N317PA

BOEING B-727 Fatal injury — PAN AMERICAN WORLD AWYS INC.

Operated by PAN AMERICAN WORLD AWYS INC. (per NTSB report)

ATA 5312

Part: BULKHEAD — CRACKED (FUSELAGE) · airframe 9,921 hrs

DURING A ROUTINE INSPECTION THE 247 BULKHEAD WAS FOUND TO BE CRACKED. THIS BULKHEAD IS THE ATTACHMENT POINT FOR THE FOREWARD END OF THE VERTICAL FIN, THIS PART WAS REPLACED WITH A NEW BULKHEAD 2150 HRS AGO, THIS STATION OPERATES A FLEET OF 16 PA-44-180S, ALL OF THE SAME SERIAL NUMBER RANGE, PURCHASED NEW FOR FLIGHT TRAINING, AND ALL OF THOSE WERE FOUND TO HAVE CRACKS IN THE SAME BULKHEAD DURING THE 2015-2016 TIME FRAME AT AN AVERAGE OF 7-9000 HRS. THE CRACKS OCCURE ON THE FWD SIDE DOUBLER UPPER RIVET ROW OUTBOARD RIVET. THE BULKHEAD EXHIBTS POOR WORKMANSHIP WITH THE -5 RIVETS BEING OVER DRIVEN WITH SIGNS OF RIVETS CREATING DIVITS IN THE DOUBLER, WHICH IS WHERE THE CRACKS ORIGINATE FROM. THE ORIGINAL BULKHEAD SHOWED THE SAME QUALITY OF WORK.

ATA 5340

Part: BRACKET — CRACKED (BS 486) · airframe 8,305 hrs

DURING A ROUTINE INSPECTION, A U-SHAPED BRACKET LOCATED AT THE TOP OF THE FIREWALL IN THE FWD FUSELAGE OF THE AIRCRAFT WAS FOUND CRACKED. THIS BRACKET ATTACHES A HAT CHANNEL ON TOP OF THE NOSE TO THE FIREWALL.

ATA 3297

Part: WIRE — FAILED (DOWNLOCK SWITCH) · airframe 8,191 hrs

IMMEDIATELY AFTER TAKEOFF, THE GEAR WARNING AND HYDRAULIC PUMP CIRCUIT BREAKERS TRIPPED. THE AIRCRAFT RETURNED FOR A SAFE LANDING. DURING A MAINTENANCE GEAR FUNCTIONAL TEST, THE ISSUE COULD NOT BE IMMEDIATELY DUPLICATED, WHEN THE TECH BEGAN TO CLOSELY INSPECTING THE LEFT GEAR DOWN LIMIT SWITCH, THE WIRES CAME APART. TWO MAJOR ISSUES WITH DESIGN OF THIS SWITCH.

ATA 5710

Part: ANGLE — CRACKED (RT WING) · airframe 7,918 hrs

DURING A PROGRESSIVE INSPECTION, AN ANGLE IN THE RT WING WAS FOUND CRACKED BEHIND THE LANDING GEAR SIDE BRACE FITTING. THE ANGLE HAD BEEN INSTALLED IAW SB 1161 & WAS CONTAINED IN KIT, PN 767-398. THE SB INDICATES THAT INSTALLATION OF THIS KIT WILL PREVENT CRACKING AND IS A TERMINATING ACTION FOR A RECURRING INSPECTION OF THE RIB.

ATA 5712

Part: RIB — CRACKED (RT WING) · airframe 7,918 hrs

DURING INSPECTION, CRACKS WERE NOTED IN A RT WING RIB AT RWS 50.05. THESE CRACKS WERE IN A RIB IMMEDIATELY ADJACENT TO THE ELECTRIC FUEL PUMP AND WERE SEEN AROUND THE RIVET HOLES WHERE RIB MEETS SPAR.

ATA 5312

Part: DOUBLER — CRACKED (BS 247 BULKHEAD) · airframe 7,771 hrs

DURING INSPECTION, A BULKHEAD DOUBLER IN THE EMPENNAGE WAS FOUND CRACKED. THE DEFECT WAS VISIBLE BY REMOVING A FAIRING THAT JOINS THE EMPENNAGE AND VERTICAL FIN AND LOOKING UP AND AFT. THE DOUBLER HAD 2 CRACKS; THEY WERE LOCATED BESIDE THE TOP, OTBD RIVETS, LT AND RT.

ATA 5720

Part: ANGLE — CRACKED (RT WING) · airframe 7,522 hrs

DURING A PROGRESSIVE INSPECTION, AN ANGLE IN THE RT WING WAS FOUND CRACKED BEHIND THE LANDING GEAR SIDE BRACE FITTING. THE CRACK HAD BEEN INSTALLED IAW SB 1161 & WAS CONTAINED IN KIT, PN 767-398.

ATA 5720

Part: ANGLE — CRACKED (LT WING) · airframe 7,522 hrs

DURING A PROGRESSIVE INSPECTION, AN ANGLE IN THE LT WING WAS FOUND CRACKED BEHIND THE LANDING GEAR SIDE BRACE FITTING. THE CRACK HAD BEEN INSTALLED IAW SB 1161 & WAS CONTAINED IN KIT PN 767-397.

ATA 3260

Part: DOWNLOCK SWITCH — SEPARATED (ZONE 700) · airframe 7,254 hrs

WHILE BEING TAXIED AFTER A MAINTENANCE ENGINE GROUND RUN, THE TECH NOTED THE LT GEAR DOWN AND LOCKED LIGHT WAS FLICKERING OFF AND ON. VISUAL INSPECTION OF THE LT GEAR DOWN LOCK SWITCH REVEALED BROKEN WIRES. THE SWITCH HAS THICK SHRINK WRAP APPLIED TO THE WIRES; IN THIS CASE, THE WIRES WERE NOT HELD STRAIGHT WHEN THE WRAP WAS SHRUNK SO SOME WIRES WERE VERY TIGHT AND OTHERS WERE LOOSE AND BULGING OUT OF THE END OF THE SHRINK WRAP. THE TIGHT WIRES WERE BROKEN OR BREAKING.

ATA 2822

Part: PUMP — BLOCKED (FUEL SYS) · airframe 7,254 hrs

ON UPWIND, THE LT ENGINE WOULD SUDDENLY LOOSE 1000 RPM FOR 1 TO 5 SECONDS AT A TIME. THE PILOT REQUESTED AND WAS GRANTED A RETURN TO THE AIRPORT. WHILE IN THE PATTERN, THE PILOT WAS ABLE TO STOP THE SURGES BY SETTING THE LEFT FUEL SELECTOR TO CROSSFEED; HE WAS ABLE TO RETURN FOR A SAFE LANDING. WHEN MAINTENANCE BEGAN A GROUND RUN OF THE ENGINE, THE TECH NOTED THE LT ELECTRIC FUEL PUMP WAS PRODUCING SIGNIFICANTLY LESS PRESSURE THAN THE RT; THE PUMP WAS REPLACED. THE LOWER CAP OF THE REMOVED PUMP WAS TAKENOFF AND A WASHER WAS FOUND STUCK TO THE MAGNET INSIDE; THE WASHER IS SUPPOSED TO BE INSTALLED AROUND THE LOWER BALL VALVE IN THE PUMP. THE BALL VALVE ITSELF WAS STUCK IN THE CLOSED POSITION, CAUSING A STOPPAGE OF FUEL. IT TOOK AT LEAST 5 POUNDS OF HAND PRESSURE TO UNSTICK THE BALL. THE VALVE SEAT WAS FOUND TO BE SEVERELY WORN, OPEN, ALLOWING THE BALL TO SEAT VERY FAR IN THE SEAT. SINCE THE PUMP HAS NO BYPASS, THE STICKING VALVE BLOCKED THE FUEL TO THE ENGINE.

ATA 3260

Part: SQUAT SWITCH — FALSE INDICATION (ZONE 700) · airframe 8,324 hrs

ACFT SQUAWKED PREVIOUSLY FOR A DOWNLOCK SWITCH HAVING BROKEN WIRES AND THE ACFT WAS HAVING A GEAR RETRACTION AND FUNCTIONAL CHECK AFTER THE SWITCH WAS REPLACED. DURING THIS CHECK THE GEAR WOULD NOT RETRACT WHEN SELECTED UP AND THE GEAR UNSAFE LIGHT AND HORN CAME ON. TROUBLESHOOTING REVEALED THE LT MAIN LANDING GEAR SQUAT SWITCH HAD WIRES THAT WERE BROKEN AND SEPARATED WHICH COULD NOT BE SEEN UNTIL THE SWITCH WAS REMOVED FROM THE GEAR. THESE SWITCHES HAVE A WIRING HARNESS COVERED IN THICK SHRINK WRAP THAT ENCOURAGES THE WIRES TO FLEX IN ONE SMALL AREA NEAR THE SWITCH BODY. THE SHRINK WRAP AND SILICONE ON THE WIRES ALSO MAKE IT EXTREMELY DIFFICULT TO SEE ANY DAMAGE OR DEFECTS WITH THE WIRES, SO EVEN DILIGENT INSPECTION MAY NOT DETECT A BROKEN WIRE.