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|
Attributes | |
ACN | 801556 |
Time | |
Date | 200808 |
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) |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician maintenance : inspector |
ASRS Report | 801556 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 801743 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : briefing performance deficiency : installation performance deficiency : scheduled maintenance performance deficiency : inspection performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
In july; I took over re-torque of #2 propeller. Mechanic X and I re-torqued blades 4; 5; and 6. I was rii inspector; mechanic X performed the maintenance. During re-torque procedure; torque adaptor broke and we had to stop task for 3 hours; and continue work on other aircraft until new tooling arrived from ZZZ1. New tooling arrived and we finished task just prior to day shift arrival. I was notified today; 43 days later; that 3 safety cables were found not installed during a propeller change in ZZZ1 hangar. We had the required task cards on hand and to the best of my knowledge had complied with all tasks required. The only thing that stands out in my mind about that night during the maintenance was the breaking of the torque adaptor and stopping the task in order to wait for another to be driven up from ZZZ1. Other than that; it was a standard 6 blade re-torque. ZZZ1 removed the #2 propeller at the hangar and noticed the safety cable and fasteners were missing. They notified a supervisor who pulled history and determined the last time propeller was worked was in ZZZ2. Notified my supervisor who notified me. I honestly do not know how the event occurred; it was 46 days ago. I performed the rii inspection and; from the data I have been presented with; it appears that the 3 safety cables and 3 retaining fasteners for the cables were not installed. More attention to detail. Minimization of distrs and interruptions of work. Callback conversation with reporter revealed the following information: reporter stated the safety cables are about the size of a pencil and are pushed through a hole in the base of the propeller blade and secured. The purpose of the safety cables is to prevent the slinging (separation) of the blade from the hub. Reporter stated they were planning on using a propeller lift support truck that had the three remaining blades on the lift; but were reassigned to another aircraft while a replacement propeller torque adaptor tool arrived. After the adaptor arrived; they realized the blade lift truck could not be raised. So they moved the truck and transferred the three remaining propeller blades to a different lift platform. Reporter stated they just did not see the three small safety cables that were left on the truck platform when they transferred the blades. They had inadvertently skipped the sentence for the safety cables installation when they returned to complete the propeller blade re-torque. The missing safety cables were found forty-three days later; still on the lift truck platform.
Original NASA ASRS Text
Title: A LEAD MECHANIC PERFORMING RII FUNCTIONS AND A MECHANIC REPORT THREE SAFETY CABLES WERE FOUND NOT INSTALLED; FORTY-THREE DAYS AFTER THEY HAD PERFORMED A SIX BLADE PROP CHANGE RE-TORQUE; ON A DHC-8-400.
Narrative: IN JULY; I TOOK OVER RE-TORQUE OF #2 PROP. MECH X AND I RE-TORQUED BLADES 4; 5; AND 6. I WAS RII INSPECTOR; MECH X PERFORMED THE MAINT. DURING RE-TORQUE PROC; TORQUE ADAPTOR BROKE AND WE HAD TO STOP TASK FOR 3 HRS; AND CONTINUE WORK ON OTHER ACFT UNTIL NEW TOOLING ARRIVED FROM ZZZ1. NEW TOOLING ARRIVED AND WE FINISHED TASK JUST PRIOR TO DAY SHIFT ARR. I WAS NOTIFIED TODAY; 43 DAYS LATER; THAT 3 SAFETY CABLES WERE FOUND NOT INSTALLED DURING A PROP CHANGE IN ZZZ1 HANGAR. WE HAD THE REQUIRED TASK CARDS ON HAND AND TO THE BEST OF MY KNOWLEDGE HAD COMPLIED WITH ALL TASKS REQUIRED. THE ONLY THING THAT STANDS OUT IN MY MIND ABOUT THAT NIGHT DURING THE MAINT WAS THE BREAKING OF THE TORQUE ADAPTOR AND STOPPING THE TASK IN ORDER TO WAIT FOR ANOTHER TO BE DRIVEN UP FROM ZZZ1. OTHER THAN THAT; IT WAS A STANDARD 6 BLADE RE-TORQUE. ZZZ1 REMOVED THE #2 PROP AT THE HANGAR AND NOTICED THE SAFETY CABLE AND FASTENERS WERE MISSING. THEY NOTIFIED A SUPVR WHO PULLED HISTORY AND DETERMINED THE LAST TIME PROP WAS WORKED WAS IN ZZZ2. NOTIFIED MY SUPVR WHO NOTIFIED ME. I HONESTLY DO NOT KNOW HOW THE EVENT OCCURRED; IT WAS 46 DAYS AGO. I PERFORMED THE RII INSPECTION AND; FROM THE DATA I HAVE BEEN PRESENTED WITH; IT APPEARS THAT THE 3 SAFETY CABLES AND 3 RETAINING FASTENERS FOR THE CABLES WERE NOT INSTALLED. MORE ATTN TO DETAIL. MINIMIZATION OF DISTRS AND INTERRUPTIONS OF WORK. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED THE SAFETY CABLES ARE ABOUT THE SIZE OF A PENCIL AND ARE PUSHED THROUGH A HOLE IN THE BASE OF THE PROP BLADE AND SECURED. THE PURPOSE OF THE SAFETY CABLES IS TO PREVENT THE SLINGING (SEPARATION) OF THE BLADE FROM THE HUB. REPORTER STATED THEY WERE PLANNING ON USING A PROP LIFT SUPPORT TRUCK THAT HAD THE THREE REMAINING BLADES ON THE LIFT; BUT WERE REASSIGNED TO ANOTHER ACFT WHILE A REPLACEMENT PROP TORQUE ADAPTOR TOOL ARRIVED. AFTER THE ADAPTOR ARRIVED; THEY REALIZED THE BLADE LIFT TRUCK COULD NOT BE RAISED. SO THEY MOVED THE TRUCK AND TRANSFERRED THE THREE REMAINING PROP BLADES TO A DIFFERENT LIFT PLATFORM. REPORTER STATED THEY JUST DID NOT SEE THE THREE SMALL SAFETY CABLES THAT WERE LEFT ON THE TRUCK PLATFORM WHEN THEY TRANSFERRED THE BLADES. THEY HAD INADVERTENTLY SKIPPED THE SENTENCE FOR THE SAFETY CABLES INSTALLATION WHEN THEY RETURNED TO COMPLETE THE PROP BLADE RE-TORQUE. THE MISSING SAFETY CABLES WERE FOUND FORTY-THREE DAYS LATER; STILL ON THE LIFT TRUCK PLATFORM.
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.