37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 436311 |
Time | |
Date | 199905 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | DC-9 30 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | None |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician maintenance : technician oversight : supervisor |
Qualification | technician : powerplant technician : fcc technician : airframe |
Experience | maintenance avionics : 15 maintenance lead technician : 15 maintenance technician : 35 |
ASRS Report | 436311 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other oversight : supervisor |
Qualification | technician : powerplant technician : airframe |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : person 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
Near the conclusion of an overnight 'B' check at approximately XD00, a quality check review of the maintenance log revealed a pilot write-up on the previous day which stated 'tailcone light came on, aborted takeoff.' the inspector immediately showed the item to the 2 maintenance supervisors on duty because there was no mention of a 'rejected takeoff, high energy stop' inspection being performed as called for in chapter 5 of the maintenance manual. Neither supervisor had knowledge of the event, but addressed the matter almost immediately. The quality control inspector initiated a non routine work card referencing the log page by number and to 'determine need for rejected takeoff inspection check in accordance with DC9 maintenance manual and take necessary action.' the operational parameters obtainable only from the flight crew involved could not be obtained quickly enough to prevent a delay. In the interim, a quality control inspector accomplished all visible inspections required with the exception of the axles beneath the brake spacers for evidence of overtemped paint and cadmium plating. The maintenance supervisor concluded that it would take less time to remove the wheels and brakes and accomplish the inspection than to wait for the as yet unknown parameters. When the left outboard brake had been removed and the axle cleaned for inspection the chief inspector accompanied by the director of maintenance arrived. The chief inspector's attention was directed to the darkly heat discolored paint by the quality control inspector in the presence of 4 mechanics. The chief inspector said, 'condition noted, I'm signing it off, close it up.' the aircraft was permitted to depart with passenger on board. Upon learning that an ASRS report was being sent, the chief inspector was directed by the director of quality assurance to direct maintenance control to have the left outboard axle inspection completed at the next layover.
Original NASA ASRS Text
Title: A DC9-30 WAS DISPATCHED IN NON COMPLIANCE WITH A LOG RPT OF A REJECTED TKOF AND THE REQUIRED HIGH ENERGY STOP AXLE AND BRAKE INSPECTION NOT ACCOMPLISHED.
Narrative: NEAR THE CONCLUSION OF AN OVERNIGHT 'B' CHK AT APPROX XD00, A QUALITY CHK REVIEW OF THE MAINT LOG REVEALED A PLT WRITE-UP ON THE PREVIOUS DAY WHICH STATED 'TAILCONE LIGHT CAME ON, ABORTED TKOF.' THE INSPECTOR IMMEDIATELY SHOWED THE ITEM TO THE 2 MAINT SUPVRS ON DUTY BECAUSE THERE WAS NO MENTION OF A 'REJECTED TKOF, HIGH ENERGY STOP' INSPECTION BEING PERFORMED AS CALLED FOR IN CHAPTER 5 OF THE MAINT MANUAL. NEITHER SUPVR HAD KNOWLEDGE OF THE EVENT, BUT ADDRESSED THE MATTER ALMOST IMMEDIATELY. THE QUALITY CTL INSPECTOR INITIATED A NON ROUTINE WORK CARD REFING THE LOG PAGE BY NUMBER AND TO 'DETERMINE NEED FOR REJECTED TKOF INSPECTION CHK IN ACCORDANCE WITH DC9 MAINT MANUAL AND TAKE NECESSARY ACTION.' THE OPERATIONAL PARAMETERS OBTAINABLE ONLY FROM THE FLC INVOLVED COULD NOT BE OBTAINED QUICKLY ENOUGH TO PREVENT A DELAY. IN THE INTERIM, A QUALITY CTL INSPECTOR ACCOMPLISHED ALL VISIBLE INSPECTIONS REQUIRED WITH THE EXCEPTION OF THE AXLES BENEATH THE BRAKE SPACERS FOR EVIDENCE OF OVERTEMPED PAINT AND CADMIUM PLATING. THE MAINT SUPVR CONCLUDED THAT IT WOULD TAKE LESS TIME TO REMOVE THE WHEELS AND BRAKES AND ACCOMPLISH THE INSPECTION THAN TO WAIT FOR THE AS YET UNKNOWN PARAMETERS. WHEN THE L OUTBOARD BRAKE HAD BEEN REMOVED AND THE AXLE CLEANED FOR INSPECTION THE CHIEF INSPECTOR ACCOMPANIED BY THE DIRECTOR OF MAINT ARRIVED. THE CHIEF INSPECTOR'S ATTN WAS DIRECTED TO THE DARKLY HEAT DISCOLORED PAINT BY THE QUALITY CTL INSPECTOR IN THE PRESENCE OF 4 MECHS. THE CHIEF INSPECTOR SAID, 'CONDITION NOTED, I'M SIGNING IT OFF, CLOSE IT UP.' THE ACFT WAS PERMITTED TO DEPART WITH PAX ON BOARD. UPON LEARNING THAT AN ASRS RPT WAS BEING SENT, THE CHIEF INSPECTOR WAS DIRECTED BY THE DIRECTOR OF QUALITY ASSURANCE TO DIRECT MAINT CTL TO HAVE THE L OUTBOARD AXLE INSPECTION COMPLETED AT THE NEXT LAYOVER.
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.