A DHC-8-200 WAS DISPATCHED AFTER #2 ENG BORESCOPE INSPECTION AND OPERATED WITH THE OUTBOARD IGNITER PLUG NOT INSTALLED.

Date: 2004-12 · Aircraft: Dash 8-200 · Phase: ground

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

Synopsis

A DHC-8-200 WAS DISPATCHED AFTER #2 ENG BORESCOPE INSPECTION AND OPERATED WITH THE OUTBOARD IGNITER PLUG NOT INSTALLED.

Narrative

ON THE EVENING OF 12/MON/04 I WAS TEMPORARILY ASSIGNED TO PREPARE ACFT X FOR A BORESCOPE. THIS INCLUDED OPENING THE COWLING AND REMOVING THE IGNITER. AFTER THIS WAS ACCOMPLISHED; I WAS IMMEDIATELY REASSIGNED TO OTHER ACFT AND WAS NOT INVOLVED IN COMPLETING THE TASK. I ASSUME THAT THERE WAS PROPER DOCUMENTATION FOR COMPLETING IT. PERSONNEL INVOLVED IN THE BORESCOPE COMPLETED COMPANY DOCUMENT JOB CARD REVISION DATE 11/MON/04. THIS DOCUMENT DOES NOT INCLUDE PROCEDURES FOR OPENING AND CLOSING THE COWLING OR REMOVING OR REINSTALLING THE IGNITER. ON 12/WED/04 I WAS CONTACTED BY COMPANY PERSONNEL AND INFORMED THAT THE ACFT; ON A ROUTINE INSPECTION; WAS FOUND TO BE DAMAGED IN ZZZ1. THIS INCLUDED BURNT COWLING; ENG MOUNT AND WIRING ON THE #2 ENG. WHEN THEY OPENED THE COWL; THEY DISCOVERED THE OUTBOARD IGNITER LAYING IN PLAIN SIGHT IN THE LOWER COWL. CURRENTLY THE ENG; AFFECTED COWLING; ENG STRUT; AND WIRING ARE BEING REPLACED ON THE #2 ENG. THIS COULD HAVE BEEN PREVENTED BY PROPER DOCUMENTATION FOR THIS TASK. THE WORK CARDS NEED TO BE EXPANDED TO INCLUDE ADDITIONAL STEPS FOR PERFORMANCE OF THIS TASK. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE BORESCOPE INSPECTION JOB CARD DID NOT HAVE PROCEDURES AND SIGNOFF BLOCKS FOR OPENING AND CLOSING OF THE COWLING. THE INSPECTOR DOING THE BORESCOPE NORMALLY REMOVES THE IGNITER; BUT IN THIS CASE THE RPTR REMOVED THE PLUG. AFTER OPENING THE COWLING AND REMOVING THE OUTBOARD IGNITER PLUG; THE RPTR WAS REASSIGNED TO ANOTHER AIRPLANE AND NO NON ROUTINE CARD WAS WRITTEN TO COVER THE STATUS OF THE AIRPLANE. THE RPTR NEVER RETURNED TO THE AIRPLANE. DAMAGE WAS INCURRED TO COWLING; ENG STRUT; WIRING; AND THE ENG WAS REPLACED. THE ENG WAS A P & W 123.

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