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|
Attributes | |
ACN | 459048 |
Time | |
Date | 199912 |
Day | Tue |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Dawn |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument pilot : multi engine |
ASRS Report | 459048 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : work cards performance deficiency : non compliance with legal requirements performance deficiency : repair |
Supplementary | |
Problem Areas | Maintenance Human Performance Flight Crew Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Early morning out of ZZZ. Arrived at aircraft for preflight. Went outside to do safety inspection. Saw mechanics working under right wing. Said they were replacing hydraulic valve. Told me not to turn on any hydraulic pumps. I went back in the aircraft to do origination preflight. There was no safety placard displayed in the cockpit warning of usage of hydraulic pumps, system, etc, as is usually displayed. I found the maintenance safety placards and turned to the one warning against turning on any hydraulic pumps and placed it on the forward pedestal. The aircraft was stuffy and warm in the cockpit and cabin. External power was connected but no air was hooked up. Flight attendant asked for some air. I started the APU and turned on the packs, knowing that the hydraulic reservoirs would be pressurized, but I did not think this would put any pressure out in the lines. I was wrong. Very soon thereafter, I noticed that the status page on the EICAS showed that the right reservoir was at zero (prior to starting the APU) and turning on the packs it reached .60. About the same time, one of the mechanics came in and said to turn off the APU, as I had pressurized the reservoir and we had lost the fluid that was in the right system. I shut down the APU and asked why he did not tell me not to start the APU. He said they just forgot to tell me. I asked if anyone was hurt. He said no. I then prepared another placard to display warning not to start the APU in case the captain came in while I was out for walkaround. Outside, I again apologized and ensured no one was hurt. Everything was ok. This failure to communicate could have caused a real problem.
Original NASA ASRS Text
Title: A B767 DURING REPLACEMENT OF A HYD COMPONENT HAD THE R RESERVOIR DEPLETED WHEN THE APU WAS OPERATED. CAUSED BY FAILURE TO PLACARD HYD AND PNEUMATIC CTLS.
Narrative: EARLY MORNING OUT OF ZZZ. ARRIVED AT ACFT FOR PREFLT. WENT OUTSIDE TO DO SAFETY INSPECTION. SAW MECHS WORKING UNDER R WING. SAID THEY WERE REPLACING HYD VALVE. TOLD ME NOT TO TURN ON ANY HYD PUMPS. I WENT BACK IN THE ACFT TO DO ORIGINATION PREFLT. THERE WAS NO SAFETY PLACARD DISPLAYED IN THE COCKPIT WARNING OF USAGE OF HYD PUMPS, SYS, ETC, AS IS USUALLY DISPLAYED. I FOUND THE MAINT SAFETY PLACARDS AND TURNED TO THE ONE WARNING AGAINST TURNING ON ANY HYD PUMPS AND PLACED IT ON THE FORWARD PEDESTAL. THE ACFT WAS STUFFY AND WARM IN THE COCKPIT AND CABIN. EXTERNAL PWR WAS CONNECTED BUT NO AIR WAS HOOKED UP. FLT ATTENDANT ASKED FOR SOME AIR. I STARTED THE APU AND TURNED ON THE PACKS, KNOWING THAT THE HYD RESERVOIRS WOULD BE PRESSURIZED, BUT I DID NOT THINK THIS WOULD PUT ANY PRESSURE OUT IN THE LINES. I WAS WRONG. VERY SOON THEREAFTER, I NOTICED THAT THE STATUS PAGE ON THE EICAS SHOWED THAT THE R RESERVOIR WAS AT ZERO (PRIOR TO STARTING THE APU) AND TURNING ON THE PACKS IT REACHED .60. ABOUT THE SAME TIME, ONE OF THE MECHS CAME IN AND SAID TO TURN OFF THE APU, AS I HAD PRESSURIZED THE RESERVOIR AND WE HAD LOST THE FLUID THAT WAS IN THE R SYS. I SHUT DOWN THE APU AND ASKED WHY HE DID NOT TELL ME NOT TO START THE APU. HE SAID THEY JUST FORGOT TO TELL ME. I ASKED IF ANYONE WAS HURT. HE SAID NO. I THEN PREPARED ANOTHER PLACARD TO DISPLAY WARNING NOT TO START THE APU IN CASE THE CAPT CAME IN WHILE I WAS OUT FOR WALKAROUND. OUTSIDE, I AGAIN APOLOGIZED AND ENSURED NO ONE WAS HURT. EVERYTHING WAS OK. THIS FAILURE TO COMMUNICATE COULD HAVE CAUSED A REAL PROB.
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.