37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 317959 |
Time | |
Date | 199510 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : ord |
State Reference | IL |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
ASRS Report | 317959 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : far non adherence other other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | other |
Narrative:
While repairing a hydraulic leak on one of my company's aircraft I removed a hydraulic supply hose from the reservoir to prevent excessive loss of hydraulic fluid. The repair to the leak went well, the paperwork was completed and the aircraft was dispatched for its destination with a minimal delay. Later that morning while reviewing the planned work for that aircraft, I noticed the flight crew had written up a low hydraulic pressure warning problem. The FBO mechanic where the aircraft landed found the hydraulic supply hose disconnected at the reservoir. The line maintenance controller for our company deferred the hydraulic pump per the MEL as inoperative due to the extended length of time the pump had been run with no fluid supply. I realized immediately that I had forgotten to reconnect the supply hose, a very sinking feeling. I feel that the time restraints as well as the constant need to 'get the plane out on time' environment, that is a situation that we deal with every day, had finally caught up to me. The hose that I forgot to reconnect can easily be forgotten as it is barred behind a couple other hoses. I do believe if I simply took the time to attach a streamer to the end of the hose and had that streamer hanging out where anyone could see it, this may have helped prevent this incident. Since I have worked in aircraft maintenance for almost 30 yrs without ever having such a situation happen before, I realize it is up to every one of us involved in aircraft maintenance to check, rechk and check again once our job is 'complete.'
Original NASA ASRS Text
Title: ACFT MAINT DISCREPANCY CREATED WHEN MECH FAILS TO RE- CONNECT THE DISCONNECTED HYD FLUID SUPPLY LINE TO THE MAIN RESERVOIR TANK.
Narrative: WHILE REPAIRING A HYD LEAK ON ONE OF MY COMPANY'S ACFT I REMOVED A HYD SUPPLY HOSE FROM THE RESERVOIR TO PREVENT EXCESSIVE LOSS OF HYD FLUID. THE REPAIR TO THE LEAK WENT WELL, THE PAPERWORK WAS COMPLETED AND THE ACFT WAS DISPATCHED FOR ITS DEST WITH A MINIMAL DELAY. LATER THAT MORNING WHILE REVIEWING THE PLANNED WORK FOR THAT ACFT, I NOTICED THE FLC HAD WRITTEN UP A LOW HYD PRESSURE WARNING PROB. THE FBO MECH WHERE THE ACFT LANDED FOUND THE HYD SUPPLY HOSE DISCONNECTED AT THE RESERVOIR. THE LINE MAINT CTLR FOR OUR COMPANY DEFERRED THE HYD PUMP PER THE MEL AS INOP DUE TO THE EXTENDED LENGTH OF TIME THE PUMP HAD BEEN RUN WITH NO FLUID SUPPLY. I REALIZED IMMEDIATELY THAT I HAD FORGOTTEN TO RECONNECT THE SUPPLY HOSE, A VERY SINKING FEELING. I FEEL THAT THE TIME RESTRAINTS AS WELL AS THE CONSTANT NEED TO 'GET THE PLANE OUT ON TIME' ENVIRONMENT, THAT IS A SIT THAT WE DEAL WITH EVERY DAY, HAD FINALLY CAUGHT UP TO ME. THE HOSE THAT I FORGOT TO RECONNECT CAN EASILY BE FORGOTTEN AS IT IS BARRED BEHIND A COUPLE OTHER HOSES. I DO BELIEVE IF I SIMPLY TOOK THE TIME TO ATTACH A STREAMER TO THE END OF THE HOSE AND HAD THAT STREAMER HANGING OUT WHERE ANYONE COULD SEE IT, THIS MAY HAVE HELPED PREVENT THIS INCIDENT. SINCE I HAVE WORKED IN ACFT MAINT FOR ALMOST 30 YRS WITHOUT EVER HAVING SUCH A SIT HAPPEN BEFORE, I REALIZE IT IS UP TO EVERY ONE OF US INVOLVED IN ACFT MAINT TO CHK, RECHK AND CHK AGAIN ONCE OUR JOB IS 'COMPLETE.'
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.