<< >> NASA ASRS Report 466256, December 1999

A DC9 incurred several hot starts due to incorrect exhaust gas temperature probes installed during engine shop buildup.

Attributes
ACN	466256
Time
Date	199912
Day	Wed
Local Time Of Day	0601 To 1200
Place
Locale Reference	airport : zzz.airport
State Reference	US
Altitude	agl single value : 0
Environment
Light	Daylight
Aircraft 1
Operator	common carrier : air carrier
Make Model Name	DC-9 30
Operating Under FAR Part	Part 121
Flight Phase	ground : maintenance ground : parked
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	instruction : instructor maintenance : technician
Qualification	technician : fcc technician : airframe technician : powerplant
Experience	maintenance technician : 6
ASRS Report	466256
Person 2
Affiliation	company : air carrier
Function	instruction : trainee maintenance : technician
Qualification	technician : powerplant technician : airframe
Events
Anomaly	aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : company policies non adherence : published procedure non adherence : far
Independent Detector	aircraft equipment other aircraft equipment : egt indication
Resolutory Action	none taken : detected after the fact
Consequence	other other
Factors
Maintenance	performance deficiency : fault isolation performance deficiency : inspection performance deficiency : non compliance with legal requirements performance deficiency : training performance deficiency : repair performance deficiency : scheduled maintenance performance deficiency : testing
Supplementary
Problem Areas	Company Maintenance Human Performance Aircraft
Primary Problem	Maintenance Human Performance

Narrative:

Wrong type egt probes installed during overhaul. This problem caused numerous hot start write-ups. Egt probe problem was discovered by maintenance after several write-ups. Several contributing factors exist for the improper installation. I was distraction from working my module while training 2 new individuals on other modules. Both type egt probes come in identical unmarked containers. The possibility also exists that the wrong probes were delivered by stores. Inspection that was required in the past, has been removed from paperwork.

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Original NASA ASRS Text

Title: A DC9 INCURRED SEVERAL HOT STARTS DUE TO INCORRECT EXHAUST GAS TEMP PROBES INSTALLED DURING ENG SHOP BUILDUP.

Narrative: WRONG TYPE EGT PROBES INSTALLED DURING OVERHAUL. THIS PROB CAUSED NUMEROUS HOT START WRITE-UPS. EGT PROBE PROB WAS DISCOVERED BY MAINT AFTER SEVERAL WRITE-UPS. SEVERAL CONTRIBUTING FACTORS EXIST FOR THE IMPROPER INSTALLATION. I WAS DISTR FROM WORKING MY MODULE WHILE TRAINING 2 NEW INDIVIDUALS ON OTHER MODULES. BOTH TYPE EGT PROBES COME IN IDENTICAL UNMARKED CONTAINERS. THE POSSIBILITY ALSO EXISTS THAT THE WRONG PROBES WERE DELIVERED BY STORES. INSPECTION THAT WAS REQUIRED IN THE PAST, HAS BEEN REMOVED FROM PAPERWORK.

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.