A DC9-30 WAS DISPATCHED AND OPERATED IN NON COMPLIANCE WITH INTERMIX ENG PERFORMANCE AND WT REDUCTION LIMITS IN ERROR.

Date: 2002-07 · Aircraft: DC-9 30 · Phase: ground

Anomalies: aircraft-equipment-problem-critical|deviation-discrepancy-procedural-far|deviation-discrepancy-procedural-maintenance|deviation-discrepancy-procedural-published-material-policy

Synopsis

A DC9-30 WAS DISPATCHED AND OPERATED IN NON COMPLIANCE WITH INTERMIX ENG PERFORMANCE AND WT REDUCTION LIMITS IN ERROR.

Narrative

ACFT WAS OPERATED FOR 3 DAYS IN REVENUE SVC WITH IMPROPER INFORMATIONAL PLACARDS AND INST INSTALLED IN COCKPIT; WITH RELATED PERFORMANCE PENALTY; DUE TO FAILURE OF COMPANY MAINT PERSONNEL TO PERFORM AN INTERNAL MAINT DOCUMENT (ENGINEERING ORDER) WHILE ACFT WAS DOWN FOR A SCHEDULED MAINT AND INSPECTION CHK. THE PROB WAS DISCOVERED BY PLT WHILE TAXIING OUT FOR TKOF; WHEN COMPARING FLT DISPATCH INFO WITH RAM AIR TEMP INDICATOR IN COCKPIT. THINGS WENT DOWNHILL FROM THERE. ACFT HAD AN ENG INTERMIX CONFIGN (JT8D-9A ON L-HAND SIDE; AND JT8D-7B ON R-HAND SIDE); PRIOR TO PROB. DUE TO A SLIGHT PWR OUTPUT REDUCTION OF THE -7B ENG; THIS INTERMIX; THROUGH THE ACCOMPLISHMENT OF AN ENGINEERING ORDER; MANDATED THAT THE ACFT BE OPERATED AT -7B PWR SETTINGS FOR EPR READINGS; AND A 2000 LB PERFORMANCE PENALTY IN MAX TKOF GROSS WT OF THE ACFT; FROM 110000 LBS TO 108000 LBS. R-HAND ENG WAS SUBSEQUENTLY CHANGED; WITH AN IDENTICAL JT8D-9A NOW INSTALLED; TO MATCH THE L SIDE. HOWEVER; AN ACCOMPANYING ENGINEERING ORDER TO REVERSE THE PREVIOUS ENGINEERING ORDER PROCS FOR THE INTERMIXED CONFIGN WAS NOT DONE; DUE TO A PAPERWORK SNAFU. CONSEQUENTLY; THE ACFT WAS NOW OPERATING UNDER A PERFORMANCE PENALTY IN TERMS OF ENG EPR PWR REDUCTIONS AND MAX TKOF WT REDUCTIONS; THOUGH BOTH PWRPLANTS WERE MATCHED WITH JT8D-9A PWR. WHEN THE ERROR WAS DISCOVERED; THE RELEVANT ENGINEERING ORDER FOR DE-INTERMIXING ENGS WAS THEN ACCOMPLISHED; WITH ASSOCIATED WT AND BAL RECALCULATION DONE THE FOLLOWING DAY. CONFUSING PAPERWORK PROCS WAS A BIG FACTOR AT THE HEART OF THE PROB; WITH POOR JUDGEMENT AND OUTDATED WORK CARDS FOR THE TASK CONTRIBUTING FACTORS; AND POOR INTERNAL COM. THE ACFT DID NOT EXPERIENCE AN INCIDENT.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.