An inspector verifying lubrication of a dhc-8-200 flap primary torque tube splines and the safety of...

Attributes
ACN	780579
Time
Date	200805
Local Time Of Day	1801 To 2400
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
Person 1
Affiliation	company : air carrier
Function	maintenance : inspector
ASRS Report	780579
Events
Anomaly	aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure
Independent Detector	other other : 1
Resolutory Action	none taken : detected after the fact
Consequence	other
Factors
Maintenance	contributing factor : briefing performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : installation performance deficiency : inspection
Supplementary
Problem Areas	Aircraft Maintenance Human Performance
Primary Problem	Maintenance Human Performance

Narrative:

In mar/08; I was assigned to the heavy check; as an inspector for aircraft X. The aircraft is positioned in the check dock with temporary wing docks (platforms) under the left and right wings. I was asked to look at an rii 'buyback' on task card; lubrication of flap primary torque tube splines; l-hand. Per the task card; the mechanics have installed the hardware loosely so that I can verify correct engagement of the splines and hardware before final assembly and safety (cotter pin). Because of the design of the temporary wing docks and that the aircraft is not on jack stands; the distance between the work area (aft spar) and the dock decking is approximately 3 1/2 - 4 ft. I was crawling on my hands and knees reaching upward with one hand to check the connection of each torque tube spline and hardware connection. After I had inspected each coupling; I gave the mechanics an 'ok' to tighten and safety each coupling. I returned to the aircraft approximately 45 mins later and inspected the safeties (cotter pin installation). In apr/08; quality control supervisor informed me of a non-routine write-up for aircraft: l-hand wing; #2 primary flap drive shaft was not properly reassembled (#2 drive shaft came off #4 flap gear box spline). We discussed how this could have happened. The only possible explanation I had was that I was crawling on my hands and knees in a confined space while inspecting the couplings. It is my understanding a mechanic and inspector found the condition after other maintenance. Non-routine was created and discrepancy was worked. Aircraft in heavy check; positioned in check dock with temporary wing docks creating limited work space when aircraft is not on jack stands. Stop using temporary wing docks; when the proper docks are available. Why can't they be positioned under the current 'C' check aircraft?

Original NASA ASRS Text

Title: AN INSPECTOR VERIFYING LUBRICATION OF A DHC-8-200 FLAP PRIMARY TORQUE TUBE SPLINES AND THE SAFETY OF EACH SPLINE COUPLING; IS INFORMED BY HIS SUPERVISOR THE DRIVE SHAFT WAS NOT PROPERLY REASSEMBLED.

Narrative: IN MAR/08; I WAS ASSIGNED TO THE HVY CHK; AS AN INSPECTOR FOR ACFT X. THE ACFT IS POSITIONED IN THE CHK DOCK WITH TEMPORARY WING DOCKS (PLATFORMS) UNDER THE L AND R WINGS. I WAS ASKED TO LOOK AT AN RII 'BUYBACK' ON TASK CARD; LUBRICATION OF FLAP PRIMARY TORQUE TUBE SPLINES; L-HAND. PER THE TASK CARD; THE MECHS HAVE INSTALLED THE HARDWARE LOOSELY SO THAT I CAN VERIFY CORRECT ENGAGEMENT OF THE SPLINES AND HARDWARE BEFORE FINAL ASSEMBLY AND SAFETY (COTTER PIN). BECAUSE OF THE DESIGN OF THE TEMPORARY WING DOCKS AND THAT THE ACFT IS NOT ON JACK STANDS; THE DISTANCE BTWN THE WORK AREA (AFT SPAR) AND THE DOCK DECKING IS APPROX 3 1/2 - 4 FT. I WAS CRAWLING ON MY HANDS AND KNEES REACHING UPWARD WITH ONE HAND TO CHK THE CONNECTION OF EACH TORQUE TUBE SPLINE AND HARDWARE CONNECTION. AFTER I HAD INSPECTED EACH COUPLING; I GAVE THE MECHS AN 'OK' TO TIGHTEN AND SAFETY EACH COUPLING. I RETURNED TO THE ACFT APPROX 45 MINS LATER AND INSPECTED THE SAFETIES (COTTER PIN INSTALLATION). IN APR/08; QUALITY CTL SUPVR INFORMED ME OF A NON-ROUTINE WRITE-UP FOR ACFT: L-HAND WING; #2 PRIMARY FLAP DRIVE SHAFT WAS NOT PROPERLY REASSEMBLED (#2 DRIVE SHAFT CAME OFF #4 FLAP GEAR BOX SPLINE). WE DISCUSSED HOW THIS COULD HAVE HAPPENED. THE ONLY POSSIBLE EXPLANATION I HAD WAS THAT I WAS CRAWLING ON MY HANDS AND KNEES IN A CONFINED SPACE WHILE INSPECTING THE COUPLINGS. IT IS MY UNDERSTANDING A MECH AND INSPECTOR FOUND THE CONDITION AFTER OTHER MAINT. NON-ROUTINE WAS CREATED AND DISCREPANCY WAS WORKED. ACFT IN HVY CHK; POSITIONED IN CHK DOCK WITH TEMPORARY WING DOCKS CREATING LIMITED WORK SPACE WHEN ACFT IS NOT ON JACK STANDS. STOP USING TEMPORARY WING DOCKS; WHEN THE PROPER DOCKS ARE AVAILABLE. WHY CAN'T THEY BE POSITIONED UNDER THE CURRENT 'C' CHK ACFT?

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.

An inspector verifying lubrication of a dhc-8-200 flap primary torque tube splines and the safety of each spline coupling; is informed by his supervisor the drive shaft was not properly reassembled.