37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 264833 |
Time | |
Date | 199402 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : msp |
State Reference | MN |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : dfw |
Operator | common carrier : air carrier |
Make Model Name | B747-100 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | ground : preflight |
Flight Plan | None |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
ASRS Report | 264833 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
Events | |
Anomaly | aircraft equipment problem : critical non adherence other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : declared emergency none taken : detected after the fact |
Consequence | faa : investigated faa : assigned or threatened penalties other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | other |
Narrative:
I gave an ok to close of hydraulic compartment on #1 engine on feb/94. Per citex. Callback conversation with reporter revealed the following information: reporter was called back for additional information to fill in the 'sketchy' report filed with ASRS. The incident deals with the final inspection of a B-747-200 that was to be returned to service for flight duty. The previous inspector had performed an inspection for aircraft damage within the nacelle and engine support area, called an 'adt' inspection. He had stated that it was not necessary to remove the rear diagonal safety caps over the safety pins during his inspection and labeled the paper work 'north/a'. Speculation has it that someone (air carrier could not find out who this was) later removed the safety caps and since there was no paper work for the removal, there was no paper work for their re-installation. The reporter, an inspector as well, looked into the nacelle support area and gave the mechanics the ok to close it up. He failed to see that the caps were missing. During the course of the 5 days ensuing this inspection the rear safety pins vibrated loose and the aircraft lost the front and rear supports on a landing at nrt airport during reversing. Fire ensued as the engine pivoted on it's center supports and dragged on the runway. Fire was controled and aircraft OTS a long time. Reporter states that the air carrier is usually in a rush for their aircraft and this being a wkend, the maintenance crews were shorthanded during the inspection. Crews felt 'pushed'. Reporter is subject to FAA penalties and air carrier fines to a substantial degree. The air carrier's paper work has been changed to correct situation.
Original NASA ASRS Text
Title: IMPROPER MAINT PROC USED AND INSPECTOR FAILED TO CATCH ERROR. ACFT LATER LOSES #1 ENG AS IT COMES OFF IT'S DIAGONAL INTERNAL SUPPORTS.
Narrative: I GAVE AN OK TO CLOSE OF HYD COMPARTMENT ON #1 ENG ON FEB/94. PER CITEX. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR WAS CALLED BACK FOR ADDITIONAL INFO TO FILL IN THE 'SKETCHY' RPT FILED WITH ASRS. THE INCIDENT DEALS WITH THE FINAL INSPECTION OF A B-747-200 THAT WAS TO BE RETURNED TO SVC FOR FLT DUTY. THE PREVIOUS INSPECTOR HAD PERFORMED AN INSPECTION FOR ACFT DAMAGE WITHIN THE NACELLE AND ENG SUPPORT AREA, CALLED AN 'ADT' INSPECTION. HE HAD STATED THAT IT WAS NOT NECESSARY TO REMOVE THE REAR DIAGONAL SAFETY CAPS OVER THE SAFETY PINS DURING HIS INSPECTION AND LABELED THE PAPER WORK 'N/A'. SPECULATION HAS IT THAT SOMEONE (ACR COULD NOT FIND OUT WHO THIS WAS) LATER REMOVED THE SAFETY CAPS AND SINCE THERE WAS NO PAPER WORK FOR THE REMOVAL, THERE WAS NO PAPER WORK FOR THEIR RE-INSTALLATION. THE RPTR, AN INSPECTOR AS WELL, LOOKED INTO THE NACELLE SUPPORT AREA AND GAVE THE MECHS THE OK TO CLOSE IT UP. HE FAILED TO SEE THAT THE CAPS WERE MISSING. DURING THE COURSE OF THE 5 DAYS ENSUING THIS INSPECTION THE REAR SAFETY PINS VIBRATED LOOSE AND THE ACFT LOST THE FRONT AND REAR SUPPORTS ON A LNDG AT NRT ARPT DURING REVERSING. FIRE ENSUED AS THE ENG PIVOTED ON IT'S CTR SUPPORTS AND DRAGGED ON THE RWY. FIRE WAS CTLED AND ACFT OTS A LONG TIME. RPTR STATES THAT THE ACR IS USUALLY IN A RUSH FOR THEIR ACFT AND THIS BEING A WKEND, THE MAINT CREWS WERE SHORTHANDED DURING THE INSPECTION. CREWS FELT 'PUSHED'. RPTR IS SUBJECT TO FAA PENALTIES AND ACR FINES TO A SUBSTANTIAL DEG. THE ACR'S PAPER WORK HAS BEEN CHANGED TO CORRECT SIT.
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.