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|
Attributes | |
ACN | 385342 |
Time | |
Date | 199711 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz |
State Reference | US |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B747-400 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | other |
Flight Plan | None |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
ASRS Report | 385342 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | other other : other |
ASRS Report | 385629 |
Events | |
Anomaly | aircraft equipment problem : critical other anomaly other |
Independent Detector | other flight crewa other other : unspecified other other : unspecified cockpit |
Resolutory Action | none taken : unable |
Consequence | Other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | other |
Narrative:
On nov/xa/97, aircraft was involved in an incident on flight xyz in which difficulty in fuel xfer from the center tank was experienced. Upon returning to YYY maintenance center on nov/xb/97, the ramp opened the center tank to find rubber surgical gloves around the fuel pickups. Aircraft had been released from ZZZ maintenance center on oct/xx/97, after completion of mpv. In addition to routine maintenance and close up the center tank was reopened and closed several times. As an aircraft inspector I was involved in clearing initial close up of the center tank. As I stated in a statement given to my supervisor I detected no rubber surgical gloves upon inspection and clearance to close. The tank was reopened 2 more times to repair leaks. I was not involved in close up at those 2 other times. Although normal clearance procedures should have found foreign objects, the surgical gloves become almost transparent when wet and pale yellow/white when dry yielding a lack of visual contrast with the top coat inside the tank. Perhaps special high visibility color gloves could be used only for fuel tank entry and special issue and accountability should be implemented. Callback conversation with reporter revealed the following information: reporter stated that had the final close up inspection been done correctly this incident would not have happened. The reporter said the procedure is to enter the tank with the mechanic and as you leave each bay and prior to plate closure all dirt, debris and foreign matter is removed and signed for on the job card. The reporter stated there were two more tank entries after the reporter's inspection due to leaks after fueling the tank.
Original NASA ASRS Text
Title: A B747-400 WAS DISPATCHED AND FLOWN WITH THE CTR FUEL TANK FUEL PICKUPS BLOCKED AND RESTR BY RUBBER SURGICAL GLOVES LEFT BY TANK MECHS.
Narrative: ON NOV/XA/97, ACFT WAS INVOLVED IN AN INCIDENT ON FLT XYZ IN WHICH DIFFICULTY IN FUEL XFER FROM THE CTR TANK WAS EXPERIENCED. UPON RETURNING TO YYY MAINT CTR ON NOV/XB/97, THE RAMP OPENED THE CTR TANK TO FIND RUBBER SURGICAL GLOVES AROUND THE FUEL PICKUPS. ACFT HAD BEEN RELEASED FROM ZZZ MAINT CTR ON OCT/XX/97, AFTER COMPLETION OF MPV. IN ADDITION TO ROUTINE MAINT AND CLOSE UP THE CTR TANK WAS REOPENED AND CLOSED SEVERAL TIMES. AS AN ACFT INSPECTOR I WAS INVOLVED IN CLRING INITIAL CLOSE UP OF THE CTR TANK. AS I STATED IN A STATEMENT GIVEN TO MY SUPVR I DETECTED NO RUBBER SURGICAL GLOVES UPON INSPECTION AND CLRNC TO CLOSE. THE TANK WAS REOPENED 2 MORE TIMES TO REPAIR LEAKS. I WAS NOT INVOLVED IN CLOSE UP AT THOSE 2 OTHER TIMES. ALTHOUGH NORMAL CLRNC PROCS SHOULD HAVE FOUND FOREIGN OBJECTS, THE SURGICAL GLOVES BECOME ALMOST TRANSPARENT WHEN WET AND PALE YELLOW/WHITE WHEN DRY YIELDING A LACK OF VISUAL CONTRAST WITH THE TOP COAT INSIDE THE TANK. PERHAPS SPECIAL HIGH VISIBILITY COLOR GLOVES COULD BE USED ONLY FOR FUEL TANK ENTRY AND SPECIAL ISSUE AND ACCOUNTABILITY SHOULD BE IMPLEMENTED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT HAD THE FINAL CLOSE UP INSPECTION BEEN DONE CORRECTLY THIS INCIDENT WOULD NOT HAVE HAPPENED. THE RPTR SAID THE PROC IS TO ENTER THE TANK WITH THE MECH AND AS YOU LEAVE EACH BAY AND PRIOR TO PLATE CLOSURE ALL DIRT, DEBRIS AND FOREIGN MATTER IS REMOVED AND SIGNED FOR ON THE JOB CARD. THE RPTR STATED THERE WERE TWO MORE TANK ENTRIES AFTER THE RPTR'S INSPECTION DUE TO LEAKS AFTER FUELING THE TANK.
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.