|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1801 To 2400|
|Locale Reference||airport : zzz|
|Altitude||agl bound lower : 0|
agl bound upper : 0
|Operator||common carrier : air carrier|
|Make Model Name||Light Transport, High Wing, 2 Turboprop Eng|
|Affiliation||company : air carrier|
|Function||other personnel other|
|Qualification||other other : other|
|Affiliation||company : air carrier|
|Function||oversight : pic|
|Qualification||pilot : atp|
|Anomaly||aircraft equipment problem : critical|
non adherence : published procedure
non adherence : far
other anomaly other
|Independent Detector||other flight crewa|
|Resolutory Action||none taken : detected after the fact|
|Primary Problem||Navigational Facility|
|Air Traffic Incident||other|
Approximately XA30 hours on the night of mar/wed/97, my crew was responsible for maintenance on air carrier aircraft xyz. The workload being rather heavy and my crew being small and undermanned, the individual crew members were spread out for the various maintenance actions required. I was placed on the scheduled phase inspection of the #1 engine. I was to be responsible for the scheduled maintenance portions of the phase check as well as the repair of any discovered discrepancies. Among these maintenance tasks was scheduled igniter removal and replacement. With various maintenance requirements going on simultaneously, I thought I had completed the inboard ignitor in its entirety. However, as discovered by the flight crew on mar/fri/97, there was a blistering of paint at the inboard ignitor door. Further inspection revealed that the inboard ignitor was not completely installed, but rather in its operational check position which is being finger tightened into the lead. Due to the fact I had started the ignitor removal and replacement at the inboard side of the engine and then moved to the outboard side, amidst other maintenance related distrs, I must have not installed the ignitor as I had believed. My sense of being pushed and overwhelmed with the maintenance requirements, coupled with the lack of manpwr, no doubt must have added to this incident.
Original NASA ASRS Text
Title: A DASH-8-100 INCURRED SLIGHT DAMAGE TO THE #1 ENG INBOARD IGNITOR DOOR DUE TO IMPROPER INSTALLATION OF THE IGNITOR PLUG AND LEAD.
Narrative: APPROX XA30 HRS ON THE NIGHT OF MAR/WED/97, MY CREW WAS RESPONSIBLE FOR MAINT ON ACR ACFT XYZ. THE WORKLOAD BEING RATHER HVY AND MY CREW BEING SMALL AND UNDERMANNED, THE INDIVIDUAL CREW MEMBERS WERE SPREAD OUT FOR THE VARIOUS MAINT ACTIONS REQUIRED. I WAS PLACED ON THE SCHEDULED PHASE INSPECTION OF THE #1 ENG. I WAS TO BE RESPONSIBLE FOR THE SCHEDULED MAINT PORTIONS OF THE PHASE CHK AS WELL AS THE REPAIR OF ANY DISCOVERED DISCREPANCIES. AMONG THESE MAINT TASKS WAS SCHEDULED IGNITER REMOVAL AND REPLACEMENT. WITH VARIOUS MAINT REQUIREMENTS GOING ON SIMULTANEOUSLY, I THOUGHT I HAD COMPLETED THE INBOARD IGNITOR IN ITS ENTIRETY. HOWEVER, AS DISCOVERED BY THE FLC ON MAR/FRI/97, THERE WAS A BLISTERING OF PAINT AT THE INBOARD IGNITOR DOOR. FURTHER INSPECTION REVEALED THAT THE INBOARD IGNITOR WAS NOT COMPLETELY INSTALLED, BUT RATHER IN ITS OPERATIONAL CHK POS WHICH IS BEING FINGER TIGHTENED INTO THE LEAD. DUE TO THE FACT I HAD STARTED THE IGNITOR REMOVAL AND REPLACEMENT AT THE INBOARD SIDE OF THE ENG AND THEN MOVED TO THE OUTBOARD SIDE, AMIDST OTHER MAINT RELATED DISTRS, I MUST HAVE NOT INSTALLED THE IGNITOR AS I HAD BELIEVED. MY SENSE OF BEING PUSHED AND OVERWHELMED WITH THE MAINT REQUIREMENTS, COUPLED WITH THE LACK OF MANPWR, NO DOUBT MUST HAVE ADDED TO THIS INCIDENT.
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.