27-96). It was also noted that the indicator pin had been safetied with the incorrect safety wire. .041 stainless steel safety wire had been used instead of .032 brass safety wire as stated in the McDonnell-Douglas DC-9 maintenance manual. It should be noted that at the time (03-27-96) of this inspection, the mechanic safetied the tail skid indicator pin with .032 stainless steel wire because he did not have .032 brass safety wire readily available. ValuJet was notified immediately by the FAA that the substitution of .032 stainless steel wire was not acceptable, this safety wire was replaced with .032 brass wire. FINDING: 2.03.05: An inspection performed by the ATL FSDO on 04-01-96 of ValuJet aircraft N939VV at ATL, indicated that N939VV had a tail skid strike. ValuJet was immediately notified of this finding. ValuJet dispatched the Vice-President of Technical Operations and the Director of Maintenance to the site of the aircraft due to the concern of the finding. At this time, ValuJet stated that the tail skid would be repiced and the tail skid adjacent structure would be inspected for damage (logsheet 49982-01). The aircraft was grounded until the planned replacement of the tail skid and the proper structural inspection of the surrounding area was accomplished. On 04-02-96, the ATL FSDO performed a follow-up inspection of N939VV at ATL. It was discovered that the planned maintenance had not been accomplished. The aircraft was prepared for flight #560 from Atlanta to Indianapolis. Passengers were boarding the aircraft. The ATL FSDO immediately inquired what action had been taken by ValuJet to correct the discrepancy noted on 04-01-96 concerning the tail skid bumper. The head/supervisor on duty stated that the tail skid bumper assembly had been replaced. The ATL FSDO stated that a follow-up inspection N939VV had just been completed and the tail skid bad not been replaced. ValuJet immediately reinspected N939VV and discovered that the tail skid bumper had not been replaced as planned. ValuJet immediately initiated the replacement of the tail skid bumper assembly (log sheet 49982 -01 and ValuJet's equipment transfer record # 66783, dated 04-02-96). FINDING: 2.03.06: On 04-02-96, aircraft N913VV was inspected by the ATL FSDO. A tail skid strike had occurred a: an previous unknown date. This discrepancy was brought to attention of Valujet and an entry was placed into N913VV's aircraft log sheet # 49961-31, as a discrepancy stating item # 1, “check tail skid for damage, ATL 04/02/96." The corrective action was “visually inspect tail skid struct. for damage, no damage found. The ValuJet maintenance inspector misinterpreted the discrepancy, the tail skid was no: inspected. Additionally, during the ATL FSDO's inspection of aircraft N913VV on 0402-96, a rivet was sheared and protruding from the aircraft's skin adjacent to the tail skid assembly (reference aircraft log sheet #49961-31, item # 2). This discrepancy was shown to a ValuJet maintenance lead technician. This discrepancy was signed as being complete on 04-02-96. A follow-up inspection of this discrepancy indicated that a corrective action had been taken according to the sign off in the corrective action column but the discrepancy was still apparent on the aircraft. This discrepancy was again brought to the attention of ValuJet (reference logsheet #49961-41, dated 04-03-96. item # 2) and the rivet was replaced. FINDING: 2.03.07: PERFORMING MAINTENANCE WITHOUT OBTAINING AND USING MAINTENANCE MANUALS. On 02-23-96, aircraft N913VV, was under going maintenance to remove and replace the right engine's starter drive spline adapter (logsheet # 40573-09). It was noted by a FAA ASI that ValuJet maintenance did not have the appropriate maintenance manual instructions to remove and replace the starter drive spline adapter. The maintenance personnel were not aware of a special too! specifically stated in the maintenance manual reference for removing a starter drive spline adapter. An FAA ASI observing this maintenance noted ValuJet's maintenance personnel beating on the sheared starter drive spline adapter with a hammer and a chisel and inquired what procedures and tooling was required to perform the task. ValuJet maintenance personnel did not have access to the appropriate maintenance manual (Pratt & Whitney JT8D maintenance manual) with instructions to perform the removal and installation of the starter drive spline assembly. Additionally, the instructions contained in the appropriate section of the maintenance manual specifically gave reference to the use of a special tool to remove the starter drive spline adapter. The result of this maintenance was an improper removal and replacement of a JT8D starter drive spline adapter. This aircraft departed on flight #183 from Atlanta to New Orleans. During the flight, the # 2 engine (right engine) lost its oil quantity and engine oil pressure resulting in an in flight engine shutdown. An inspection of the previous installation revealed that oil was leaking from a starter garlock seal that may have been damaged during the previous removal and replacement of the starter drive spline adapter that was accomplished in Atlanta. (logsheet # 40573-17). INDING: 2.03.08: FAILURE TO PROPERLY MAINTAIN ATL LINE MAINTENANCE SHIFT CHANGE OR WORK INTERRUPTION RECORD. On 04-15-96, the ATL line maintenance base shift change records (formVJ-M027) were inspected and evaluated for being complete and maintained per ValuJet's SP 8136. The ATL line maintenance base has not maintained the shift change record according to the instructions contained in ValuJet's SP 8136. A review of ValuJet's shift change record (form VJ-M027) maintained at the ATL line maintenance station has indicated that many forms are incomplete. In some cases, no shift turn over has occurred. In addition to a written shift change report, the off going supervisor shall, prior to the end of his shift, personally contact the on coming supervisor and thoroughly discuss the status of all incomplete work on aircraft, engines and appliances being turned over to the on coming shift. NOTE: Shift turn over procedures are not addressed in the General MTC Manual (SP) Orientation Course. 2.04 TRAINING PROGRAMS ESCRIPTION OF ORGANIZATION AND INSPECTION DATA: ValuJet provides initial technical training relative to the line mechanic's job requirements and maintenance esponsibilities. Initial technical training for aircraft maintenance personnel consist of a minimum of 32 hours raining for each fleet aircrafi type and 8 hours per engine type. An additional Orientation Training Program is conducted and requires a minimum of 4 hours training. ValuJet also conducts a Required Inspected Items (RI) course for selected qualified individuals. ValuJet is currently conducting training for line maintenance personnel consisting of a DC-9 familiarization course of 40 hours duration. Another 8 hour course encompasses ValuJet's Standard Practice Manual's xrocedures. Due to the current findings and observations, Valulet is currently updating its maintenance training to include 1 specific focus on the performance of quality line maintenance checks, interpretation of line maintenance outine work cards and procedures. -INDING: 2.04.01: Valulet's maintenance personnel are deficient in the performance of “N”, “A”, and “B” checks. This concern has been brought to the attention of Valulet's management personnel. NOTE: ValuJet is currently evaluating training for line maintenance personnel and has implemented a training curriculum for performance of "N", "A", and "B" checks. Additional training for the initial DC-9 Familiarization Course is being planned and additional aircraft maintenance instructors have been hired to assume the additional training programs. For comparison purposes only, ValuJet's familiarization training is considerably less than other operators of >C-9s. Airlines denoted with an asterisk “*” also give new hire mechanics supplemental courses on specific aircraft "stems (avionics, electrical, troubleshooting, etc...) within the first year of employment. 26-755 97-6 2.08 MEL/DEFERRED MAINTENANCE ESCRIPTION OF ORGANIZATION AND INSPECTION DATA: ValuJet's line maintenance utilizes the FAA approved DC-9 Minimum Equipment List (MEL) and an When using the MEL, compliance with the stated preamble, definitions, and conditions and limitations of the MEL document is required. The "M" symbol indicates a requirement for a specific maintenance procedure that nust be accomplished prior to release of the aircraft. These items are normally accomplished by maintenance >ersonnel. INDING: 2.08.01: FAILURE TO PROPERLY DEFER ITEMS PER ValuJet'S MEL. A follow up of FINDINGS disclosed that ValuJet's line maintenance personnel received very limited training on the use of the MEL/CDL document's procedures and instructions. The total time devoted to training line maintenance personnel on the use of the ValuJet's MEL/CDL is "less than 30 minutes." ValuJet relies heavily on “on-thejob" training during actual performance of deferring maintenance. Improper “M" procedures most frequently observed were not pulling or collaring circuit breakers to deactivate a system or not placarding per the MEL's instructions. INDING: 2.08.02: On 02-23-96, aircraft N916VV was inspected by FAA personnel. During this inspection, the Captain of the aircraft was notified that a left-hand navigation light was inoperative. The captain indicated that the aircraft could depart without the navigation light during light and "saw no problem with continuing." The Captain was reminded to follow his MEL procedures. The navigation light was deferred before the aircraft's departure. INDING: 2.08.03: On 02-26-96, aircraft N906VJ was inspected in MDW by FAA personnel. The aircraft's logbook indicated that a inboard flap fairing was removed without any CDL reference. This item was not properly deferred in accordance with ValuJet's MEL/CDL procedures. This oversight was brought to the attention of ValuJet and the takeoff and landing parameters were adjusted due to the weight penalty. INDING: 2.08.04: On 02-24-96, aircraft ship number 935, the TCAS system was deferred for the "TCAS fail light keep cycling on and off", this was deferred by ValuJet's line On 02-26-96, aircraft N935VV was inspected at the DFW airport by FAA personnel. A |