37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 461234 |
Time | |
Date | 200001 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : dfw.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-500 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 14 |
ASRS Report | 461234 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Qualification | technician : inspection authority technician : powerplant technician : airframe |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | aircraft equipment other aircraft equipment : trim indication |
Resolutory Action | flight crew : overcame equipment problem none taken : unable |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals performance deficiency : repair performance deficiency : inspection performance deficiency : installation |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Maintenance Manual |
Narrative:
On jan/wed/00, I was assigned the task of installing a B737 r-hand medium large transport uplock mechanism. I installed the uplock per maintenance manual 32-32-31/401. Maintenance manual 32-32-31/401 paragraph C subparagraph north tells me to reconnect any hydraulic lines that were disconnected. I inadvertently overlooked the step that tells you to reconnect the line and the aircraft was released with a plug in the ground spoiler interlock valve hydraulic line. The aircraft flew on jan/tue/00 and the attached in-flight write-up was reported. I was notified by my foreman on jan/wed/00 that I was involved with this incident, and I then realized that I had missed reconnecting the line, which resulted in this report. This incident could have been prevented if the maintenance manual had stated that a leak check and a directional control check of the flight controls was required after disconnecting a hydraulic line. Callback conversation with reporter revealed the following information: the reporter stated the maintenance manual just stated to reconnect any lines disconnected during the uplock replacement. The reporter said since the manual is for a B737-300 and 500 it should state exactly what lines are to be disconnected and the system tests required.
Original NASA ASRS Text
Title: A B737-500 WAS DISPATCHED IN NON COMPLIANCE WITH THE GND SPOILERS NOT HYDRAULICALLY CONNECTED RESULTING IN EXCESSIVE TRIM REQUIRED FOR FLT.
Narrative: ON JAN/WED/00, I WAS ASSIGNED THE TASK OF INSTALLING A B737 R-HAND MLG UPLOCK MECHANISM. I INSTALLED THE UPLOCK PER MAINT MANUAL 32-32-31/401. MAINT MANUAL 32-32-31/401 PARAGRAPH C SUBPARAGRAPH N TELLS ME TO RECONNECT ANY HYD LINES THAT WERE DISCONNECTED. I INADVERTENTLY OVERLOOKED THE STEP THAT TELLS YOU TO RECONNECT THE LINE AND THE ACFT WAS RELEASED WITH A PLUG IN THE GND SPOILER INTERLOCK VALVE HYD LINE. THE ACFT FLEW ON JAN/TUE/00 AND THE ATTACHED INFLT WRITE-UP WAS RPTED. I WAS NOTIFIED BY MY FOREMAN ON JAN/WED/00 THAT I WAS INVOLVED WITH THIS INCIDENT, AND I THEN REALIZED THAT I HAD MISSED RECONNECTING THE LINE, WHICH RESULTED IN THIS RPT. THIS INCIDENT COULD HAVE BEEN PREVENTED IF THE MAINT MANUAL HAD STATED THAT A LEAK CHK AND A DIRECTIONAL CTL CHK OF THE FLT CTLS WAS REQUIRED AFTER DISCONNECTING A HYD LINE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE MAINT MANUAL JUST STATED TO RECONNECT ANY LINES DISCONNECTED DURING THE UPLOCK REPLACEMENT. THE RPTR SAID SINCE THE MANUAL IS FOR A B737-300 AND 500 IT SHOULD STATE EXACTLY WHAT LINES ARE TO BE DISCONNECTED AND THE SYS TESTS REQUIRED.
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.