37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 434144 |
Time | |
Date | 199904 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : iah.airport |
State Reference | TX |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : iah.tower |
Operator | common carrier : air carrier |
Make Model Name | ATR 42 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : taxi landing : roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 434144 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : commercial pilot : instrument |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : company policies non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : strut pressure indicator other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : testing performance deficiency : repair performance deficiency : fault isolation |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Maintenance had worked on aircraft (ATR42-320) prior to departure for a low right strut. While it was still low, they assured crew it was fixed. On taxi out, aircraft listed about 3-4 degrees to left. Feeling this was unsafe, I elected to return to ramp. During my turning maneuver, I lost brakes and we smelled rubber 'smoke' in cockpit, stopped aircraft and shut down engines. Crash fire rescue equipment responded. No injuries, no fire. Maintenance towed aircraft to hangar. The strut prior to departure was very low. The aircraft had been written up for bad struts previously. Maintenance did not use pressure gauge and overpressurized right strut, causing problem. This aircraft was returned to service and I flew it again. During landing, the brakes failed. I was PF and slowed, after notifying tower, through reverse and emergency brakes. I taxied clear of runway 27 and a brake temperature 'hot' illuminated. Crash fire rescue equipment was dispatched. #3 tire was blown (possible fuse plugs). This was the same aircraft which lost brakes and had strut problem earlier in day. I was assigned to fly it again, even though it was obviously not completely fixed. Strut on right side was bottomed out after landing with aircraft full of passenger. Callback conversation with reporter revealed the following information: the reporter stated prior to departure the maintenance manager and the chief pilot were summoned to the gate to observe the aircraft and its list to the left. The reporter said the maintenance manager assured everyone involved that the airplane was 'ok for service.' the reporter said after he taxied out, lost braking and were towed back to the gate it was found the right strut was extended to the point the ground/air switches were activated. The reporter stated with the ground/air switch activated, the brakes were deactivated. The reporter said when the aircraft was returned to service with another signoff for the strut servicing it still had the same list and high strut. The reporter said the crew made 1 trip and returned to iah where the brakes again failed and a tire was blown. The reporter said the only report from maintenance on the fix was the right strut was again svced per the maintenance manual.
Original NASA ASRS Text
Title: AN ATR42-320 ON TAXI OUT LOST BRAKING AND WAS TOWED TO GATE FOR MAINT. ACFT WAS REPAIRED AND OPERATED BY THE SAME CREW. ON TRIP RETURN TO IAH THE ACFT LOST BRAKING AGAIN BLOWING #3 TIRE.
Narrative: MAINT HAD WORKED ON ACFT (ATR42-320) PRIOR TO DEP FOR A LOW R STRUT. WHILE IT WAS STILL LOW, THEY ASSURED CREW IT WAS FIXED. ON TAXI OUT, ACFT LISTED ABOUT 3-4 DEGS TO L. FEELING THIS WAS UNSAFE, I ELECTED TO RETURN TO RAMP. DURING MY TURNING MANEUVER, I LOST BRAKES AND WE SMELLED RUBBER 'SMOKE' IN COCKPIT, STOPPED ACFT AND SHUT DOWN ENGS. CFR RESPONDED. NO INJURIES, NO FIRE. MAINT TOWED ACFT TO HANGAR. THE STRUT PRIOR TO DEP WAS VERY LOW. THE ACFT HAD BEEN WRITTEN UP FOR BAD STRUTS PREVIOUSLY. MAINT DID NOT USE PRESSURE GAUGE AND OVERPRESSURIZED R STRUT, CAUSING PROB. THIS ACFT WAS RETURNED TO SVC AND I FLEW IT AGAIN. DURING LNDG, THE BRAKES FAILED. I WAS PF AND SLOWED, AFTER NOTIFYING TWR, THROUGH REVERSE AND EMER BRAKES. I TAXIED CLR OF RWY 27 AND A BRAKE TEMP 'HOT' ILLUMINATED. CFR WAS DISPATCHED. #3 TIRE WAS BLOWN (POSSIBLE FUSE PLUGS). THIS WAS THE SAME ACFT WHICH LOST BRAKES AND HAD STRUT PROB EARLIER IN DAY. I WAS ASSIGNED TO FLY IT AGAIN, EVEN THOUGH IT WAS OBVIOUSLY NOT COMPLETELY FIXED. STRUT ON R SIDE WAS BOTTOMED OUT AFTER LNDG WITH ACFT FULL OF PAX. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED PRIOR TO DEP THE MAINT MGR AND THE CHIEF PLT WERE SUMMONED TO THE GATE TO OBSERVE THE ACFT AND ITS LIST TO THE L. THE RPTR SAID THE MAINT MGR ASSURED EVERYONE INVOLVED THAT THE AIRPLANE WAS 'OK FOR SVC.' THE RPTR SAID AFTER HE TAXIED OUT, LOST BRAKING AND WERE TOWED BACK TO THE GATE IT WAS FOUND THE R STRUT WAS EXTENDED TO THE POINT THE GND/AIR SWITCHES WERE ACTIVATED. THE RPTR STATED WITH THE GND/AIR SWITCH ACTIVATED, THE BRAKES WERE DEACTIVATED. THE RPTR SAID WHEN THE ACFT WAS RETURNED TO SVC WITH ANOTHER SIGNOFF FOR THE STRUT SVCING IT STILL HAD THE SAME LIST AND HIGH STRUT. THE RPTR SAID THE CREW MADE 1 TRIP AND RETURNED TO IAH WHERE THE BRAKES AGAIN FAILED AND A TIRE WAS BLOWN. THE RPTR SAID THE ONLY RPT FROM MAINT ON THE FIX WAS THE R STRUT WAS AGAIN SVCED PER THE MAINT MANUAL.
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.