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|
Attributes | |
ACN | 315477 |
Time | |
Date | 199509 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : sby |
State Reference | MD |
Altitude | agl bound lower : 100 agl bound upper : 500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : sby |
Operator | common carrier : air carrier |
Make Model Name | Dash 8 Series Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | climbout : initial climbout : takeoff |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 140 flight time total : 22500 flight time type : 8800 |
ASRS Report | 315476 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time total : 5800 |
ASRS Report | 315477 |
Events | |
Anomaly | aircraft equipment problem : critical other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified |
Resolutory Action | flight crew : overcame equipment problem other |
Consequence | faa : investigated |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Narrative:
Gear unsafe light on gear retraction. Returned and landed. Callback conversation with reporter revealed the following information: after landing, the flight crew discovered layers of bubble wrap secured around the gear uplock in the left main wheel well. Apparently, the mechanic on the preceding night's shift kept bumping into the uplock so he used bubble wrap for a buffer. Reporter states that this is a routine maintenance procedure. A major contributing factor was the fact that the first mechanic did not remove the wrap or indicate its presence to the subsequent mechanic. The error continued past a mechanic, a lead mechanic, a quality control person, and the first officer's preflight. FAA inspector termed the incident as a real human factors story.
Original NASA ASRS Text
Title: DH8 FLC RECEIVED A GEAR UNSAFE LIGHT AFTER TKOF AND GEAR RETRACTION.
Narrative: GEAR UNSAFE LIGHT ON GEAR RETRACTION. RETURNED AND LANDED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: AFTER LNDG, THE FLC DISCOVERED LAYERS OF BUBBLE WRAP SECURED AROUND THE GEAR UPLOCK IN THE L MAIN WHEEL WELL. APPARENTLY, THE MECH ON THE PRECEDING NIGHT'S SHIFT KEPT BUMPING INTO THE UPLOCK SO HE USED BUBBLE WRAP FOR A BUFFER. RPTR STATES THAT THIS IS A ROUTINE MAINT PROC. A MAJOR CONTRIBUTING FACTOR WAS THE FACT THAT THE FIRST MECH DID NOT REMOVE THE WRAP OR INDICATE ITS PRESENCE TO THE SUBSEQUENT MECH. THE ERROR CONTINUED PAST A MECH, A LEAD MECH, A QUALITY CTL PERSON, AND THE FO'S PREFLT. FAA INSPECTOR TERMED THE INCIDENT AS A REAL HUMAN FACTORS STORY.
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.