37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 447644 |
Time | |
Date | 199908 |
Day | Tue |
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 | A320 |
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 : 14 |
ASRS Report | 447644 |
Person 2 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
Qualification | technician : airframe technician : powerplant |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Resolutory Action | none taken : unable |
Consequence | other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : tooling contributing factor : lighting performance deficiency : repair performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
On the night of aug/xa/99, I was assigned to perform the #9A check on the #1 engine of an A320. I followed the job card procedures which require the deactivation of the hydraulic thrust reverser control unit by installing a safety pin in the control unit. While I continued with the engine service I found a couple of discrepancies that would need to be addressed. Once the service was completed, I proceeded on to a leaking hydraulic line, and then to help 2 associates with some case cooling mount bearings they were having trouble replacing. As time pressed on, it was near to pushout and run the engines for leak checks. It was at this point I became rushed and missed reactivating the thrust reverser hydraulic control unit. I did not realize my mistake until I was on my way home and the aircraft was already airborne. At once I called the station maintenance controller and explained the problem. I was told he would contact the line maintenance controller and allow them to handle notifying the air crew. Callback conversation with reporter revealed the following information: the reporter stated the last step on the job card was restore the aircraft to normal. The reporter said the job card did direct the technician to install the lockout pin but did not direct the technician to remove the pin. The reporter stated that no operations check of the reverser was required on the job card.
Original NASA ASRS Text
Title: AN AIRBUS 320 WAS DISPATCHED IN NON COMPLIANCE WITH #1 REVERSER LOCKED OUT FOR MAINT.
Narrative: ON THE NIGHT OF AUG/XA/99, I WAS ASSIGNED TO PERFORM THE #9A CHK ON THE #1 ENG OF AN A320. I FOLLOWED THE JOB CARD PROCS WHICH REQUIRE THE DEACTIVATION OF THE HYD THRUST REVERSER CTL UNIT BY INSTALLING A SAFETY PIN IN THE CTL UNIT. WHILE I CONTINUED WITH THE ENG SVC I FOUND A COUPLE OF DISCREPANCIES THAT WOULD NEED TO BE ADDRESSED. ONCE THE SVC WAS COMPLETED, I PROCEEDED ON TO A LEAKING HYD LINE, AND THEN TO HELP 2 ASSOCIATES WITH SOME CASE COOLING MOUNT BEARINGS THEY WERE HAVING TROUBLE REPLACING. AS TIME PRESSED ON, IT WAS NEAR TO PUSHOUT AND RUN THE ENGS FOR LEAK CHKS. IT WAS AT THIS POINT I BECAME RUSHED AND MISSED REACTIVATING THE THRUST REVERSER HYD CTL UNIT. I DID NOT REALIZE MY MISTAKE UNTIL I WAS ON MY WAY HOME AND THE ACFT WAS ALREADY AIRBORNE. AT ONCE I CALLED THE STATION MAINT CTLR AND EXPLAINED THE PROB. I WAS TOLD HE WOULD CONTACT THE LINE MAINT CTLR AND ALLOW THEM TO HANDLE NOTIFYING THE AIR CREW. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE LAST STEP ON THE JOB CARD WAS RESTORE THE ACFT TO NORMAL. THE RPTR SAID THE JOB CARD DID DIRECT THE TECHNICIAN TO INSTALL THE LOCKOUT PIN BUT DID NOT DIRECT THE TECHNICIAN TO REMOVE THE PIN. THE RPTR STATED THAT NO OPS CHK OF THE REVERSER WAS REQUIRED ON THE JOB CARD.
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.