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|
Attributes | |
ACN | 444510 |
Time | |
Date | 199907 |
Day | Fri |
Place | |
Locale Reference | airport : zzz.airport |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 10 |
ASRS Report | 444510 |
Person 2 | |
Function | oversight : supervisor |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance supervisor : 8 maintenance technician : 7 |
ASRS Report | 444512 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure non adherence : company policies other anomaly |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : investigated other other |
Factors | |
Maintenance | contributing factor : work cards performance deficiency : repair performance deficiency : non compliance with legal requirements performance deficiency : installation performance deficiency : inspection performance deficiency : testing |
Supplementary | |
Problem Areas | Company Chart Or Publication Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I inspected an installation of a r-hand main landing gear trunnion bearing and link. The day was jul/xa/99 in the evening. The mechanic signed off on the work and I stamped off on the inspection of the work on a routine work card, although the brake hydraulic lines were not connected. The connection of the lines were noted on a form attached to a non routine card being worked with the routine card. Later I found out that the form which the brake line work was noted on was lost. No documentation for the brake work existed after the loss of the paperwork. The result was the plane was released for service without the hydraulic brake lines connected for the r-hand main gear. They were later found and connected. Callback conversation with reporter revealed the following information: the reporter stated the loss of an attachment card to a routine landing gear job card was the cause of the airplane being released with no right main landing gear brakes. The reporter said the paperwork now in place works as follows: a routine landing gear job card is assigned to 1 or more technicians to remove the landing gear and its control number is entered on a work control card and in the computer. The reporter stated as the technicians begin to remove the landing gear and disconnect linkage and hydraulic lines they use an 'attachment' card with reference to the landing gear routine job card and is actually attached to the job card listing bits and pieces removed from the landing gear and hydraulic lines capped. The reporter said this 'attachment' card is not numbered nor is it entered on the work control card or computer. The reporter stated in this incident the attachment card was lost and all write-ups on the card were lost and no one in the 5 shifts working on the gear knew an attachment card existed. The reporter said the company paperwork is archaic and will have to be updated to prevent another serious incident. The reporter said the aircraft was released and a test flight was accomplished with a pilot report of 'soft' right brakes and #3 brake was replaced. The reporter stated at this point the error should have been caught since the brake replacement requires hydraulic pressure to allow brake bleeding per the maintenance manual. The reporter stated the aircraft went into revenue service for 2 days before the right main gear brakes were discovered inoperative. The reporter said the FAA has conducted an interview for their investigation.
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED AND OPERATED IN NON COMPLIANCE WITH THE R MAIN LNDG GEAR BRAKES INOP.
Narrative: I INSPECTED AN INSTALLATION OF A R-HAND MAIN LNDG GEAR TRUNNION BEARING AND LINK. THE DAY WAS JUL/XA/99 IN THE EVENING. THE MECH SIGNED OFF ON THE WORK AND I STAMPED OFF ON THE INSPECTION OF THE WORK ON A ROUTINE WORK CARD, ALTHOUGH THE BRAKE HYD LINES WERE NOT CONNECTED. THE CONNECTION OF THE LINES WERE NOTED ON A FORM ATTACHED TO A NON ROUTINE CARD BEING WORKED WITH THE ROUTINE CARD. LATER I FOUND OUT THAT THE FORM WHICH THE BRAKE LINE WORK WAS NOTED ON WAS LOST. NO DOCUMENTATION FOR THE BRAKE WORK EXISTED AFTER THE LOSS OF THE PAPERWORK. THE RESULT WAS THE PLANE WAS RELEASED FOR SVC WITHOUT THE HYD BRAKE LINES CONNECTED FOR THE R-HAND MAIN GEAR. THEY WERE LATER FOUND AND CONNECTED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE LOSS OF AN ATTACHMENT CARD TO A ROUTINE LNDG GEAR JOB CARD WAS THE CAUSE OF THE AIRPLANE BEING RELEASED WITH NO R MAIN LNDG GEAR BRAKES. THE RPTR SAID THE PAPERWORK NOW IN PLACE WORKS AS FOLLOWS: A ROUTINE LNDG GEAR JOB CARD IS ASSIGNED TO 1 OR MORE TECHNICIANS TO REMOVE THE LNDG GEAR AND ITS CTL NUMBER IS ENTERED ON A WORK CTL CARD AND IN THE COMPUTER. THE RPTR STATED AS THE TECHNICIANS BEGIN TO REMOVE THE LNDG GEAR AND DISCONNECT LINKAGE AND HYD LINES THEY USE AN 'ATTACHMENT' CARD WITH REF TO THE LNDG GEAR ROUTINE JOB CARD AND IS ACTUALLY ATTACHED TO THE JOB CARD LISTING BITS AND PIECES REMOVED FROM THE LNDG GEAR AND HYD LINES CAPPED. THE RPTR SAID THIS 'ATTACHMENT' CARD IS NOT NUMBERED NOR IS IT ENTERED ON THE WORK CTL CARD OR COMPUTER. THE RPTR STATED IN THIS INCIDENT THE ATTACHMENT CARD WAS LOST AND ALL WRITE-UPS ON THE CARD WERE LOST AND NO ONE IN THE 5 SHIFTS WORKING ON THE GEAR KNEW AN ATTACHMENT CARD EXISTED. THE RPTR SAID THE COMPANY PAPERWORK IS ARCHAIC AND WILL HAVE TO BE UPDATED TO PREVENT ANOTHER SERIOUS INCIDENT. THE RPTR SAID THE ACFT WAS RELEASED AND A TEST FLT WAS ACCOMPLISHED WITH A PLT RPT OF 'SOFT' R BRAKES AND #3 BRAKE WAS REPLACED. THE RPTR STATED AT THIS POINT THE ERROR SHOULD HAVE BEEN CAUGHT SINCE THE BRAKE REPLACEMENT REQUIRES HYD PRESSURE TO ALLOW BRAKE BLEEDING PER THE MAINT MANUAL. THE RPTR STATED THE ACFT WENT INTO REVENUE SVC FOR 2 DAYS BEFORE THE R MAIN GEAR BRAKES WERE DISCOVERED INOP. THE RPTR SAID THE FAA HAS CONDUCTED AN INTERVIEW FOR THEIR INVESTIGATION.
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.