|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1201 To 1800|
|Locale Reference||airport : zzz.airport|
|Altitude||agl single value : 0|
|Operator||common carrier : air carrier|
|Make Model Name||Dash 8-300|
|Operating Under FAR Part||Part 121|
|Flight Phase||ground : maintenance|
|Affiliation||company : air carrier|
|Qualification||technician : airframe|
technician : powerplant
|Experience||maintenance technician : 20|
|Affiliation||company : air carrier|
|Function||maintenance : technician|
|Anomaly||aircraft equipment problem : critical|
other anomaly other
|Resolutory Action||none taken : detected after the fact|
|Maintenance||contributing factor : work cards|
contributing factor : briefing
performance deficiency : unqualified personnel
performance deficiency : training
|Problem Areas||Environmental Factor|
Maintenance Human Performance
On jul/sun/03, I reported for duty at XA30 hours. I was informed by the lead mechanic that a #2 engine, #2 propeller blade change was in progress, and that we would be involved in the installation on our shift. The propeller blade had been removed by the previous shift, and we would be waiting for a part to be flown in (ball separator). I was also informed I would be the delegate inspector since the work would be a 'required inspection item.' when the ball separator arrived the installation process was initiated utilizing the air carrier work card #61-10-07R (propeller blade right&right). The procedure was followed, completed and aircraft run-up and leak checked. With task completed, logbook 'rii' block was signed and aircraft released for service. On jul/mon/03, I was informed by my supervisor that a vibration discrepancy was reported by the flight crew in ZZZ1 on jul/wed/03, on #2 engine of aircraft. A maintenance crew was sent to ZZZ1 and the #2 propeller required replacement due to damage found at the #2 propeller blade hub area. I was also told that the propeller manufacture representative with air carrier suspects improper assembly of the #2 propeller blade after initial review of the propeller. As of the submittal of this report, I understand an analysis of the removed propeller is being completed by air carrier propeller shop. Details have not been released to me as of this date and time. Although I feel everything was followed procedurally for this maintenance task, some working conditions concern me: air carrier has closed 2 maintenance facilities recently. A tremendous amount of work has been shifted to ZZZ line maintenance, with no increase in staffing, or improvements in working conditions. All maintenance tasks are done on the ramp, in all WX conditions. Maintenance tasks that have never been done on the ZZZ line are being scheduled there now. Lack of manpower is a critical issue for the amount of ZZZ flts. Formal training for some of these maintenance tasks is non-existent. In reviewing my training records, I find no record of propeller blade removal/replacement training. Only 3 mechanics were on duty this particular shift, and I was placed in the delegated inspector role by default (lack of manpower). Callback conversation with reporter revealed the following information: the reporter stated the actual cause of the propeller vibration was the replaced blade bearing outer race had failed. The reporter said the company never directly advised the technicians of the blade bearing failure but the information was gathered from several unofficial sources. The reporter stated the propeller manufacturer's representative stated before the propeller teardown that it was improper installation and assembly of the #2 blade that caused the vibration. The reporter said none of the 3 persons working the propeller blade replacement were trained on propeller maintenance. The reporter stated with maintenance facility closures and a constant turnover of technicians xferred from shops to line work mostly untrained the situation has become critical.
Original NASA ASRS Text
Title: A DEHAVILLAND 8 RPTED A PROP DISCREPANCY IMMEDIATELY AFTER A PROP BLADE WAS REPLACED. CAUSED BY A BEARING RACE FAILURE.
Narrative: ON JUL/SUN/03, I RPTED FOR DUTY AT XA30 HRS. I WAS INFORMED BY THE LEAD MECH THAT A #2 ENG, #2 PROP BLADE CHANGE WAS IN PROGRESS, AND THAT WE WOULD BE INVOLVED IN THE INSTALLATION ON OUR SHIFT. THE PROP BLADE HAD BEEN REMOVED BY THE PREVIOUS SHIFT, AND WE WOULD BE WAITING FOR A PART TO BE FLOWN IN (BALL SEPARATOR). I WAS ALSO INFORMED I WOULD BE THE DELEGATE INSPECTOR SINCE THE WORK WOULD BE A 'REQUIRED INSPECTION ITEM.' WHEN THE BALL SEPARATOR ARRIVED THE INSTALLATION PROCESS WAS INITIATED UTILIZING THE ACR WORK CARD #61-10-07R (PROP BLADE R&R). THE PROC WAS FOLLOWED, COMPLETED AND ACFT RUN-UP AND LEAK CHKED. WITH TASK COMPLETED, LOGBOOK 'RII' BLOCK WAS SIGNED AND ACFT RELEASED FOR SVC. ON JUL/MON/03, I WAS INFORMED BY MY SUPVR THAT A VIBRATION DISCREPANCY WAS RPTED BY THE FLT CREW IN ZZZ1 ON JUL/WED/03, ON #2 ENG OF ACFT. A MAINT CREW WAS SENT TO ZZZ1 AND THE #2 PROP REQUIRED REPLACEMENT DUE TO DAMAGE FOUND AT THE #2 PROP BLADE HUB AREA. I WAS ALSO TOLD THAT THE PROP MANUFACTURE REPRESENTATIVE WITH ACR SUSPECTS IMPROPER ASSEMBLY OF THE #2 PROP BLADE AFTER INITIAL REVIEW OF THE PROP. AS OF THE SUBMITTAL OF THIS RPT, I UNDERSTAND AN ANALYSIS OF THE REMOVED PROP IS BEING COMPLETED BY ACR PROP SHOP. DETAILS HAVE NOT BEEN RELEASED TO ME AS OF THIS DATE AND TIME. ALTHOUGH I FEEL EVERYTHING WAS FOLLOWED PROCEDURALLY FOR THIS MAINT TASK, SOME WORKING CONDITIONS CONCERN ME: ACR HAS CLOSED 2 MAINT FACILITIES RECENTLY. A TREMENDOUS AMOUNT OF WORK HAS BEEN SHIFTED TO ZZZ LINE MAINT, WITH NO INCREASE IN STAFFING, OR IMPROVEMENTS IN WORKING CONDITIONS. ALL MAINT TASKS ARE DONE ON THE RAMP, IN ALL WX CONDITIONS. MAINT TASKS THAT HAVE NEVER BEEN DONE ON THE ZZZ LINE ARE BEING SCHEDULED THERE NOW. LACK OF MANPOWER IS A CRITICAL ISSUE FOR THE AMOUNT OF ZZZ FLTS. FORMAL TRAINING FOR SOME OF THESE MAINT TASKS IS NON-EXISTENT. IN REVIEWING MY TRAINING RECORDS, I FIND NO RECORD OF PROP BLADE REMOVAL/REPLACEMENT TRAINING. ONLY 3 MECHS WERE ON DUTY THIS PARTICULAR SHIFT, AND I WAS PLACED IN THE DELEGATED INSPECTOR ROLE BY DEFAULT (LACK OF MANPOWER). CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE ACTUAL CAUSE OF THE PROP VIBRATION WAS THE REPLACED BLADE BEARING OUTER RACE HAD FAILED. THE RPTR SAID THE COMPANY NEVER DIRECTLY ADVISED THE TECHNICIANS OF THE BLADE BEARING FAILURE BUT THE INFO WAS GATHERED FROM SEVERAL UNOFFICIAL SOURCES. THE RPTR STATED THE PROP MANUFACTURER'S REPRESENTATIVE STATED BEFORE THE PROP TEARDOWN THAT IT WAS IMPROPER INSTALLATION AND ASSEMBLY OF THE #2 BLADE THAT CAUSED THE VIBRATION. THE RPTR SAID NONE OF THE 3 PERSONS WORKING THE PROP BLADE REPLACEMENT WERE TRAINED ON PROP MAINT. THE RPTR STATED WITH MAINT FACILITY CLOSURES AND A CONSTANT TURNOVER OF TECHNICIANS XFERRED FROM SHOPS TO LINE WORK MOSTLY UNTRAINED THE SIT HAS BECOME CRITICAL.
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.