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|
Attributes | |
ACN | 448642 |
Time | |
Date | 199909 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Fokker 100 |
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 : 12 |
ASRS Report | 448642 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 1 maintenance technician : 21 |
ASRS Report | 448378 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : non compliance with mel non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : landing gear |
Resolutory Action | flight crew : landed as precaution |
Consequence | other other |
Factors | |
Maintenance | contributing factor : engineering procedure contributing factor : schedule pressure performance deficiency : inspection performance deficiency : repair |
Supplementary | |
Problem Areas | Aircraft Company Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
The aircraft had 3 'open items' to address. This one was a crack in the right main landing gear door. It was removed per an engineering authority/authorized confign deviation list (cdl) and called for the door sequence valve to be secured in the 'door open' position. The engineering authority/authorized did not include a picture or description of how to accomplish this. There was no maintenance manual reference, and the maintenance manual has nothing describing how to accomplish this procedure (that could be found). Without documentation showing how to secure the valve with the door off, I was left to interpret the situation best I could. The usual pressure to return an aircraft to service and, at the beginning of the shift a maintenance manager made a speech (to only 1 of 7 crews at work on the 'line') indicating 'a serious increase in production was forthcoming or corrective action by management would be taken.' (my words) there was also specific verbal pressure to get this aircraft ready as soon as possible (reiterated because we moved up the estimated time of repair), even though there were 12 more aircraft in various states of repair. I'm not implying these factors were responsible for my decision to secure the valve in the 'door up' position instead of 'door open.' but human factors being what they are, one isn't always cognizant of all the influences in making some decisions.
Original NASA ASRS Text
Title: A FOKKER 100 RETURNED TO THE FIELD IMMEDIATELY AFTER TKOF DUE TO UNABLE TO RETRACT THE LNDG GEAR CAUSED BY IMPROPER LNDG GEAR DOOR REMOVAL PROCS.
Narrative: THE ACFT HAD 3 'OPEN ITEMS' TO ADDRESS. THIS ONE WAS A CRACK IN THE R MAIN LNDG GEAR DOOR. IT WAS REMOVED PER AN ENGINEERING AUTH CONFIGN DEV LIST (CDL) AND CALLED FOR THE DOOR SEQUENCE VALVE TO BE SECURED IN THE 'DOOR OPEN' POS. THE ENGINEERING AUTH DID NOT INCLUDE A PICTURE OR DESCRIPTION OF HOW TO ACCOMPLISH THIS. THERE WAS NO MAINT MANUAL REF, AND THE MAINT MANUAL HAS NOTHING DESCRIBING HOW TO ACCOMPLISH THIS PROC (THAT COULD BE FOUND). WITHOUT DOCUMENTATION SHOWING HOW TO SECURE THE VALVE WITH THE DOOR OFF, I WAS LEFT TO INTERPRET THE SIT BEST I COULD. THE USUAL PRESSURE TO RETURN AN ACFT TO SVC AND, AT THE BEGINNING OF THE SHIFT A MAINT MGR MADE A SPEECH (TO ONLY 1 OF 7 CREWS AT WORK ON THE 'LINE') INDICATING 'A SERIOUS INCREASE IN PRODUCTION WAS FORTHCOMING OR CORRECTIVE ACTION BY MGMNT WOULD BE TAKEN.' (MY WORDS) THERE WAS ALSO SPECIFIC VERBAL PRESSURE TO GET THIS ACFT READY ASAP (REITERATED BECAUSE WE MOVED UP THE ESTIMATED TIME OF REPAIR), EVEN THOUGH THERE WERE 12 MORE ACFT IN VARIOUS STATES OF REPAIR. I'M NOT IMPLYING THESE FACTORS WERE RESPONSIBLE FOR MY DECISION TO SECURE THE VALVE IN THE 'DOOR UP' POS INSTEAD OF 'DOOR OPEN.' BUT HUMAN FACTORS BEING WHAT THEY ARE, ONE ISN'T ALWAYS COGNIZANT OF ALL THE INFLUENCES IN MAKING SOME DECISIONS.
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.