Mechanic replaces rudder actuator only to discover later that he reused a part that should also have...

Attributes
ACN	269833
Time
Date	199404
Day	Tue
Local Time Of Day	1201 To 1800
Place
Locale Reference	airport : ord
State Reference	IL
Altitude	agl bound lower : 0 agl bound upper : 0
Aircraft 1
Operator	common carrier : air carrier
Make Model Name	B727 Undifferentiated or Other Model
Operating Under FAR Part	Part 121
Flight Phase	other
Flight Plan	None
Person 1
Affiliation	company : air carrier
Function	other personnel other
Qualification	other other : other
ASRS Report	269833
Person 2
Affiliation	company : air carrier
Function	oversight : supervisor
Qualification	other other : other
Events
Anomaly	aircraft equipment problem : critical non adherence : published procedure other anomaly other
Independent Detector	other other : unspecified
Resolutory Action	none taken : detected after the fact
Consequence	Other
Supplementary
Air Traffic Incident	other

Narrative:

On X/apr/94 I replaced a lower rudder actuator on a boeing 727. During installation, the maintenance manual called out to transfer a pressure switch and its mounting plate from the removed unit to the new actuator. This I did, as an assembly. New self-locking bolts were used and no leakage was noted when pressurized. Later in the month, I did a routine check of the plane's history and found that this mounting plate had been replaced as a cause of fluid loss at denver on Y/apr/94. Reviewing the manual, I found that this part should have been replaced in another section of the maintenance manual that was only listed as optional in the actuator replacement procedures. The note (in maintenance manual) should be revised that implies transferring this plate. The maintenance manual reference for replacement of this part should be listed as a required procedure. In addition, this part is not generally stocked in the inventory and should be part of the rudder actuator replacement kit.

Original NASA ASRS Text

Title: MECH REPLACES RUDDER ACTUATOR ONLY TO DISCOVER LATER THAT HE REUSED A PART THAT SHOULD ALSO HAVE BEEN REPLACED.

Narrative: ON X/APR/94 I REPLACED A LOWER RUDDER ACTUATOR ON A BOEING 727. DURING INSTALLATION, THE MAINT MANUAL CALLED OUT TO TRANSFER A PRESSURE SWITCH AND ITS MOUNTING PLATE FROM THE REMOVED UNIT TO THE NEW ACTUATOR. THIS I DID, AS AN ASSEMBLY. NEW SELF-LOCKING BOLTS WERE USED AND NO LEAKAGE WAS NOTED WHEN PRESSURIZED. LATER IN THE MONTH, I DID A ROUTINE CHK OF THE PLANE'S HISTORY AND FOUND THAT THIS MOUNTING PLATE HAD BEEN REPLACED AS A CAUSE OF FLUID LOSS AT DENVER ON Y/APR/94. REVIEWING THE MANUAL, I FOUND THAT THIS PART SHOULD HAVE BEEN REPLACED IN ANOTHER SECTION OF THE MAINT MANUAL THAT WAS ONLY LISTED AS OPTIONAL IN THE ACTUATOR REPLACEMENT PROCS. THE NOTE (IN MAINT MANUAL) SHOULD BE REVISED THAT IMPLIES TRANSFERRING THIS PLATE. THE MAINT MANUAL REF FOR REPLACEMENT OF THIS PART SHOULD BE LISTED AS A REQUIRED PROC. IN ADDITION, THIS PART IS NOT GENERALLY STOCKED IN THE INVENTORY AND SHOULD BE PART OF THE RUDDER ACTUATOR REPLACEMENT KIT.

Data retrieved from NASA's ASRS site as of July 2007 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 replaces rudder actuator only to discover later that he reused a part that should also have been replaced.