37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 436482 |
Time | |
Date | 199905 |
Day | Thu |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | MD-11 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance lead technician : 2 maintenance technician : 30 |
ASRS Report | 436482 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance lead technician : 11 maintenance technician : 7 |
ASRS Report | 436483 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : person 5 |
Resolutory Action | flight crew : landed as precaution none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : work cards contributing factor : schedule pressure performance deficiency : testing performance deficiency : repair performance deficiency : inspection |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I was lead mechanic on aircraft. During maintenance, reverser was pinned. No log entry was made and no one was informed at turnover. I released the aircraft for service which made an air turn-back because a passenger noticed a panel flapping on #1 pylon. On arrival at the gate, the reverser pin was found installed. Callback conversation with reporter revealed the following information: the reporter stated the young man who installed the lockout pin was really following the procedures used on the lockheed L1011 where any engine work requires pinning the thrust reversers. The reporter said the panel used for access to install the lockout pin is 2 inches by 4 inches and is located in the leading edge of the pylon and will close flush to the pylon skin after the lockout pin is installed. The reporter said after the lockout pin is installed and the door flaps closed, there is no way a visual check from the ground will determine the status of the reverser. The reporter stated the lockout pin has no streamer attached as it is stored in the same 3 inch by 4 inch compartment and in a high heat area. The reporter said this type of incident has happened before and the company is in the process of changing the job cards. The reporter said the technician who installed the pin cannot be excused for not making a write-up that the pin was installed.
Original NASA ASRS Text
Title: AN MD11 WAS DISPATCHED IN NON COMPLIANCE WITH THE #1 ENG THRUST REVERSER LOCKED IN THE FORWARD THRUST POS.
Narrative: I WAS LEAD MECH ON ACFT. DURING MAINT, REVERSER WAS PINNED. NO LOG ENTRY WAS MADE AND NO ONE WAS INFORMED AT TURNOVER. I RELEASED THE ACFT FOR SVC WHICH MADE AN AIR TURN-BACK BECAUSE A PAX NOTICED A PANEL FLAPPING ON #1 PYLON. ON ARR AT THE GATE, THE REVERSER PIN WAS FOUND INSTALLED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE YOUNG MAN WHO INSTALLED THE LOCKOUT PIN WAS REALLY FOLLOWING THE PROCS USED ON THE LOCKHEED L1011 WHERE ANY ENG WORK REQUIRES PINNING THE THRUST REVERSERS. THE RPTR SAID THE PANEL USED FOR ACCESS TO INSTALL THE LOCKOUT PIN IS 2 INCHES BY 4 INCHES AND IS LOCATED IN THE LEADING EDGE OF THE PYLON AND WILL CLOSE FLUSH TO THE PYLON SKIN AFTER THE LOCKOUT PIN IS INSTALLED. THE RPTR SAID AFTER THE LOCKOUT PIN IS INSTALLED AND THE DOOR FLAPS CLOSED, THERE IS NO WAY A VISUAL CHK FROM THE GND WILL DETERMINE THE STATUS OF THE REVERSER. THE RPTR STATED THE LOCKOUT PIN HAS NO STREAMER ATTACHED AS IT IS STORED IN THE SAME 3 INCH BY 4 INCH COMPARTMENT AND IN A HIGH HEAT AREA. THE RPTR SAID THIS TYPE OF INCIDENT HAS HAPPENED BEFORE AND THE COMPANY IS IN THE PROCESS OF CHANGING THE JOB CARDS. THE RPTR SAID THE TECHNICIAN WHO INSTALLED THE PIN CANNOT BE EXCUSED FOR NOT MAKING A WRITE-UP THAT THE PIN WAS INSTALLED.
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.