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|
Attributes | |
ACN | 291714 |
Time | |
Date | 199412 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : gso |
State Reference | NC |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : swf |
Operator | common carrier : air carrier |
Make Model Name | B727-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | other |
Flight Plan | None |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
ASRS Report | 291714 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
ASRS Report | 291856 |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : published procedure other anomaly other |
Independent Detector | other other : unspecified |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Air Traffic Incident | other |
Narrative:
A cordless drill was left in the left hand, inboard trailing edge flap well of boeing 727 following maintenance ending at approximately AM00 on dec/mon/94. The drill caused subsequent minor damage to the right hand inboard trailing edge fore flap and lower wing trailing edge panel at some point during the first 2 flight operations of the day. Although it is not known by me how the drill was left in flap well or by whom, I, as an inspector aircraft, was assigned to and worked this aircraft prior to its departure for revenue flight. It is my belief that a comprehensive tool inventory accounting system should be in place as company policy, to be utilized following aircraft maintenance prior to releasing an aircraft for flight. This policy should mandate that all tools be accounted for prior to release of aircraft. The cordless drill in the flap well was first noticed by a passenger during a flight from pit to clt. It was reported by the passenger and subsequently investigated in clt by air carrier maintenance persons. Part of my job on this aircraft was to perform, with other inspectors on duty, a 'final walk-around' inspection prior to flight. This is accomplished with the aircraft basically in normal flight condition, i.e., panels closed, flaps retracted, spoilers and other devices stowed, landing gear safety pins removed, etc. This occurrence could have been prevented by a thorough inspection prior to 'close-up' of the aircraft after maintenance. Air carrier does not have such a policy. The type of maintenance performed on the aircraft prior to flight with the drill in flap well was a routine, scheduled '1/4 C' check. Callback conversation with reporter revealed the following information: the reporter is a final inspector for a major air carrier and also a union representative for his mechanic's union. He states that he has heard nothing yet from the FAA. One of the mechanics was terminated because he could not account for the drill motor. He has since gotten his job back with a 30 day suspension. The air carrier has a manned tool crib at gso, but the crew that performs 'C' checks has their own tools for which there is no real accountability. The mechanic that was terminated lost track of the drill motor that he had been using, thinking that someone had 'borrowed' it. He got another to close the panels that had been opened. The mechanic was in a rush as there was an imminent shift change and the aircraft was expected on the gate. The reporter states that the air carrier is planning a tool accountability procedure to preclude this from happening again. The reporter is trying to get some changes made in 'job cards' to require an inspection of open areas before they are closed up. Supplemental information from acn 291856: the incident could be avoided if an additional job card was issued in which, before retracting the flaps at the end of the check, all flap well area and kruger flaps would be inspected for foreign object damage. Supplemental information from acn 291924: to prevent a recurrence, I would suggest adding a stop to the job procedure card to check flap wells with flaps full extended for tools, rags, etc. Supplemental information from acn 291927: if the cordless drill was checked out (signed for by someone) it would have been easier to trace who had it last.
Original NASA ASRS Text
Title: CORDLESS DRILL MOTOR LEFT IN FLAP AREA.
Narrative: A CORDLESS DRILL WAS LEFT IN THE L HAND, INBOARD TRAILING EDGE FLAP WELL OF BOEING 727 FOLLOWING MAINT ENDING AT APPROX AM00 ON DEC/MON/94. THE DRILL CAUSED SUBSEQUENT MINOR DAMAGE TO THE R HAND INBOARD TRAILING EDGE FORE FLAP AND LOWER WING TRAILING EDGE PANEL AT SOME POINT DURING THE FIRST 2 FLT OPS OF THE DAY. ALTHOUGH IT IS NOT KNOWN BY ME HOW THE DRILL WAS LEFT IN FLAP WELL OR BY WHOM, I, AS AN INSPECTOR ACFT, WAS ASSIGNED TO AND WORKED THIS ACFT PRIOR TO ITS DEP FOR REVENUE FLT. IT IS MY BELIEF THAT A COMPREHENSIVE TOOL INVENTORY ACCOUNTING SYS SHOULD BE IN PLACE AS COMPANY POLICY, TO BE UTILIZED FOLLOWING ACFT MAINT PRIOR TO RELEASING AN ACFT FOR FLT. THIS POLICY SHOULD MANDATE THAT ALL TOOLS BE ACCOUNTED FOR PRIOR TO RELEASE OF ACFT. THE CORDLESS DRILL IN THE FLAP WELL WAS FIRST NOTICED BY A PAX DURING A FLT FROM PIT TO CLT. IT WAS RPTED BY THE PAX AND SUBSEQUENTLY INVESTIGATED IN CLT BY ACR MAINT PERSONS. PART OF MY JOB ON THIS ACFT WAS TO PERFORM, WITH OTHER INSPECTORS ON DUTY, A 'FINAL WALK-AROUND' INSPECTION PRIOR TO FLT. THIS IS ACCOMPLISHED WITH THE ACFT BASICALLY IN NORMAL FLT CONDITION, I.E., PANELS CLOSED, FLAPS RETRACTED, SPOILERS AND OTHER DEVICES STOWED, LNDG GEAR SAFETY PINS REMOVED, ETC. THIS OCCURRENCE COULD HAVE BEEN PREVENTED BY A THOROUGH INSPECTION PRIOR TO 'CLOSE-UP' OF THE ACFT AFTER MAINT. ACR DOES NOT HAVE SUCH A POLICY. THE TYPE OF MAINT PERFORMED ON THE ACFT PRIOR TO FLT WITH THE DRILL IN FLAP WELL WAS A ROUTINE, SCHEDULED '1/4 C' CHK. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR IS A FINAL INSPECTOR FOR A MAJOR ACR AND ALSO A UNION REPRESENTATIVE FOR HIS MECH'S UNION. HE STATES THAT HE HAS HEARD NOTHING YET FROM THE FAA. ONE OF THE MECHS WAS TERMINATED BECAUSE HE COULD NOT ACCOUNT FOR THE DRILL MOTOR. HE HAS SINCE GOTTEN HIS JOB BACK WITH A 30 DAY SUSPENSION. THE ACR HAS A MANNED TOOL CRIB AT GSO, BUT THE CREW THAT PERFORMS 'C' CHKS HAS THEIR OWN TOOLS FOR WHICH THERE IS NO REAL ACCOUNTABILITY. THE MECH THAT WAS TERMINATED LOST TRACK OF THE DRILL MOTOR THAT HE HAD BEEN USING, THINKING THAT SOMEONE HAD 'BORROWED' IT. HE GOT ANOTHER TO CLOSE THE PANELS THAT HAD BEEN OPENED. THE MECH WAS IN A RUSH AS THERE WAS AN IMMINENT SHIFT CHANGE AND THE ACFT WAS EXPECTED ON THE GATE. THE RPTR STATES THAT THE ACR IS PLANNING A TOOL ACCOUNTABILITY PROC TO PRECLUDE THIS FROM HAPPENING AGAIN. THE RPTR IS TRYING TO GET SOME CHANGES MADE IN 'JOB CARDS' TO REQUIRE AN INSPECTION OF OPEN AREAS BEFORE THEY ARE CLOSED UP. SUPPLEMENTAL INFO FROM ACN 291856: THE INCIDENT COULD BE AVOIDED IF AN ADDITIONAL JOB CARD WAS ISSUED IN WHICH, BEFORE RETRACTING THE FLAPS AT THE END OF THE CHK, ALL FLAP WELL AREA AND KRUGER FLAPS WOULD BE INSPECTED FOR FOREIGN OBJECT DAMAGE. SUPPLEMENTAL INFO FROM ACN 291924: TO PREVENT A RECURRENCE, I WOULD SUGGEST ADDING A STOP TO THE JOB PROC CARD TO CHK FLAP WELLS WITH FLAPS FULL EXTENDED FOR TOOLS, RAGS, ETC. SUPPLEMENTAL INFO FROM ACN 291927: IF THE CORDLESS DRILL WAS CHKED OUT (SIGNED FOR BY SOMEONE) IT WOULD HAVE BEEN EASIER TO TRACE WHO HAD IT LAST.
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.