37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 777093 |
Time | |
Date | 200803 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | Dash 8-200 |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
ASRS Report | 777093 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 777909 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : 1 |
Resolutory Action | none taken : unable |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Chart Or Publication Company Maintenance Human Performance Environmental Factor |
Primary Problem | Maintenance Human Performance |
Narrative:
While performing an 'a' check in the engine shop with the engine (serial number off wing from aircraft X; #1 position); the following was found: fuel pump high pressure filter housing cover safetied backwards (pulling cover in a loose direction or counterclockwise); cover was found to be finger loose. Cover has 2 each o-rings. The outboard o-ring in the cover was found to be improperly placed between the outboard and inboard o-ring grooves. During 'a' check inspection; the high pressure filter element was changed. Quality check maintenance procedure new o-ring packings from stock were installed correctly; proper torque was applied and safety wire was installed in a correct direction to prevent loosening of the filter housing cover. Suggest fuel filter element replacement -- both high and low pressure on engine system should be rii'ed as are all fuel pressure tubes and hoses. Supplemental information from acn 777909: I've just been notified about an aircraft that I worked on a while ago. The aircraft number I remembered it was an a-chk. What happened was that I installed the fuel filter wrong; and did not notice that the safety wire was loose when I did it. Problem was I looked on how the filter was installed before and put it back the same way; but the way it was before wasn't tightening all the way and I thought it was ok like that because it was safety wire and there was no leak; but still I installed in the same condition. Obviously there were no defects to the aircraft; but when the engine was removed; someone found out that the filter was incorrectly installed. The filter is hard to see where it is located at; and could be installed wrong from either the first person who installed it or the person who installed it for the first time who doesn't know how it's supposed to be on there.
Original NASA ASRS Text
Title: A DEHAVILLAND DHC-8 INSPECTOR PERFORMING AN 'A' CHECK ON AN OFF-WING ENGINE FINDS FUEL PUMP HIGH PRESSURE FILTER HOUSING COVER SAFETIED BACKWARDS; PULLING THE COVER LOOSE.
Narrative: WHILE PERFORMING AN 'A' CHK IN THE ENG SHOP WITH THE ENG (SERIAL NUMBER OFF WING FROM ACFT X; #1 POS); THE FOLLOWING WAS FOUND: FUEL PUMP HIGH PRESSURE FILTER HOUSING COVER SAFETIED BACKWARDS (PULLING COVER IN A LOOSE DIRECTION OR COUNTERCLOCKWISE); COVER WAS FOUND TO BE FINGER LOOSE. COVER HAS 2 EACH O-RINGS. THE OUTBOARD O-RING IN THE COVER WAS FOUND TO BE IMPROPERLY PLACED BTWN THE OUTBOARD AND INBOARD O-RING GROOVES. DURING 'A' CHK INSPECTION; THE HIGH PRESSURE FILTER ELEMENT WAS CHANGED. QUALITY CHK MAINT PROC NEW O-RING PACKINGS FROM STOCK WERE INSTALLED CORRECTLY; PROPER TORQUE WAS APPLIED AND SAFETY WIRE WAS INSTALLED IN A CORRECT DIRECTION TO PREVENT LOOSENING OF THE FILTER HOUSING COVER. SUGGEST FUEL FILTER ELEMENT REPLACEMENT -- BOTH HIGH AND LOW PRESSURE ON ENG SYS SHOULD BE RII'ED AS ARE ALL FUEL PRESSURE TUBES AND HOSES. SUPPLEMENTAL INFO FROM ACN 777909: I'VE JUST BEEN NOTIFIED ABOUT AN ACFT THAT I WORKED ON A WHILE AGO. THE ACFT NUMBER I REMEMBERED IT WAS AN A-CHK. WHAT HAPPENED WAS THAT I INSTALLED THE FUEL FILTER WRONG; AND DID NOT NOTICE THAT THE SAFETY WIRE WAS LOOSE WHEN I DID IT. PROB WAS I LOOKED ON HOW THE FILTER WAS INSTALLED BEFORE AND PUT IT BACK THE SAME WAY; BUT THE WAY IT WAS BEFORE WASN'T TIGHTENING ALL THE WAY AND I THOUGHT IT WAS OK LIKE THAT BECAUSE IT WAS SAFETY WIRE AND THERE WAS NO LEAK; BUT STILL I INSTALLED IN THE SAME CONDITION. OBVIOUSLY THERE WERE NO DEFECTS TO THE ACFT; BUT WHEN THE ENG WAS REMOVED; SOMEONE FOUND OUT THAT THE FILTER WAS INCORRECTLY INSTALLED. THE FILTER IS HARD TO SEE WHERE IT IS LOCATED AT; AND COULD BE INSTALLED WRONG FROM EITHER THE FIRST PERSON WHO INSTALLED IT OR THE PERSON WHO INSTALLED IT FOR THE FIRST TIME WHO DOESN'T KNOW HOW IT'S SUPPOSED TO BE ON THERE.
Data retrieved from NASA's ASRS site as of May 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.