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Attributes | |
ACN | 437566 |
Time | |
Date | 199905 |
Day | Wed |
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 | B747-100 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe technician : fcc |
Experience | maintenance technician : 23 |
ASRS Report | 437566 |
Person 2 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
Qualification | technician : powerplant technician : airframe |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure non adherence : company policies non adherence : far |
Independent Detector | other other : 968 |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Company Aircraft |
Primary Problem | Company |
Narrative:
After doing the cargo door electrical departure check and pulling the circuit breakers, I did a visual check of the red stripes through the lower edge view ports on the aft cargo door. I could not see part of the stripe in the second hole from the aft side of door. So door was opened and could not determine if a complete stripe was there. Opened and closed aft cargo door several times and watched the operation through the complete cycle. Door closed and locked properly. Talked to captain and decided to push aircraft off gate and then call and defer the partial stripe. Air carrier line maintenance said the aircraft could not leave ZZZ with a partial stripe. As the plane started to taxi, I called ZZZ maintenance to bring back the plane to the gate xw. He said ok. About 5 mins later, the maintenance controller called back and asked if I wanted the plane in the penalty box or the gate. I said the gate because we would have to go into the cargo compartment. About 5 mins later, the controller called and said the plane was going to go to xy. I went to xy to explain the situation with the mechanic there. This took about 10 mins. In the meantime, I went to put a maintenance item in the computer. As I was writing the problem up, I was informed that the aircraft was released to leave ZZZ and it took off. Someone (a foreman or someone in the control center) decided on their own to override air carrier maintenance and allow the aircraft to leave ZZZ with a known problem. Callback conversation with reporter revealed the following information: the reporter stated the procedure after the cargo doors are closed is to visually check the latch locks for the red stripe and then pull the circuit breaker for the latch motor. The reporter said the latch lock view ports are getting hard to see through due to crazing, dirt and lens deterioration. The reporter said in this event 7 latches were observed locked but 1 could not be verified due to the lens condition. This required opening the door, having someone inside to verify the latch operation.
Original NASA ASRS Text
Title: A B747-200 WAS DISPATCHED WITH THE FORWARD AND AFT CARGO DOOR LATCH LOCK VIEW PORT LENSES OBSCURED, DIRTY AND CRAZED MAKING THE LATCH LOCK VERIFICATION DIFFICULT.
Narrative: AFTER DOING THE CARGO DOOR ELECTRICAL DEP CHK AND PULLING THE CIRCUIT BREAKERS, I DID A VISUAL CHK OF THE RED STRIPES THROUGH THE LOWER EDGE VIEW PORTS ON THE AFT CARGO DOOR. I COULD NOT SEE PART OF THE STRIPE IN THE SECOND HOLE FROM THE AFT SIDE OF DOOR. SO DOOR WAS OPENED AND COULD NOT DETERMINE IF A COMPLETE STRIPE WAS THERE. OPENED AND CLOSED AFT CARGO DOOR SEVERAL TIMES AND WATCHED THE OP THROUGH THE COMPLETE CYCLE. DOOR CLOSED AND LOCKED PROPERLY. TALKED TO CAPT AND DECIDED TO PUSH ACFT OFF GATE AND THEN CALL AND DEFER THE PARTIAL STRIPE. ACR LINE MAINT SAID THE ACFT COULD NOT LEAVE ZZZ WITH A PARTIAL STRIPE. AS THE PLANE STARTED TO TAXI, I CALLED ZZZ MAINT TO BRING BACK THE PLANE TO THE GATE XW. HE SAID OK. ABOUT 5 MINS LATER, THE MAINT CTLR CALLED BACK AND ASKED IF I WANTED THE PLANE IN THE PENALTY BOX OR THE GATE. I SAID THE GATE BECAUSE WE WOULD HAVE TO GO INTO THE CARGO COMPARTMENT. ABOUT 5 MINS LATER, THE CTLR CALLED AND SAID THE PLANE WAS GOING TO GO TO XY. I WENT TO XY TO EXPLAIN THE SIT WITH THE MECH THERE. THIS TOOK ABOUT 10 MINS. IN THE MEANTIME, I WENT TO PUT A MAINT ITEM IN THE COMPUTER. AS I WAS WRITING THE PROB UP, I WAS INFORMED THAT THE ACFT WAS RELEASED TO LEAVE ZZZ AND IT TOOK OFF. SOMEONE (A FOREMAN OR SOMEONE IN THE CTL CTR) DECIDED ON THEIR OWN TO OVERRIDE ACR MAINT AND ALLOW THE ACFT TO LEAVE ZZZ WITH A KNOWN PROB. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE PROC AFTER THE CARGO DOORS ARE CLOSED IS TO VISUALLY CHK THE LATCH LOCKS FOR THE RED STRIPE AND THEN PULL THE CIRCUIT BREAKER FOR THE LATCH MOTOR. THE RPTR SAID THE LATCH LOCK VIEW PORTS ARE GETTING HARD TO SEE THROUGH DUE TO CRAZING, DIRT AND LENS DETERIORATION. THE RPTR SAID IN THIS EVENT 7 LATCHES WERE OBSERVED LOCKED BUT 1 COULD NOT BE VERIFIED DUE TO THE LENS CONDITION. THIS REQUIRED OPENING THE DOOR, HAVING SOMEONE INSIDE TO VERIFY THE LATCH OP.
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.