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|
Attributes | |
ACN | 919861 |
Time | |
Date | 201011 |
Local Time Of Day | 0001-0600 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Light | Night |
Aircraft 1 | |
Make Model Name | Dash 8-100 |
Operating Under FAR Part | Part 121 |
Flight Phase | Parked |
Component | |
Aircraft Component | Chip Detector |
Person 1 | |
Function | Lead Technician |
Qualification | Maintenance Airframe Maintenance Powerplant |
Events | |
Anomaly | Aircraft Equipment Problem Critical Deviation - Procedural Maintenance Deviation - Procedural Published Material / Policy |
Narrative:
Three aircraft stayed overnight. I was lead mechanic in charge of two of the three aircraft. I was a 'working' lead that night because manpower was short and there was a heavy workload to accomplish. The aircraft was scheduled for a line check that night amongst other things. I cleared a couple task cards on my other aircraft and came over to a dhc-8-100 to do a paperwork scan and noticed that there were a stack of write-ups made from the line check. I assessed the priority of the work. There was one write-up that took priority over all the others and it was the #2 engine main oil tank chip detector was flagged. I proceeded to get my tools and take out the chip detector. Knowing that this was an inspection necessary task; I showed it to the (quality control) qc representative. He assessed the debris which was a little tiny sliver of metal that bridged the gap between the magnetic poles. He categorized it to be allowable fuzz and instructed me to go ahead and reinstall the chip detector; torque and safety as required. He watched me install the chip detector; made sure it was torqued to the right value and inspected my safety wire.after all other maintenance was complied with; I ran the engine and we did a leak check. After the leak check; I checked the engine condition panel to see if the chip detector had flagged a second time. It had not. The quality control representative wrote the wording in the corrective action block of the write-up and I signed for the work done since I was the one who performed it. I trusted that he looked everything up and had the knowledge to know if anything else had to be documented. I was thinking that the quality control department would know the proper action to take. It came time to finalize all the paperwork to release the plane and I didn't think twice that there was suppose to be any other action taken for the chip detector.when I came into work three nights later; I was alerted that the proper maintenance actions were not taken. We were supposed to perform workcard 79-79-xx which is for chip detector debris collection and inspection. That workcard refers to another workcard if any debris is found. The other workcard is 79-79-xy which tells you to perform a patch check of the oil filters and collect debris to send to the lab for analysis. I was told that the aircraft was diverted into ZZZ for the proper maintenance actions.I was notified by my supervisor that the proper maintenance procedures were not followed. He said that a dayshift quality control inspector was auditing the paperwork package and noticed that there should have been other workcards issued typically when this instance happens. Once the problem was identified; the aircraft was diverted for proper maintenance which included draining the main oil tank; cleaning and inspecting the main oil filter and strainer and leak checking the components that were disturbed. A way for this situation to be avoided on my part is to always double check what the quality control department says and look at the procedures for myself; to determine the proper course of action. I should not have taken his word for it on what was supposed to be done.
Original NASA ASRS Text
Title: A Lead Line Mechanic describes how assumptions; workload; and lack of communications in the work environment contributed to a DHC-8-100 aircraft being diverted due to proper maintenance procedures not being followed after metal had been found on the #2 engine chip detector.
Narrative: Three aircraft stayed overnight. I was Lead Mechanic in charge of two of the three aircraft. I was a 'working' Lead that night because manpower was short and there was a heavy workload to accomplish. The aircraft was scheduled for a Line Check that night amongst other things. I cleared a couple task cards on my other aircraft and came over to a DHC-8-100 to do a paperwork scan and noticed that there were a stack of write-ups made from the Line Check. I assessed the priority of the work. There was one write-up that took priority over all the others and it was the #2 Engine Main Oil Tank Chip Detector was flagged. I proceeded to get my tools and take out the chip detector. Knowing that this was an inspection necessary task; I showed it to the (Quality Control) QC Representative. He assessed the debris which was a little tiny sliver of metal that bridged the gap between the magnetic poles. He categorized it to be allowable fuzz and instructed me to go ahead and reinstall the chip detector; torque and safety as required. He watched me install the chip detector; made sure it was torqued to the right value and inspected my safety wire.After all other maintenance was complied with; I ran the engine and we did a Leak Check. After the Leak Check; I checked the Engine Condition Panel to see if the chip detector had flagged a second time. It had not. The Quality Control Representative wrote the wording in the Corrective Action block of the write-up and I signed for the work done since I was the one who performed it. I trusted that he looked everything up and had the knowledge to know if anything else had to be documented. I was thinking that the Quality Control Department would know the proper action to take. It came time to finalize all the paperwork to release the plane and I didn't think twice that there was suppose to be any other action taken for the chip detector.When I came into work three nights later; I was alerted that the proper maintenance actions were not taken. We were supposed to perform Workcard 79-79-XX which is for Chip Detector Debris Collection and Inspection. That workcard refers to another workcard if any debris is found. The other workcard is 79-79-XY which tells you to perform a patch check of the oil filters and collect debris to send to the lab for analysis. I was told that the aircraft was diverted into ZZZ for the proper maintenance actions.I was notified by my Supervisor that the proper maintenance procedures were not followed. He said that a Dayshift Quality Control Inspector was auditing the paperwork package and noticed that there should have been other workcards issued typically when this instance happens. Once the problem was identified; the aircraft was diverted for proper maintenance which included draining the main oil tank; cleaning and inspecting the main oil filter and strainer and leak checking the components that were disturbed. A way for this situation to be avoided on my part is to always double check what the Quality Control Department says and look at the procedures for myself; to determine the proper course of action. I should not have taken his word for it on what was supposed to be done.
Data retrieved from NASA's ASRS site as of April 2012 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.