY THE MAINT COMPLIANCE SYS TO ATTACH IT TO THE PROP BLADE. IF THE MAINT COMPLIANCE SYS IS WRONG HERE; WHERE ELSE IS IT WRONG? THE PAPER METHOD AND OLD TRACKING SYS WAS MUCH EASIER; AND LESS CONFUSING; AS A MECH; TO OPERATE. I WOULD BE MUCH HAPPIER IF THE ACR WOULD COME UP WITH A BETTER SYS. PAPER ONLY WOULD BE NICE! WE HAVE TO ENTER IN INFO SEVERAL TIMES FOR DOING THE SAME JOB. WE HAVE TO SIGN OFF A LOG PAGE; ENTER IT INTO THE MAINT COMPLIANCE SYS; AND THEN IF IT IS A MAX HRS SINCE REPAIR MEL; WE HAVE TO SIGN THE NON ROUTINE CARD WITH THE WORK ORDER AS WELL. SO FOR DOING MY JOB; I HAVE TO SIGN FOR IT 3 DIFFERENT TIMES. JUST THIS PAST WK I WENT TO REMOVE A BRAKE FROM ACFT X AND THE MAINT COMPLIANCE SYS WOULD NOT LET ME ATTACHED A PART NUMBER/ENGINEERING CHANGE SPECIFIC TASK CARD BECAUSE THE TASK WAS NOT APPLICABLE TO THE BRAKE INSTALLED ON THE #3 POS. WE ONLY HAVE 1 TASK CARD FOR REMOVING A Q200 BRAKE; AND THE MAINT COMPLIANCE SYS SAID THAT IT WAS WRONG AND MY LEAD ENDED UP WRITING IN THE INFO ACROSS THE TOP OF THE CARD; DUE TO THE INFAMOUS 'MAINT COMPLIANCE SYS GLITCH AND/OR SOMETIMES HAVING A MIND OF ITS OWN.' I DO NOT TRUST THE MAINT COMPLIANCE SYS ONE BIT; AND NOW MY JOB IS IN LIMBO BECAUSE OF USING THE INFO THE ACR AND THIS MAINT COMPLIANCE SYS HAS PROVIDED ME AS A MECH. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED THE DOWTY Q-400 PROPS ARE MADE OF CARBON FIBER MATERIAL UTILIZING A NICKEL SHEATH LEADING EDGE THAT HAS BEEN PRONE TO DELAMINATION AND SEPARATION; MOSTLY FROM WATER OR MOISTURE INGRESS. WHEN SEARCHING FOR THE REQUIRED INSPECTION TASK CARD FOR THE SPECIFIC PROP NEEDING A LEADING EDGE OR BLADE TIP REPAIR; THE MECHANIC USES THE MAINT COMPLIANCE SYSTEM. HOWEVER; THE TYPE OF REPAIR THE SYSTEM TELLS THE MECHANIC TO FOLLOW HAS BEEN FOUND TO BE ASSIGNING THE WRONG REPAIR TASK CARDS TO AN INCORRECT SERIAL NUMBERED PROP. THE NUMEROUS INACCURACIES OF THEIR SYSTEM ALSO CONFLICTS WITH THE PROP MANUFACTURER; DOWTY'S MAINT MANUAL PROCEDURES.
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.