37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 814812 |
Time | |
Date | 200812 |
Local Time Of Day | 0601 To 1200 |
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 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician oversight : supervisor |
ASRS Report | 814812 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
ASRS Report | 814937 |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper documentation other anomaly other |
Independent Detector | other other : 4 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : briefing contributing factor : work cards contributing factor : engineering procedure contributing factor : manuals performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft was in MEL 49-00-1; was cleared by mr X. Mr Y was the lead mechanic for the aircraft. The MEL stated 2 attempts to start and APU failed. I asked the lead mechanic why the APU inspection per task was not completed. I was told the combustor drain valve was post-modification and the inspection was not required. I had him talk to quality control and was told the rii was not required. The igniters were replaced and was the fix for the APU. The signoff included the functional test of the APU. This task takes you to subtask; which is the start procedure for the APU. The mechanic did perform the inspection of the APU per supplements; however; he did not include the verbiage 'inspected per air carrier supplement.' step 13 was not required as the combustor drain valve was post-modification. Step 13 only applied to pre-modification part #164161-100 so an rii was not missed. It was felt that when complying with the inspection task it implies that the supplemental task was complied with as well. The documentation on log page was not clear and did not indicate the supplement task had been complied with. Also did not state that the combustor drain valve was inspected and found to be post-modification. I failed to follow up and require a better signoff. Many factors led up to me missing this information and performing a better review. I was working in the office alone and there were many distrs. All the supervisors have been spending a good deal of time learning the new time clock system. This is taking our focus away from the aircraft and the paperwork. The supervisors including myself have also been under a tremendous amount of stress lately due to the reorganization of the supervisor positions by management. The plan was implemented very poorly as information was leaked early allowing rumors to build. A fair amount of uncertainty existed and still does; not knowing what department or what shift we will be working on. It has been a significant distraction as it is causing a disruption in our family lives. All of these events have helped lead up to the mistakes that took place. Provide a clear signoff that the supplement was complied with and indicate the combustor drain valve was inspected pre- or post-modification. Include in the supplemental task; a step or note to document on the signoff that combustor drain valve was inspected and found to be pre-modification or post-modification. North/a (not applicable) step 13A as required. Supplemental information from acn 814937: I was the lead on aircraft and the APU was on MEL. The mechanic performed a repair to it by changing the igniters and since the APU had 2 'fail to start' reports on the pre-modification; drain valve requires an inspection. The mechanic informed me that the drain valve was a post-modification; which does not require an inspection. I checked with quality control and was told that no removal and inspection was required on the post-modification drain valves. The supervisor saw that the paperwork did not show an APU drain valve inspection due to 2 'fail to starts.' the APU was placed on MEL deferral and the aircraft was routed to ZZZ for the inspection; and then the APU deferral was cleared and the aircraft was placed back into service. I don't know if there is a problem with the amm task between pre- or post-modification drain valves or that the mechanic misidentifies the drain valve. I can only go by the information that I am given at the time by the mechanic. Modify all the Q400 APU drain valves to a post-modification status so that there is no confusion about what type of drain valve is installed on the aircraft. Supplemental information from acn 814813: I cleared an APU MEL on aircraft X by changing igniter plugs. I also complied with a visual inspection (combustor drain valve installed was post-modification; therefore; not an raa inspection); but I did not state that I complied with the inspection. The aircraft flew a couple legs before a dayshift supervisor noticed this in the paperwork. They deferred the APU again until the inspection was complied with in ZZZ. The dayshift supervisor reviewing the package later on discovered it. I feel that if in mysignoff I state compliance with the amm task for a functional or operational test of the APU; then compliance of the supplement inspection is implied.
Original NASA ASRS Text
Title: A MAINTENANCE SUPERVISOR; LEAD MECHANIC AND MECHANIC DESCRIBE THEIR INVOLVEMENT WITH A Q400 APU MEL THAT WAS CLEARED; BUT LATER DEFERRED AGAIN; DUE TO UNCLEAR LOGBOOK SIGNOFF CONCERNING INSPECTION OF THE APU COMBUSTOR DRAIN VALVE.
Narrative: ACFT WAS IN MEL 49-00-1; WAS CLRED BY MR X. MR Y WAS THE LEAD MECH FOR THE ACFT. THE MEL STATED 2 ATTEMPTS TO START AND APU FAILED. I ASKED THE LEAD MECH WHY THE APU INSPECTION PER TASK WAS NOT COMPLETED. I WAS TOLD THE COMBUSTOR DRAIN VALVE WAS POST-MODIFICATION AND THE INSPECTION WAS NOT REQUIRED. I HAD HIM TALK TO QUALITY CTL AND WAS TOLD THE RII WAS NOT REQUIRED. THE IGNITERS WERE REPLACED AND WAS THE FIX FOR THE APU. THE SIGNOFF INCLUDED THE FUNCTIONAL TEST OF THE APU. THIS TASK TAKES YOU TO SUBTASK; WHICH IS THE START PROC FOR THE APU. THE MECH DID PERFORM THE INSPECTION OF THE APU PER SUPPLEMENTS; HOWEVER; HE DID NOT INCLUDE THE VERBIAGE 'INSPECTED PER ACR SUPPLEMENT.' STEP 13 WAS NOT REQUIRED AS THE COMBUSTOR DRAIN VALVE WAS POST-MODIFICATION. STEP 13 ONLY APPLIED TO PRE-MODIFICATION PART #164161-100 SO AN RII WAS NOT MISSED. IT WAS FELT THAT WHEN COMPLYING WITH THE INSPECTION TASK IT IMPLIES THAT THE SUPPLEMENTAL TASK WAS COMPLIED WITH AS WELL. THE DOCUMENTATION ON LOG PAGE WAS NOT CLEAR AND DID NOT INDICATE THE SUPPLEMENT TASK HAD BEEN COMPLIED WITH. ALSO DID NOT STATE THAT THE COMBUSTOR DRAIN VALVE WAS INSPECTED AND FOUND TO BE POST-MODIFICATION. I FAILED TO FOLLOW UP AND REQUIRE A BETTER SIGNOFF. MANY FACTORS LED UP TO ME MISSING THIS INFO AND PERFORMING A BETTER REVIEW. I WAS WORKING IN THE OFFICE ALONE AND THERE WERE MANY DISTRS. ALL THE SUPVRS HAVE BEEN SPENDING A GOOD DEAL OF TIME LEARNING THE NEW TIME CLOCK SYSTEM. THIS IS TAKING OUR FOCUS AWAY FROM THE ACFT AND THE PAPERWORK. THE SUPVRS INCLUDING MYSELF HAVE ALSO BEEN UNDER A TREMENDOUS AMOUNT OF STRESS LATELY DUE TO THE REORGANIZATION OF THE SUPVR POSITIONS BY MGMNT. THE PLAN WAS IMPLEMENTED VERY POORLY AS INFO WAS LEAKED EARLY ALLOWING RUMORS TO BUILD. A FAIR AMOUNT OF UNCERTAINTY EXISTED AND STILL DOES; NOT KNOWING WHAT DEPT OR WHAT SHIFT WE WILL BE WORKING ON. IT HAS BEEN A SIGNIFICANT DISTR AS IT IS CAUSING A DISRUPTION IN OUR FAMILY LIVES. ALL OF THESE EVENTS HAVE HELPED LEAD UP TO THE MISTAKES THAT TOOK PLACE. PROVIDE A CLEAR SIGNOFF THAT THE SUPPLEMENT WAS COMPLIED WITH AND INDICATE THE COMBUSTOR DRAIN VALVE WAS INSPECTED PRE- OR POST-MODIFICATION. INCLUDE IN THE SUPPLEMENTAL TASK; A STEP OR NOTE TO DOCUMENT ON THE SIGNOFF THAT COMBUSTOR DRAIN VALVE WAS INSPECTED AND FOUND TO BE PRE-MODIFICATION OR POST-MODIFICATION. N/A (NOT APPLICABLE) STEP 13A AS REQUIRED. SUPPLEMENTAL INFO FROM ACN 814937: I WAS THE LEAD ON ACFT AND THE APU WAS ON MEL. THE MECH PERFORMED A REPAIR TO IT BY CHANGING THE IGNITERS AND SINCE THE APU HAD 2 'FAIL TO START' RPTS ON THE PRE-MODIFICATION; DRAIN VALVE REQUIRES AN INSPECTION. THE MECH INFORMED ME THAT THE DRAIN VALVE WAS A POST-MODIFICATION; WHICH DOES NOT REQUIRE AN INSPECTION. I CHKED WITH QUALITY CTL AND WAS TOLD THAT NO REMOVAL AND INSPECTION WAS REQUIRED ON THE POST-MODIFICATION DRAIN VALVES. THE SUPVR SAW THAT THE PAPERWORK DID NOT SHOW AN APU DRAIN VALVE INSPECTION DUE TO 2 'FAIL TO STARTS.' THE APU WAS PLACED ON MEL DEFERRAL AND THE ACFT WAS ROUTED TO ZZZ FOR THE INSPECTION; AND THEN THE APU DEFERRAL WAS CLEARED AND THE ACFT WAS PLACED BACK INTO SVC. I DON'T KNOW IF THERE IS A PROB WITH THE AMM TASK BTWN PRE- OR POST-MODIFICATION DRAIN VALVES OR THAT THE MECH MISIDENTS THE DRAIN VALVE. I CAN ONLY GO BY THE INFO THAT I AM GIVEN AT THE TIME BY THE MECH. MODIFY ALL THE Q400 APU DRAIN VALVES TO A POST-MODIFICATION STATUS SO THAT THERE IS NO CONFUSION ABOUT WHAT TYPE OF DRAIN VALVE IS INSTALLED ON THE ACFT. SUPPLEMENTAL INFO FROM ACN 814813: I CLEARED AN APU MEL ON ACFT X BY CHANGING IGNITER PLUGS. I ALSO COMPLIED WITH A VISUAL INSPECTION (COMBUSTOR DRAIN VALVE INSTALLED WAS POST-MODIFICATION; THEREFORE; NOT AN RAA INSPECTION); BUT I DID NOT STATE THAT I COMPLIED WITH THE INSPECTION. THE ACFT FLEW A COUPLE LEGS BEFORE A DAYSHIFT SUPVR NOTICED THIS IN THE PAPERWORK. THEY DEFERRED THE APU AGAIN UNTIL THE INSPECTION WAS COMPLIED WITH IN ZZZ. THE DAYSHIFT SUPVR REVIEWING THE PACKAGE LATER ON DISCOVERED IT. I FEEL THAT IF IN MYSIGNOFF I STATE COMPLIANCE WITH THE AMM TASK FOR A FUNCTIONAL OR OPERATIONAL TEST OF THE APU; THEN COMPLIANCE OF THE SUPPLEMENT INSPECTION IS IMPLIED.
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.