37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 929538 |
Time | |
Date | 201101 |
Local Time Of Day | 1201-1800 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Make Model Name | PA-28 Cherokee/Archer/Dakota/Pillan/Warrior |
Operating Under FAR Part | Part 91 |
Flight Phase | Parked |
Flight Plan | None |
Person 1 | |
Function | Single Pilot |
Qualification | Flight Crew Instrument Flight Crew Private |
Experience | Flight Crew Last 90 Days 20 Flight Crew Total 400 Flight Crew Type 50 |
Events | |
Anomaly | Aircraft Equipment Problem Critical Deviation - Procedural FAR Deviation - Procedural Published Material / Policy |
Narrative:
I operated an aircraft that was later discovered to be not airworthy at the time I took-off. After flying aircraft to an away-from-base maintenance facility and extensively studying the logbooks for the aircraft which was rented from a local flight school; it was discovered that there were a number of omitted logbook entries and other missing or incomplete paperwork for the aircraft. An aileron was re-skinned and re-painted with form 337 only partially being completed and without a copy being forwarded to the local FSDO. Additionally; there was no logbook record of the repaired aileron being removed or for it being reinstalled on the aircraft or for the aileron's balance being checked after painting; though the repairs were clearly accomplished. In the course of providing background information to the repair facility; we investigated a number of components in the aircraft's charging system which had been burning-out voltage regulators; circuit breakers; and alternators on a regular basis for over a year. We discovered that the alternator installed in the aircraft was of twice the capacity of that approved for the aircraft. The over-sized alternator was according to the logbook; first installed when the aircraft's engine was replaced with an overhauled engine in 2009--when the alternator problems began (determined only with the benefit of hindsight). I do not believe the erroneous installation was intentional; though it has been costly; and apparently dangerous; for everyone involved. Subsequent replacements; accomplished by numerous facilities; merely replaced the part number of the removed component without verifying its approval for the aircraft's serial number.during further research we came to the conclusion that although the particular oversize alternator was not approved for that specific year and serial number of aircraft; because of extensive avionics upgrades; (the addition of a heated pitot tube; and the addition of anti-collision strobes all done in 2005) an alternator of additional capacity would actually be required to maintain sufficient electrical power to the aircraft's electrical buses during a maximum load condition--especially likely in IMC. It was also discovered that the alternator field breaker was wrong by any criteria used; the alternator main-breaker was undersized for the alternator output; the alternator wiring was grossly undersized for the output capacity of the installed unit; and the ammeter (now mysteriously shunted) was not able to meter the rated capacity of the installed alternator.though; thankfully the only damages were monetary; clearly such an installation was a fire hazard and not airworthy. Unapproved methods; techniques; and practices were evidently used to accomplish some of the upgrades performed in 2005; and this is an underlying factor in the ongoing maintenance issues this aircraft has experienced. Routine maintenance like oil changes and tire changes performed by one of the flight school's experienced instructors; although performed in accordance with applicable airworthiness standards were never recorded in either the airframe's or engine's logbooks. The instructor's--emphasis on was--the person in charge of maintaining the airworthiness of the aircraft and evidently put greater stock in flying the aircraft as much as possible; than maintaining a safe and airworthy aircraft--particularly with respect to completing the paperwork. Again with the benefit of hindsight; I realized that this instructor exhibits an 'anti-authority' hazardous attitude. That attitude has endangered the safety of myself and other people who have operated the aircraft and indirectly led to my operating an un-airworthy aircraft.my own failure to personally verify the airworthiness of the aircraft beyond verifying tach time with upcoming inspection times as posted on the bulletin board and verifying that the arow documents and tomato flames [acronyms] equipment were present; directly resulted inthis infraction. It is worth noting though; that the steps I took are standard industry practice for renting aircraft and this is a safety issue that ought to be addressed--I was appalled to learn of the actual state of repair of this beautiful looking; beautiful flying aircraft. Flight students should really get more instruction about how to determine the airworthiness status of an aircraft than they currently do because they are the ones ultimately responsible! It was only after experiencing a charging system failure in IMC in the aircraft that I became more familiar with the ongoing problems and I ultimately lent my expertise as a skilled troubleshooter and dug deep into records that I discovered the depth of the underlying problem; sloppy maintenance.from this narrative it may be evident that I operated the aircraft more than once prior to learning of its true airworthiness status and that it had been continually un-airworthy since at least 2009. Additionally; numerous other people have operated the aircraft during the time it was un-airworthy. None of the occurrences were intentional in any way; to enumerate them would be an onerous and unproductive task. All discrepancies on the aircraft have been satisfactorily corrected; the charging system has been completely upgraded; the person in charge of maintenance has been replaced; and a fantastic working relationship with an exceptional maintenance facility has been developed for the future.
Original NASA ASRS Text
Title: General Aviation pilot describes discovering that an aircraft he ferried to a maintenance facility had been operated for years in an un-airworthy condition. Maintenance; repairs; and upgrades had been accomplished over the years without proper documentation. A history of electrical system failures was traced to an upgraded alternator without the necessary upgraded system components.
Narrative: I operated an aircraft that was later discovered to be not airworthy at the time I took-off. After flying aircraft to an away-from-base Maintenance Facility and extensively studying the logbooks for the aircraft which was rented from a local flight school; it was discovered that there were a number of omitted logbook entries and other missing or incomplete paperwork for the aircraft. An aileron was re-skinned and re-painted with form 337 only partially being completed and without a copy being forwarded to the local FSDO. Additionally; there was no logbook record of the repaired aileron being removed or for it being reinstalled on the aircraft or for the aileron's balance being checked after painting; though the repairs were clearly accomplished. In the course of providing background information to the repair facility; we investigated a number of components in the aircraft's charging system which had been burning-out voltage regulators; circuit breakers; and alternators on a regular basis for over a year. We discovered that the alternator installed in the aircraft was of twice the capacity of that approved for the aircraft. The over-sized alternator was according to the logbook; first installed when the aircraft's engine was replaced with an overhauled engine in 2009--when the alternator problems began (determined only with the benefit of hindsight). I do not believe the erroneous installation was intentional; though it has been costly; and apparently dangerous; for everyone involved. Subsequent replacements; accomplished by numerous facilities; merely replaced the part number of the removed component without verifying its approval for the aircraft's serial number.During further research we came to the conclusion that although the particular oversize alternator was not approved for that specific year and serial number of aircraft; because of extensive avionics upgrades; (the addition of a heated pitot tube; and the addition of anti-collision strobes all done in 2005) an alternator of additional capacity would actually be required to maintain sufficient electrical power to the aircraft's electrical buses during a maximum load condition--especially likely in IMC. It was also discovered that the alternator field breaker was wrong by any criteria used; the alternator main-breaker was undersized for the alternator output; the alternator wiring was grossly undersized for the output capacity of the installed unit; and the ammeter (now mysteriously shunted) was not able to meter the rated capacity of the installed alternator.Though; thankfully the only damages were monetary; clearly such an installation was a fire hazard and not airworthy. Unapproved methods; techniques; and practices were evidently used to accomplish some of the upgrades performed in 2005; and this is an underlying factor in the ongoing maintenance issues this aircraft has experienced. Routine maintenance like oil changes and tire changes performed by one of the flight school's experienced instructors; although performed in accordance with applicable airworthiness standards were never recorded in either the airframe's or engine's logbooks. The instructor's--emphasis on was--the person in charge of maintaining the airworthiness of the aircraft and evidently put greater stock in flying the aircraft as much as possible; than maintaining a safe and airworthy aircraft--particularly with respect to completing the paperwork. Again with the benefit of hindsight; I realized that this instructor exhibits an 'anti-authority' hazardous attitude. That attitude has endangered the safety of myself and other people who have operated the aircraft and indirectly led to my operating an un-airworthy aircraft.My own failure to personally verify the airworthiness of the aircraft beyond verifying tach time with upcoming inspection times as posted on the bulletin board and verifying that the AROW documents and TOMATO FLAMES [acronyms] equipment were present; directly resulted inthis infraction. It is worth noting though; that the steps I took are standard industry practice for renting aircraft and this is a safety issue that ought to be addressed--I was appalled to learn of the actual state of repair of this beautiful looking; beautiful flying aircraft. Flight students should really get more instruction about how to determine the airworthiness status of an aircraft than they currently do because they are the ones ultimately responsible! It was only after experiencing a charging system failure in IMC in the aircraft that I became more familiar with the ongoing problems and I ultimately lent my expertise as a skilled troubleshooter and dug deep into records that I discovered the depth of the underlying problem; sloppy maintenance.From this narrative it may be evident that I operated the aircraft more than once prior to learning of its true airworthiness status and that it had been continually un-airworthy since at least 2009. Additionally; numerous other people have operated the aircraft during the time it was un-airworthy. None of the occurrences were intentional in any way; to enumerate them would be an onerous and unproductive task. All discrepancies on the aircraft have been satisfactorily corrected; the charging system has been completely upgraded; the person in charge of maintenance has been replaced; and a fantastic working relationship with an exceptional maintenance facility has been developed for the future.
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.