37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 455801 |
Time | |
Date | 199911 |
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 | DC-10 10 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 34 |
ASRS Report | 455801 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : cabin pressure indication |
Resolutory Action | flight crew : overcame equipment problem |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : fault isolation performance deficiency : testing performance deficiency : logbook entry performance deficiency : inspection |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Air carrier aircraft xyz departed ZZZ with the center accessory compartment door left open by mistake. After the departure call back by the crew, the captain elected to continue on to abc at a reduced flight altitude due to aircraft pressurization problems associated with the door. 1) the center accessory door being unnoticed as 'open' by the crew was traced to a broken ground terminal on the door warning switch. 2) the inability to contact the airplane to request a return to gate by VHF radio by the ramp operations folks is a matter being addressed by management as this is written. 3) this airplane, and its other air carrier sister ships, has been in service only a very short time period and the 'weird' items are appearing and disappearing across the entire maintenance system with these airplanes. The continuing and seemingly interrelated maintenance problems with airplane xyz has been brought to maintenance management's attention. A brief maintenance review shows stabilizer trim warning, cac door warning, cargo door control power, crew oxygen indication, lavatory flush motor control, and CSD indication problems appear interrelated and are directly affected by service bulletin sb xxw correct compliance (or) B1-339 rccb intermittent operation. A maintenance planning meeting has been pending on this airplane to 'verify' service bulletin compliance since nov/xa/99. The concept of a door left open for flight is abhorrent, but the system to guard against this possibility was not working.
Original NASA ASRS Text
Title: A DC10-10 IMMEDIATELY AFTER TKOF RPTED BEING UNABLE TO PRESSURIZE THE CABIN CAUSED BY A CTR ACCESSORY COMPARTMENT DOOR OPEN. FLT CONTINUED AT LOW ALT.
Narrative: ACR ACFT XYZ DEPARTED ZZZ WITH THE CTR ACCESSORY COMPARTMENT DOOR LEFT OPEN BY MISTAKE. AFTER THE DEP CALL BACK BY THE CREW, THE CAPT ELECTED TO CONTINUE ON TO ABC AT A REDUCED FLT ALT DUE TO ACFT PRESSURIZATION PROBS ASSOCIATED WITH THE DOOR. 1) THE CTR ACCESSORY DOOR BEING UNNOTICED AS 'OPEN' BY THE CREW WAS TRACED TO A BROKEN GND TERMINAL ON THE DOOR WARNING SWITCH. 2) THE INABILITY TO CONTACT THE AIRPLANE TO REQUEST A RETURN TO GATE BY VHF RADIO BY THE RAMP OPS FOLKS IS A MATTER BEING ADDRESSED BY MGMNT AS THIS IS WRITTEN. 3) THIS AIRPLANE, AND ITS OTHER ACR SISTER SHIPS, HAS BEEN IN SVC ONLY A VERY SHORT TIME PERIOD AND THE 'WEIRD' ITEMS ARE APPEARING AND DISAPPEARING ACROSS THE ENTIRE MAINT SYS WITH THESE AIRPLANES. THE CONTINUING AND SEEMINGLY INTERRELATED MAINT PROBS WITH AIRPLANE XYZ HAS BEEN BROUGHT TO MAINT MGMNT'S ATTN. A BRIEF MAINT REVIEW SHOWS STABILIZER TRIM WARNING, CAC DOOR WARNING, CARGO DOOR CTL PWR, CREW OXYGEN INDICATION, LAVATORY FLUSH MOTOR CTL, AND CSD INDICATION PROBS APPEAR INTERRELATED AND ARE DIRECTLY AFFECTED BY SVC BULLETIN SB XXW CORRECT COMPLIANCE (OR) B1-339 RCCB INTERMITTENT OP. A MAINT PLANNING MEETING HAS BEEN PENDING ON THIS AIRPLANE TO 'VERIFY' SVC BULLETIN COMPLIANCE SINCE NOV/XA/99. THE CONCEPT OF A DOOR LEFT OPEN FOR FLT IS ABHORRENT, BUT THE SYS TO GUARD AGAINST THIS POSSIBILITY WAS NOT WORKING.
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.