FORM FAA Approved Repair Station A1YY277N 005 · 2015. 1. 26. · IBAN : IT 96 L 08327 03398...

Nayak Aircraft Services Italy Srl Aeroporto Roma Fiumicino-Building 33A-00054 Fiumicino (RM) Italy FAA Approved Repair Station A1YY277N

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INFO LETTER Number Subject

2015-004 MD-11 T/REV PRESS INDICATION FAULT

NASIT_FAA_FORM_005 REV 1 DATE 12-12-12 Page 1 of 13

QUALITY SAFETY SECURITY TRAINING RISK CLASS LRO MRO HRO

OR # OR-2015-004 DATE 22-JAN-2015 FEEDBACK REQUIRED Y N

SUBJECT MD-11 T/REV PRESS INDICATION FAULT

APPLICABILITY All technical staff qualified under Nayak Italy FAA (A1YY277N) holding UPS employee number

SUMMARY Present document is published following to event occurred to UPS MD-11 (PW4000) Tail Reg N271UP at the location of Koln/Bonn Airport (CGN)

INVESTIGATION REQUIRED Y N INVESTIGATION DUE DATE 31-jan-2015 See investigation results published in Appendix 1

Hazard Identification Non correct MEL appliance to Thrust Reverser System

Safety Action: Y N Department N/A Due Date : N/A Accepted Y N Name N/A Date : N/A Corrective Action / Preventive Action Closing date

All staff is requested to carefully read Appendix 1 06-FEB-2015

Staff is requested to electronic acknowledge read and sign the link at last page 06-FEB-2015

Closed Y N by Date: Extended Y N by Date:

Accountable Manager Quality & Safety Manager H&S Workers’ Rep. (If Applicable)

N/A

Stamp + Signature Stamp + Signature Stamp + Signature

Received Y N by

Date

Name Surname Signature + Stamp dd-mmm-yyy

THIS FIELD MUST BE SIGNED BY DEPARTMENT MANAGER OR RESPONSIBLE PERSON AS CONFIRMATION THAT INFO LETTER CONTENTS HAVE TRANSFERRED TO ALL STAFFER. INDIVIDUAL R&S MUST BE CERTIFIED ON DEDICATED PAGE AT THE END OF THIS DOCUMENT


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NAYAK AIRCRAFT SERVICES ITALY S.r.l. socio unico FAA Authorized Repair Station – Approval n° A1YY277N

Sede Legale | Head Office ITALY C.Fisc. & P.IVA | VAT : Filiale Estera | Foreign Branch FRANCE Edificio 33A Lato Pista - Varco Doganale 1 IT-08313041009 Porte de l’Arenas, Hall C - 455, Promenade des Anglais Via Francesco de Pinedo snc Tel. +39.06.65.29.066 06299 – NICE – Cedex 3 – FRANCE 00054 – Fiumicino Aeroporto (Roma) - ITALY Tel. +39.06.69.30.56.95 SIREN: 792301004–SIRET: 792301000400026-APE: 5223Z CCIAA – ROMA REA n° 1088805 Fax. +39.06.60.51.36.11 TVA: FR-86792301004 - Fax: +33 (0) 4.89.88.65.48 Cap. Soc. | Share Cap. € 281.792,22 E-Mail IT: [email protected] IBAN : FR 76 1910 6006 9743 6351 4965 693 IBAN : IT 96 L 08327 03398 000000013200 E-Mail FR: [email protected] BIC : AGRIFRPP891 BIC : ROMAITRR Web: www.nayak.aero Pag. 2 / 13

APPENDIX 1 Facts:

1. Foreword

On Jan 20th following a UPS Airworthiness Irregularity Event Report issued by Hong Kong (HGK) UPS Maintenance Vendor it was communicated the following

2. Information about involved engineer: a. FAA A&P Part 65 Certified (A&P License Number 2566543, issued on 22 Jan 2010 b. Received his last continuation training:

i. Human Factor; 9-dec-2014 ii. EWIS 25-may-2014 iii. Fuel Tanks Safety21-feb-2014

c. Completed MD11 Gen Fam. Course (40 Hours) on 28-May-2012 d. Long experience in UPS Maintenance Operation, previously contracted by Air Berlin Technik

(former UPS maintenance vendor at the location of CGN) e. No particular issues related to shift planning and extra hours working in the past (operation

started on 01 Jan 2015)

# Question Y N Remarks

1 Did he work any extra time in the last past week or days ? Yes but within limits

2 Did he work more than six consecutive days with no interruption of 24 hours

3 Did he use any substance that would have impaired his ability to work

4 Did he feel fit for the job assigned

5 Did he have all the documented instructions (check lists)with him while performing the tasks? Specify the task.

UPS MEL&Dispatch Maintenance Procedure 78-30-1 & 78-34-3

6 Was he under pressure to complete the job, was he late on the assigned duty?

7 Was he under pressure to complete that job because been assigned to assist another aircraft?

Assigned only for this job


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3. Investigation Results a. Investigation of the causes has revealed that indeed this reported malfunction has a long

history and different UPS gateways were involved in the trouble shooting and deferral of this item. Limited to the last few months, N271 aircraft maintenance history report printed out from UPS IMPACT system revealed the following:


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i. Rejected take off was done in KMCI (Kansas City) on 30 Oct 2014 due to REV 2 PRESS FAULT

ii. Corrective action was to defer number 2 T/R iaw MEL 78-30-01

b. MEL analysis revealed that i. Following a REV2 PRESS FAULT light illuminated, the correct MEL to be applied

should have been the MEL 78-34-3 and not 78-30-1


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ii. For N271UP,due to effectivity interval shown, MEL 78-34-3 could not be applied. Defect should have fixed before the next flight.

c. Even if taking in account the definitions listed in the foreword “UPS Definitions” point 8

and also considering applicable the MEL title to the aircraft, such deferral could not have been performed as note reported in the Operational Procedures clearly states that

d. MEL 78-30-1 applied by KMCI was not the correct MEL, aircraft had to be put in AOG condition up to performance of needed corrective action.

e. During the period, 30 Oct 2014-20 Jan 2015 the aircraft flew for UPS operations and the MEL

was checked by several Maintenance Organizations without definitely solving the problem or re appliying the same, wrong, MEL 78-30-1 as per maintenance history below reported


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f. On Jan 13th 2015, at the location of CGN the following event occurred

g. a/c N271UP performed a rejected take-off below 80 kts, Nayak Maintenance CGN applied MEL 78-30-1.

h. On Jan 20th 2015, a the location of HGK the following event occurred


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i. HGK Maintenance, performed the below listed actions, clearing MEL and put the aircraft to

serviceable condition.

j. On the 20 Jan 2015, aircraft N271UP arrived in CGN, and technical problem was finally

solved by founding qty 3 chafed wires next to the connector D4987P. Wire bundle was removed, replacement of worned wires was perfomed as per image below


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k. MEL Procedures in UPS are regulated by GMM Chapter 03.05.01.03 “Procedures-Minimum Equipment Items” here below shown


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5. Root Cause

a. Following the analysis of the events performed, it appear the fact that not only one root cause generated the event, rather than occurrence can be addressed to a combination of contributing factor here below described:

i. MEL 78-30-1 applied by KMCI was not the correct MEL, aircraft had to be

put in AOG condition up to performance of needed corrective action.

ii. Aircraft had to be grounded at first occurrence due to REV2 PRESS FAULT illuminated light

iii. Continue repetitive malfunctions generated a convincement that the

MEL 78-30-01 can be applicable. (Human Factor Issue, Lack of Assertiveness)

iv. Also UPS AMC who is in charged for the MEL´s administration did not

contribute to clarify the irregularity and assigned the control number to all the station involved.

v. Nayak Gateway KCGN, looking at the history of the item, wrongly

supposed that what had been done before, applying the MEL 78-30-01, was correct and did not take in consideration to look deep in the deferral procedure. (Human Factor Issue, Lack of Assertiveness).

6. Corrective Action for Nayak Maintenance Staff

a. All KCGN gateway engineers involved in the wrong application of the #2 T/Rev deferral have

been investigated and temporary limited on their own FAA Repair Station authorization per a period of 10 days in which they will be re-trained in the correct use of the MEL procedures.

b. After the training period they will be audited by the FAA Repair Station Chief inspector in the use of the MEL procedure.

c. Completed result of the investigation will be disseminated to all the FAA Repair Station employee via info letter to be Read and Sign to make aware of the importance to use the MEL in the correct way not depending only on the past history but having every time a full new exam of the procedures.


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APPENDIX 2 DICHIARAZIONE DI AVVENUTA INFORMAZIONE E FORMAZIONE

TRAINING & INFORMATION STATEMENT ai sensi degli articoli 36 e 37 del D.Lgs. 81-2008 e smi (Italia)

ai sensi dell’articolo L4121-1 del “Code du Travail” (Francia) e smi ai sensi del “Arbeitsschutzgesetz” (Germania)

as per Italian Health & Safety Law DLGS 81/2008 art. 36 & 37 an following modifications

as per French Health & Safety Law Code du Travail article L4121-1 and following modifications as per German Health & Safety Law “Arbeitsschutzgesetz” and following modification

Io sottoscritto I undersigned __________________________________________________

Nato a Born in _______________________________

In data At date ____\____\________

DICHIARO / STATES

di aver ricevuto debita formazione/informazione sui contenuti delle pubblicazioni sotto riportate nonché copia di esse : to have received information/training about the contents of the publications below reported and copy of the same :

1. Info Letter 2014-033 “ AUDIT PARIS CDG FINDING” Dichiaro quindi di essere stato informato dal datore di lavoro sui contenuti della suddetta comunicazione informativa e di averne compreso i contenuti. I declare, therefore, to have been informed by the employer on the contents of this communication and information to understand the contents. In good faith

/Date & Signature

After reading please sign the Appendix 2 and send a scan copy to [email protected]; [email protected]; [email protected]

FORM FAA Approved Repair Station A1YY277N 005 · 2015. 1. 26. · IBAN : IT 96 L 08327 03398...

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Transcript of FORM FAA Approved Repair Station A1YY277N 005 · 2015. 1. 26. · IBAN : IT 96 L 08327 03398...