Question

ASRS Examples

Everyone in the aviation community has the ability to affect safety. The examples below are taken from the ASRS and show that there are many players in the safety value chain. These examples are provided throughout the book to illustrate issues in the actual words of those commercial aviation professionals who experienced a safety event. The italicized portions that follow are the actual by aviation professionals to report the situation that they faced and 1 they experienced. Following each narrative, there is a question posed reader connect the report with the content of the chapter.

Maintenance

Title: Hydraulic System: crossed pressure lines

While troubleshooting the cause of two previous replacements of hydraulic system reservoir pressurization manifold, a Maintenance found that "crisscrossed" pneumatic pressure lines were preventing pressurization of the Blue hydraulic system.
After discovering that we were going to install [an A-319's] hydraulic pressure manifold for the third time, I decided to figure out why the folds were not pressurizing the Blue hydraulic reservoir to 50 PS I. hours of troubleshooting the problem, I found that the left engine . supply line in the left wheel well . . . was connected to a "tee" [fitting that sup plies all three hydraulic reservoirs thereby bypassing the [pre manifold completely and probably over-pressurizing the reservoirs.

The Blue system pneumatic supply line (going to the hydraulic reservoir) was connected to a "union" [fitting], which is the manifold supply connection from the left engine thereby never supplying pneumatic pressure to the Blue reservoir. So, the lines were crisscrossed.
Both “B" nuts will fit on either connection and there is plenty of room for the lines to cross and not chafe on anything. It appeared that neither line had been replaced . . . . When an Airbus comes into the hangar, a low-pressure check of each Green, Yellow and Blue hydraulic reservoir’s head pressure is per formed using ground service air. Although the Blue reservoir's head pressure was above the 22 PSI that sets off warnings in the cockpit, it was not possible to increase the head pressure by applying service air to see if the reservoir pressurization manifold was functioning.
When the Blue head pressure did not respond, the thought was that the mani¬fold was again at fault. The aircraft had been flying for some time with the lines crossed, but since the Blue hydraulic reservoir head pressure never went below 22 PSI, no discrepancies were noted. Maintenance history showed the aircraft did have hydraulic issues with the Green and Yellow systems oozing hydraulic fluid, but those discrepancies were probably caused by high reservoir head pressures from the crossed pneumatic supply lines.

Question for the reader: what are the ethical implications of not looking for the root issues behind recurring maintenance problems?

Answer 1

Ethics play a crucial part in maintenance and inspection of the equipment. With ethical guidelines, the inspection managers would identify the root-cause of the problem before repairs are made. The ethical implications for not looking the root issues behind recurring maintenance problems are:

· Poses threat to the safety of the workers’ life

· Results in great losses to the company

· Results in manufacturing defects

· Results in company selling faulty products or provides inadequate services to the customers

· Further delays in not identifying the root-causes results in more damages to the equipment further damaging other connected equipment as well.

· Results in company’s failure to adhere to the ethical values and legal regulations.

· Recurring maintenance problems lead to break-down of the whole equipment; in other words, a part of the recurring maintenance problems results in break-down of the entire equipment leading to great financial losses.

· Results in loss of employee trust and investor relations.

Thus, it is pertinent to say that before undertaking repair of any part maintenance like that of installing [an A-319's] hydraulic pressure manifold for a third time, would only result in more damages to other part of the equipment. Additioanlly, Maintenance history showed the aircraft did have hydraulic issues with the Green and Yellow systems oozing hydraulic fluid. This showed that poor maintenance and repairs without diagnosing the root-causes posed danger to the performance of the aircraft thus threatening the safety of the passengers. If the inspection and maintenance managers does not identify the root-cause (such as high reservoir head pressures from the crossed pneumatic supply lines), then just repair work for the other parts would just be futile. It only leads to further failure of performance of the aircraft. Thus, analyzing the root-causes and rectifying them is essential for safety and performance of the aircraft.

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