Narrative:

On aug/xa/99 upon reporting to work, I was informed that aircraft xyz (per log) had a service difficulty report incident. Upon takeoff roll, pilots experienced trouble being unable to keep the nosewheel on the runway at 80 KTS. Takeoff was aborted and the aircraft returned to the gate. This was aircraft xyz, flight X departing from ZZZ, us. An immediate investigation was launched by the company under the watchful eye of the FAA. An l-chk had been completed on aircraft xyz on aug/xx/99. During the l-chk, both elevator power control actuating cylinders and associated universal joints were removed due to leakage and wear. During the removal of the universal joints, the elevator rod end was also removed to check for wear and to facilitate easier access to safeties on the universal attach bolts. Upon reassemble of this installation on both sides, mechanics missed the torque and safeties on both elevator rod ends. Work was thoroughly documented throughout the replacement process and in the interest of aviation safety, I will enclose copies of work performed less mechanic identify. There was direct involvement by more than 14 mechanics (including inspectors). Being directly involved as the mechanic removing both units and loosely assembling the universal assemblies on both left and right elevator, I was questioned thoroughly why I removed the unit as I did and why I loosely assembled it. I believed I had properly signed off the work I performed on jul/xd/99 and jul/xe/99 even referencing the ipc for proper terminology. The aircraft logs leave it very apparent that safeties were not present on the elevator rod ends on both elevators. In the preliminary investigation findings we found were training (or lack of training), nomenclature (amm/ipc calling the elevator rod end interchangeably with elevator eyebolt), shift turnovers (first shift to third shift), poor access to area (overhead) and numerous human factors involving people misinterping others' written turnovers and tunnel vision along with other factors. My recommendations to the investigating team were to include the closing panel into the required inspection program so that a final inspection of this flight control actuator mounting nut was required before closing the small panel over this area. I believe there would be no way a safety on a 3/4 inch keyed lock nut would be missed. Callback conversation with reporter revealed the following information: the reporter stated the exact condition of the rod end bolts was written on the job card as installed loosely. The reporter said this was ignored or not noticed when the next shift started on the job. The reporter stated no verbal shift turnover was accomplished in regard to the loose rod ends or his write-up. The reporter said a conflict existed between the illustrated parts catalog which referred to the rod ends as 'eye bolts' and the maintenance manual terminology was rod ends. The reporter said that since this incident, the illustrated parts catalog has been changed to agree with the maintenance manual. The reporter said the required final inspection missed the loosely attached bolt and the .750 inch keyed lock nut. The reporter stated the aircraft made 64 flts before the power units became detached from the elevators.

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Original NASA ASRS Text

Title: A DC9-30 REJECTED TKOF AT 80 KTS WHEN UNABLE TO KEEP THE NOSE GEAR ON THE GND CAUSED BY THE ELEVATORS LOCKED IN FULL NOSE UP POS.

Narrative: ON AUG/XA/99 UPON RPTING TO WORK, I WAS INFORMED THAT ACFT XYZ (PER LOG) HAD A SVC DIFFICULTY RPT INCIDENT. UPON TKOF ROLL, PLTS EXPERIENCED TROUBLE BEING UNABLE TO KEEP THE NOSEWHEEL ON THE RWY AT 80 KTS. TKOF WAS ABORTED AND THE ACFT RETURNED TO THE GATE. THIS WAS ACFT XYZ, FLT X DEPARTING FROM ZZZ, US. AN IMMEDIATE INVESTIGATION WAS LAUNCHED BY THE COMPANY UNDER THE WATCHFUL EYE OF THE FAA. AN L-CHK HAD BEEN COMPLETED ON ACFT XYZ ON AUG/XX/99. DURING THE L-CHK, BOTH ELEVATOR PWR CTL ACTUATING CYLINDERS AND ASSOCIATED UNIVERSAL JOINTS WERE REMOVED DUE TO LEAKAGE AND WEAR. DURING THE REMOVAL OF THE UNIVERSAL JOINTS, THE ELEVATOR ROD END WAS ALSO REMOVED TO CHK FOR WEAR AND TO FACILITATE EASIER ACCESS TO SAFETIES ON THE UNIVERSAL ATTACH BOLTS. UPON REASSEMBLE OF THIS INSTALLATION ON BOTH SIDES, MECHS MISSED THE TORQUE AND SAFETIES ON BOTH ELEVATOR ROD ENDS. WORK WAS THOROUGHLY DOCUMENTED THROUGHOUT THE REPLACEMENT PROCESS AND IN THE INTEREST OF AVIATION SAFETY, I WILL ENCLOSE COPIES OF WORK PERFORMED LESS MECH IDENT. THERE WAS DIRECT INVOLVEMENT BY MORE THAN 14 MECHS (INCLUDING INSPECTORS). BEING DIRECTLY INVOLVED AS THE MECH REMOVING BOTH UNITS AND LOOSELY ASSEMBLING THE UNIVERSAL ASSEMBLIES ON BOTH L AND R ELEVATOR, I WAS QUESTIONED THOROUGHLY WHY I REMOVED THE UNIT AS I DID AND WHY I LOOSELY ASSEMBLED IT. I BELIEVED I HAD PROPERLY SIGNED OFF THE WORK I PERFORMED ON JUL/XD/99 AND JUL/XE/99 EVEN REFING THE IPC FOR PROPER TERMINOLOGY. THE ACFT LOGS LEAVE IT VERY APPARENT THAT SAFETIES WERE NOT PRESENT ON THE ELEVATOR ROD ENDS ON BOTH ELEVATORS. IN THE PRELIMINARY INVESTIGATION FINDINGS WE FOUND WERE TRAINING (OR LACK OF TRAINING), NOMENCLATURE (AMM/IPC CALLING THE ELEVATOR ROD END INTERCHANGEABLY WITH ELEVATOR EYEBOLT), SHIFT TURNOVERS (FIRST SHIFT TO THIRD SHIFT), POOR ACCESS TO AREA (OVERHEAD) AND NUMEROUS HUMAN FACTORS INVOLVING PEOPLE MISINTERPING OTHERS' WRITTEN TURNOVERS AND TUNNEL VISION ALONG WITH OTHER FACTORS. MY RECOMMENDATIONS TO THE INVESTIGATING TEAM WERE TO INCLUDE THE CLOSING PANEL INTO THE REQUIRED INSPECTION PROGRAM SO THAT A FINAL INSPECTION OF THIS FLT CTL ACTUATOR MOUNTING NUT WAS REQUIRED BEFORE CLOSING THE SMALL PANEL OVER THIS AREA. I BELIEVE THERE WOULD BE NO WAY A SAFETY ON A 3/4 INCH KEYED LOCK NUT WOULD BE MISSED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE EXACT CONDITION OF THE ROD END BOLTS WAS WRITTEN ON THE JOB CARD AS INSTALLED LOOSELY. THE RPTR SAID THIS WAS IGNORED OR NOT NOTICED WHEN THE NEXT SHIFT STARTED ON THE JOB. THE RPTR STATED NO VERBAL SHIFT TURNOVER WAS ACCOMPLISHED IN REGARD TO THE LOOSE ROD ENDS OR HIS WRITE-UP. THE RPTR SAID A CONFLICT EXISTED BTWN THE ILLUSTRATED PARTS CATALOG WHICH REFERRED TO THE ROD ENDS AS 'EYE BOLTS' AND THE MAINT MANUAL TERMINOLOGY WAS ROD ENDS. THE RPTR SAID THAT SINCE THIS INCIDENT, THE ILLUSTRATED PARTS CATALOG HAS BEEN CHANGED TO AGREE WITH THE MAINT MANUAL. THE RPTR SAID THE REQUIRED FINAL INSPECTION MISSED THE LOOSELY ATTACHED BOLT AND THE .750 INCH KEYED LOCK NUT. THE RPTR STATED THE ACFT MADE 64 FLTS BEFORE THE PWR UNITS BECAME DETACHED FROM THE ELEVATORS.

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.