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|
Attributes | |
ACN | 172605 |
Time | |
Date | 199103 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : mco |
State Reference | FL |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | other |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
ASRS Report | 172605 |
Person 2 | |
Affiliation | Other |
Function | other personnel other |
Qualification | other other : other |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | other |
Consequence | other Other |
Supplementary | |
Air Traffic Incident | other |
Narrative:
Medium large transport made unscheduled, uneventful landing after dispatched on a flight from the airport where I work. I assigned a veteran mechanic to relieve the midnight mechanic and complete the servicing of nose strut on medium large transport. When 3-PERSONNEL crew explained the difficulty they were having servicing the strut, I asked if they were using the extension tool needed due to the deeply recessed shrader valve on the strut casting. Crew had forgotten the tool. The relatively new mechanic did not know of the tools existence. I lamented that no one knew how to accomplish this basic task. They spent 2 hours trying to figure it out, and didn't consult the manual. A few mins later I heard the mechanic I'd assigned to do the job asking to borrow a wrong size wrench. I made a mental note: 1) no tools, 2) doesn't know the size of a shrader valve after 12 yrs! During this same time, had to verify corrections to an engine ignition system and so a second mechanic, 16 yrs experience, was assigned to work with the first. Lastly, the hydraulic system quantities had to be checked, system bled of air and svced if necessary. With less than 30 mins before departure, I felt it was time to check progress. Found 1 mechanic trying to hear the igniter firing above the roar of the APU, cargo loading and other engines running. First mechanic had strut servicing equipment hooked up, leaking, and saying, 'it's not good, it leaks.' shrader valve outer nut was backed off, preventing extension tool seal from contacting valve. I learned he had no ruler/tape measure. Said he'd borrow one. Told him he was to useown his own. He said he had one at hangar. Told him to go get it. I then worked with other mechanic to service the strut to proper height. Crew pressurized hydraulic system so we could check them. Mechanic said nose gear doors didn't close when 'pumps were turned on.' reminded him they were mechanical doors. First mechanic returned. Told him strut was svced and to 'put the captain and close everything up.' 'what cap?', he said. Frustrated, I said, 'just finish the job.' with engine ignition corrections not yet verified, I started the engine on previously inoperative ignition system. Mechanics didn't try to run engine because they didn't remember how (though qualified on paper to do so). Engine started. Removed placard from panel and told mechanics to close cowling. Since less than 20 mins till departure, I brought log with me. Entered airworthiness released into log. Final item prior to dispatch after overnight maintenance is walk-around. As a x-chk, another sign-off sheet is provided per operations manual. After departure, flight declared emergency due to nose gear vibration. Crew forgot to check nose gear doors! No aircraft damage. Only 1 nose gear door was latched. Flight refueled and continued west/O incident. Mechanics showed no concern. One looked for an alibi by searching the main manual for 'close the doors' instructions, but in 1 hour never found section dealing with nose gear strut servicing. Also, medium large transport nose gear door system is supposed to relatch upon gear cycling--this aircraft did not function in flight as advertised. I've heard incidents like this attributed to 'pressure of the moment.' in 31 yrs, have heard many excuses. As lead mechanic, I don't expect others to know everything. What does shock me is how many mechanics do not know quickly and west/O coaching how to find out how to do something. Common practice for mechanics to be taught to 'just ask somebody' how to do jobs, instead of consulting the manual first. Some tasks are tightly monitored via routine task oriented worksheets with step by step procedures and inspections and various stages. Don't have too many problems with these tasks. But, most work is not done in this way--the a&P is thought to be sufficiently qualified, and should be considering the schooling required to get an a&P license. I have not control over mechanics company assigns me. My a&P licensed supervisors aren't qualified by company training to perform navigation system, CAT ii and ii system maintenance, or inspection duties. This doesn't cause them to refrain from signing off maintenance log malfunctions related to these system. When reminded of this, they defer to a mechanic who is qualified. Usually short flight delay incurred. Our training department has been reduced can't keep mechanics current in all job phases. I believe loophole exists in far's. In order for aircraft mechanic to keep license valid, he must work on aircraft for 6 out of 24 months, unless he is management in company that performs aircraft maintenance. My company uses a&P supervisors who have been working in baggage services, automotive, bldg maintenance and other non aircraft maintenance related departments. Yet company puts them in positions where they sign off log discrepancies and maintenance--or perform quality assurance inspections. It doesn't surprise me that we have aircraft flying with wheel chocks in the wheel wells, etc. Solution: much more surveillance by a credible agency over the training and day to day habits in the airline industry. I don't think the FAA does the job well enough. The FAA is too cozy with airline mgrs and there aren't enough FAA inspectors. Some whom I know came from airline supervision and management. They were part of the problem, until feeling the squeeze, they, through connections, went to work for the FAA. When these guys communications around, most of us laugh at them. They know why too!! Others never worked on a commercial airliner under conditions prevalent at an airline. I once had one inspect my widebody transport and all its paperwork undergoing a b-chk. Only thing he found wrong was trash outside a container in an upper deck lav. Either we are a model company, or this inspection was narrowly focused. He has been promoted several times since. My bet is FAA is loaded with guys like that. This causes a lack of credibility in the agency and its many competent inspectors. The system must be working ok because we're not in the headlines often. But my coworkers and I see many areas needed improvements. Since 1978, I've had fewer parts, less time and more poorly trained and motivated mechanics with which to operate.
Original NASA ASRS Text
Title: MECHANIC COMPLAINT REGARDING COMPANY TRAINING AND INSPECTION OF MAINTENANCE PROCS.
Narrative: MLG MADE UNSCHEDULED, UNEVENTFUL LNDG AFTER DISPATCHED ON A FLT FROM THE ARPT WHERE I WORK. I ASSIGNED A VETERAN MECH TO RELIEVE THE MIDNIGHT MECH AND COMPLETE THE SVCING OF NOSE STRUT ON MLG. WHEN 3-PERSONNEL CREW EXPLAINED THE DIFFICULTY THEY WERE HAVING SVCING THE STRUT, I ASKED IF THEY WERE USING THE EXTENSION TOOL NEEDED DUE TO THE DEEPLY RECESSED SHRADER VALVE ON THE STRUT CASTING. CREW HAD FORGOTTEN THE TOOL. THE RELATIVELY NEW MECH DID NOT KNOW OF THE TOOLS EXISTENCE. I LAMENTED THAT NO ONE KNEW HOW TO ACCOMPLISH THIS BASIC TASK. THEY SPENT 2 HRS TRYING TO FIGURE IT OUT, AND DIDN'T CONSULT THE MANUAL. A FEW MINS LATER I HEARD THE MECH I'D ASSIGNED TO DO THE JOB ASKING TO BORROW A WRONG SIZE WRENCH. I MADE A MENTAL NOTE: 1) NO TOOLS, 2) DOESN'T KNOW THE SIZE OF A SHRADER VALVE AFTER 12 YRS! DURING THIS SAME TIME, HAD TO VERIFY CORRECTIONS TO AN ENG IGNITION SYS AND SO A SECOND MECH, 16 YRS EXPERIENCE, WAS ASSIGNED TO WORK WITH THE FIRST. LASTLY, THE HYD SYS QUANTITIES HAD TO BE CHKED, SYS BLED OF AIR AND SVCED IF NECESSARY. WITH LESS THAN 30 MINS BEFORE DEP, I FELT IT WAS TIME TO CHK PROGRESS. FOUND 1 MECH TRYING TO HEAR THE IGNITER FIRING ABOVE THE ROAR OF THE APU, CARGO LOADING AND OTHER ENGS RUNNING. FIRST MECH HAD STRUT SVCING EQUIP HOOKED UP, LEAKING, AND SAYING, 'IT'S NOT GOOD, IT LEAKS.' SHRADER VALVE OUTER NUT WAS BACKED OFF, PREVENTING EXTENSION TOOL SEAL FROM CONTACTING VALVE. I LEARNED HE HAD NO RULER/TAPE MEASURE. SAID HE'D BORROW ONE. TOLD HIM HE WAS TO USEOWN HIS OWN. HE SAID HE HAD ONE AT HANGAR. TOLD HIM TO GO GET IT. I THEN WORKED WITH OTHER MECH TO SVC THE STRUT TO PROPER HEIGHT. CREW PRESSURIZED HYD SYS SO WE COULD CHK THEM. MECH SAID NOSE GEAR DOORS DIDN'T CLOSE WHEN 'PUMPS WERE TURNED ON.' REMINDED HIM THEY WERE MECHANICAL DOORS. FIRST MECH RETURNED. TOLD HIM STRUT WAS SVCED AND TO 'PUT THE CAPT AND CLOSE EVERYTHING UP.' 'WHAT CAP?', HE SAID. FRUSTRATED, I SAID, 'JUST FINISH THE JOB.' WITH ENG IGNITION CORRECTIONS NOT YET VERIFIED, I STARTED THE ENG ON PREVIOUSLY INOP IGNITION SYS. MECHS DIDN'T TRY TO RUN ENG BECAUSE THEY DIDN'T REMEMBER HOW (THOUGH QUALIFIED ON PAPER TO DO SO). ENG STARTED. REMOVED PLACARD FROM PANEL AND TOLD MECHS TO CLOSE COWLING. SINCE LESS THAN 20 MINS TILL DEP, I BROUGHT LOG WITH ME. ENTERED AIRWORTHINESS RELEASED INTO LOG. FINAL ITEM PRIOR TO DISPATCH AFTER OVERNIGHT MAINT IS WALK-AROUND. AS A X-CHK, ANOTHER SIGN-OFF SHEET IS PROVIDED PER OPS MANUAL. AFTER DEP, FLT DECLARED EMER DUE TO NOSE GEAR VIBRATION. CREW FORGOT TO CHK NOSE GEAR DOORS! NO ACFT DAMAGE. ONLY 1 NOSE GEAR DOOR WAS LATCHED. FLT REFUELED AND CONTINUED W/O INCIDENT. MECHS SHOWED NO CONCERN. ONE LOOKED FOR AN ALIBI BY SEARCHING THE MAIN MANUAL FOR 'CLOSE THE DOORS' INSTRUCTIONS, BUT IN 1 HR NEVER FOUND SECTION DEALING WITH NOSE GEAR STRUT SVCING. ALSO, MLG NOSE GEAR DOOR SYS IS SUPPOSED TO RELATCH UPON GEAR CYCLING--THIS ACFT DID NOT FUNCTION IN FLT AS ADVERTISED. I'VE HEARD INCIDENTS LIKE THIS ATTRIBUTED TO 'PRESSURE OF THE MOMENT.' IN 31 YRS, HAVE HEARD MANY EXCUSES. AS LEAD MECH, I DON'T EXPECT OTHERS TO KNOW EVERYTHING. WHAT DOES SHOCK ME IS HOW MANY MECHS DO NOT KNOW QUICKLY AND W/O COACHING HOW TO FIND OUT HOW TO DO SOMETHING. COMMON PRACTICE FOR MECHS TO BE TAUGHT TO 'JUST ASK SOMEBODY' HOW TO DO JOBS, INSTEAD OF CONSULTING THE MANUAL FIRST. SOME TASKS ARE TIGHTLY MONITORED VIA ROUTINE TASK ORIENTED WORKSHEETS WITH STEP BY STEP PROCS AND INSPECTIONS AND VARIOUS STAGES. DON'T HAVE TOO MANY PROBS WITH THESE TASKS. BUT, MOST WORK IS NOT DONE IN THIS WAY--THE A&P IS THOUGHT TO BE SUFFICIENTLY QUALIFIED, AND SHOULD BE CONSIDERING THE SCHOOLING REQUIRED TO GET AN A&P LICENSE. I HAVE NOT CTL OVER MECHS COMPANY ASSIGNS ME. MY A&P LICENSED SUPVRS AREN'T QUALIFIED BY COMPANY TRNING TO PERFORM NAV SYS, CAT II AND II SYS MAINT, OR INSPECTION DUTIES. THIS DOESN'T CAUSE THEM TO REFRAIN FROM SIGNING OFF MAINT LOG MALFUNCTIONS RELATED TO THESE SYS. WHEN REMINDED OF THIS, THEY DEFER TO A MECH WHO IS QUALIFIED. USUALLY SHORT FLT DELAY INCURRED. OUR TRNING DEPT HAS BEEN REDUCED CAN'T KEEP MECHS CURRENT IN ALL JOB PHASES. I BELIEVE LOOPHOLE EXISTS IN FAR'S. IN ORDER FOR ACFT MECH TO KEEP LICENSE VALID, HE MUST WORK ON ACFT FOR 6 OUT OF 24 MONTHS, UNLESS HE IS MGMNT IN COMPANY THAT PERFORMS ACFT MAINT. MY COMPANY USES A&P SUPVRS WHO HAVE BEEN WORKING IN BAGGAGE SVCS, AUTOMOTIVE, BLDG MAINT AND OTHER NON ACFT MAINT RELATED DEPTS. YET COMPANY PUTS THEM IN POSITIONS WHERE THEY SIGN OFF LOG DISCREPANCIES AND MAINT--OR PERFORM QUALITY ASSURANCE INSPECTIONS. IT DOESN'T SURPRISE ME THAT WE HAVE ACFT FLYING WITH WHEEL CHOCKS IN THE WHEEL WELLS, ETC. SOLUTION: MUCH MORE SURVEILLANCE BY A CREDIBLE AGENCY OVER THE TRNING AND DAY TO DAY HABITS IN THE AIRLINE INDUSTRY. I DON'T THINK THE FAA DOES THE JOB WELL ENOUGH. THE FAA IS TOO COZY WITH AIRLINE MGRS AND THERE AREN'T ENOUGH FAA INSPECTORS. SOME WHOM I KNOW CAME FROM AIRLINE SUPERVISION AND MGMNT. THEY WERE PART OF THE PROB, UNTIL FEELING THE SQUEEZE, THEY, THROUGH CONNECTIONS, WENT TO WORK FOR THE FAA. WHEN THESE GUYS COMS AROUND, MOST OF US LAUGH AT THEM. THEY KNOW WHY TOO!! OTHERS NEVER WORKED ON A COMMERCIAL AIRLINER UNDER CONDITIONS PREVALENT AT AN AIRLINE. I ONCE HAD ONE INSPECT MY WDB AND ALL ITS PAPERWORK UNDERGOING A B-CHK. ONLY THING HE FOUND WRONG WAS TRASH OUTSIDE A CONTAINER IN AN UPPER DECK LAV. EITHER WE ARE A MODEL COMPANY, OR THIS INSPECTION WAS NARROWLY FOCUSED. HE HAS BEEN PROMOTED SEVERAL TIMES SINCE. MY BET IS FAA IS LOADED WITH GUYS LIKE THAT. THIS CAUSES A LACK OF CREDIBILITY IN THE AGENCY AND ITS MANY COMPETENT INSPECTORS. THE SYS MUST BE WORKING OK BECAUSE WE'RE NOT IN THE HEADLINES OFTEN. BUT MY COWORKERS AND I SEE MANY AREAS NEEDED IMPROVEMENTS. SINCE 1978, I'VE HAD FEWER PARTS, LESS TIME AND MORE POORLY TRAINED AND MOTIVATED MECHS WITH WHICH TO OPERATE.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.