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|
Attributes | |
ACN | 220399 |
Time | |
Date | 199208 |
Day | Sun |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : lax |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 2 Turbojet Eng |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : cfi pilot : atp pilot : commercial |
Experience | flight time last 90 days : 200 flight time total : 17000 flight time type : 300 |
ASRS Report | 220399 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : commercial pilot : flight engineer pilot : instrument pilot : atp |
Experience | flight time last 90 days : 228 flight time total : 6500 flight time type : 2000 |
ASRS Report | 220406 |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : far |
Independent Detector | other other : unspecified |
Resolutory Action | none taken : detected after the fact other |
Consequence | Other |
Supplementary | |
Primary Problem | Airport |
Air Traffic Incident | other |
Narrative:
Aircraft had 2 tires changed in ewr and the mechanics forgot to reconnect the brake hydraulic lines on the #4 and #6 brakes. The lines had been taped back to the bogie beam to keep them out of the way while the tires were being changed. Apparently, the job was signed off by maintenance as being witnessed by a maintenance supervisor. This took place at least '3' days before I picked the aircraft up in lax. However, when the flight engineer made his walk-around inspection he missed the disconnected brakes because by that time the lines were covered with tar and grease. Not until another crew picked up the aircraft and the tape had broken loose and the brake lines were hanging down did the flight engineer find the problem. Upon that captain's investigation with maintenance, he found there was no record of the lines being disconnected and placarded for any malfunction. Therefore, the lines were inadvertently left disconnected. The reason the other 2 brakes, on the right main strut, did not get hot on landing was because we were very light early that morning and I used min selection on the automatic-brake panel. As I stated early on, I knew nothing was wrong and as far as I was concerned, the flight took place without incident. Not until my safety officer contacted me did I find all this out. It is obvious air carrier's maintenance inspector's missed this when they inspected this job prior to signing off the logbook if they inspected the job at all prior to signing off the logbook if they inspected the job at all. My flight engineer was not the only engineer to miss this problem. My crew was the last of 3 or 4 crews to miss it until it was discovered. Supplemental information from acn 220406: to prevent this from occurring in the future, I recommend that easily seen (colored) tape be used (if the practice of taping back lines is a normal procedure). This would make it easier to identify the fact. Callback conversation with reporter revealed the following information: multiple callbacks. Reporter attempted to find out if the maintenance department had made any changes in their procedures. No apparent changes have been made. His attempts and those of the union safety chairman were unsuccessful.
Original NASA ASRS Text
Title: WDB FLOWN SEVERAL DAYS WITH 2 BRAKES INOP.
Narrative: ACFT HAD 2 TIRES CHANGED IN EWR AND THE MECHS FORGOT TO RECONNECT THE BRAKE HYD LINES ON THE #4 AND #6 BRAKES. THE LINES HAD BEEN TAPED BACK TO THE BOGIE BEAM TO KEEP THEM OUT OF THE WAY WHILE THE TIRES WERE BEING CHANGED. APPARENTLY, THE JOB WAS SIGNED OFF BY MAINT AS BEING WITNESSED BY A MAINT SUPVR. THIS TOOK PLACE AT LEAST '3' DAYS BEFORE I PICKED THE ACFT UP IN LAX. HOWEVER, WHEN THE FLT ENGINEER MADE HIS WALK-AROUND INSPECTION HE MISSED THE DISCONNECTED BRAKES BECAUSE BY THAT TIME THE LINES WERE COVERED WITH TAR AND GREASE. NOT UNTIL ANOTHER CREW PICKED UP THE ACFT AND THE TAPE HAD BROKEN LOOSE AND THE BRAKE LINES WERE HANGING DOWN DID THE FLT ENGINEER FIND THE PROBLEM. UPON THAT CAPT'S INVESTIGATION WITH MAINT, HE FOUND THERE WAS NO RECORD OF THE LINES BEING DISCONNECTED AND PLACARDED FOR ANY MALFUNCTION. THEREFORE, THE LINES WERE INADVERTENTLY LEFT DISCONNECTED. THE REASON THE OTHER 2 BRAKES, ON THE R MAIN STRUT, DID NOT GET HOT ON LNDG WAS BECAUSE WE WERE VERY LIGHT EARLY THAT MORNING AND I USED MIN SELECTION ON THE AUTO-BRAKE PANEL. AS I STATED EARLY ON, I KNEW NOTHING WAS WRONG AND AS FAR AS I WAS CONCERNED, THE FLT TOOK PLACE WITHOUT INCIDENT. NOT UNTIL MY SAFETY OFFICER CONTACTED ME DID I FIND ALL THIS OUT. IT IS OBVIOUS ACR'S MAINT INSPECTOR'S MISSED THIS WHEN THEY INSPECTED THIS JOB PRIOR TO SIGNING OFF THE LOGBOOK IF THEY INSPECTED THE JOB AT ALL PRIOR TO SIGNING OFF THE LOGBOOK IF THEY INSPECTED THE JOB AT ALL. MY FLT ENGINEER WAS NOT THE ONLY ENGINEER TO MISS THIS PROBLEM. MY CREW WAS THE LAST OF 3 OR 4 CREWS TO MISS IT UNTIL IT WAS DISCOVERED. SUPPLEMENTAL INFO FROM ACN 220406: TO PREVENT THIS FROM OCCURRING IN THE FUTURE, I RECOMMEND THAT EASILY SEEN (COLORED) TAPE BE USED (IF THE PRACTICE OF TAPING BACK LINES IS A NORMAL PROC). THIS WOULD MAKE IT EASIER TO IDENT THE FACT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: MULTIPLE CALLBACKS. RPTR ATTEMPTED TO FIND OUT IF THE MAINT DEPT HAD MADE ANY CHANGES IN THEIR PROCS. NO APPARENT CHANGES HAVE BEEN MADE. HIS ATTEMPTS AND THOSE OF THE UNION SAFETY CHAIRMAN WERE UNSUCCESSFUL.
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.