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|
Attributes | |
ACN | 443124 |
Time | |
Date | 199907 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Dusk |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 443124 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : r.h. pneumatic bleed press |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : repair |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
Ship xyz had an inoperative APU and therefore required a ground assisted airstart. The equipment service person stated she had little experience with airstarts so I asked that she get help for the start. The right engine was started and the equipment service person was having difficulty disconnecting the right hose. In her effort to remove the airhose she spun the hose connector and it separated from the aircraft attached to the hose coupling. The pilot shut the air off from the engine. A few moments later her assistant handed me the coupling that separated from the aircraft duct. I reinstalled the coupler back onto the duct. The aircraft was dispatched with the right engine running and the left engine to be started during taxi. All appeared normal at departure. About 1 hour after departure an equipment service person brought a check valve to my crew chief stating he found it on the airstart cart. Upon researching the part and further investigation we found that this valve did indeed belong to ship xyz and immediately notified maintenance control. During the course of the flight the airstart door blew open and departed the aircraft. Contributing factor: inexperienced newer people at times not working with a partner in more involved duties.
Original NASA ASRS Text
Title: B757-200 WAS DISPATCHED IN NON COMPLIANCE WITH THE R PNEUMATIC GND CONNECTOR AND CHK VALVE TORN OUT OF THE ACFT AND NO LOG OR MAINT ACTION TAKEN.
Narrative: SHIP XYZ HAD AN INOP APU AND THEREFORE REQUIRED A GND ASSISTED AIRSTART. THE EQUIP SVC PERSON STATED SHE HAD LITTLE EXPERIENCE WITH AIRSTARTS SO I ASKED THAT SHE GET HELP FOR THE START. THE R ENG WAS STARTED AND THE EQUIP SVC PERSON WAS HAVING DIFFICULTY DISCONNECTING THE R HOSE. IN HER EFFORT TO REMOVE THE AIRHOSE SHE SPUN THE HOSE CONNECTOR AND IT SEPARATED FROM THE ACFT ATTACHED TO THE HOSE COUPLING. THE PLT SHUT THE AIR OFF FROM THE ENG. A FEW MOMENTS LATER HER ASSISTANT HANDED ME THE COUPLING THAT SEPARATED FROM THE ACFT DUCT. I REINSTALLED THE COUPLER BACK ONTO THE DUCT. THE ACFT WAS DISPATCHED WITH THE R ENG RUNNING AND THE L ENG TO BE STARTED DURING TAXI. ALL APPEARED NORMAL AT DEP. ABOUT 1 HR AFTER DEP AN EQUIP SVC PERSON BROUGHT A CHK VALVE TO MY CREW CHIEF STATING HE FOUND IT ON THE AIRSTART CART. UPON RESEARCHING THE PART AND FURTHER INVESTIGATION WE FOUND THAT THIS VALVE DID INDEED BELONG TO SHIP XYZ AND IMMEDIATELY NOTIFIED MAINT CTL. DURING THE COURSE OF THE FLT THE AIRSTART DOOR BLEW OPEN AND DEPARTED THE ACFT. CONTRIBUTING FACTOR: INEXPERIENCED NEWER PEOPLE AT TIMES NOT WORKING WITH A PARTNER IN MORE INVOLVED DUTIES.
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.