Mechanic working a dehavilland dhc-8-400 aircraft reports he overlooked the first step of the amm re...

Attributes
ACN	797198
Time
Date	200807
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	Q400 (Formerly Dash 8-400)
Person 1
Affiliation	company : air carrier
Function	maintenance : technician
ASRS Report	797198
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 : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : testing performance deficiency : installation
Supplementary
Problem Areas	Environmental Factor Maintenance Human Performance Aircraft
Primary Problem	Maintenance Human Performance

Narrative:

When removing the flaps position indicator unit for replacement; the first step of the maintenance manual task was overlooked. The flaps were not lowered to 35 degrees per the amm. The event happened at the ZZZ maintenance hardstand. The event was realized when reviewing the amm at the start of the shift the next day. The event occurred due to trying to hurry and get a job done; and flat out ignorance with not following the amm to the letter. To prevent future recurrence of this event; the amm should be read and understood before starting the task. Callback conversation with reporter revealed the following information: reporter stated the flap position indication unit (fpiu) is located in the cabin under the center floorboard and bolted to structure. Reporter stated the dhc-8's do not have a lower avionics compartment. Many of the aircraft's electrical/avionics equipment are also located under the cabin floorboards. Reporter stated although he had not positioned the flaps to 35; when removing the fpiu; the operations check was somehow still successful after he replaced the fpiu.

Original NASA ASRS Text

Title: MECHANIC WORKING A DEHAVILLAND DHC-8-400 ACFT REPORTS HE OVERLOOKED THE FIRST STEP OF THE AMM REQUIRING FLAPS BE LOWERED TO THE 35 DEGREE POSITION BEFORE REMOVING THE FLAP POSITION INDICATION UNIT (FPIU).

Narrative: WHEN REMOVING THE FLAPS POS INDICATOR UNIT FOR REPLACEMENT; THE FIRST STEP OF THE MAINT MANUAL TASK WAS OVERLOOKED. THE FLAPS WERE NOT LOWERED TO 35 DEGS PER THE AMM. THE EVENT HAPPENED AT THE ZZZ MAINT HARDSTAND. THE EVENT WAS REALIZED WHEN REVIEWING THE AMM AT THE START OF THE SHIFT THE NEXT DAY. THE EVENT OCCURRED DUE TO TRYING TO HURRY AND GET A JOB DONE; AND FLAT OUT IGNORANCE WITH NOT FOLLOWING THE AMM TO THE LETTER. TO PREVENT FUTURE RECURRENCE OF THIS EVENT; THE AMM SHOULD BE READ AND UNDERSTOOD BEFORE STARTING THE TASK. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED THE FLAP POSITION INDICATION UNIT (FPIU) IS LOCATED IN THE CABIN UNDER THE CENTER FLOORBOARD AND BOLTED TO STRUCTURE. REPORTER STATED THE DHC-8'S DO NOT HAVE A LOWER AVIONICS COMPARTMENT. MANY OF THE ACFT'S ELECTRICAL/AVIONICS EQUIPMENT ARE ALSO LOCATED UNDER THE CABIN FLOORBOARDS. REPORTER STATED ALTHOUGH HE HAD NOT POSITIONED THE FLAPS TO 35; WHEN REMOVING THE FPIU; THE OPS CHECK WAS SOMEHOW STILL SUCCESSFUL AFTER HE REPLACED THE FPIU.

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.

Mechanic working a dehavilland dhc-8-400 aircraft reports he overlooked the first step of the amm requiring flaps be lowered to the 35 degree position before removing the flap position indication unit (fpiu).