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|
Attributes | |
ACN | 466490 |
Time | |
Date | 200003 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Dusk |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B777 Undifferentiated or Other Model |
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 : repairman technician : powerplant technician : airframe |
Experience | maintenance avionics : 15 maintenance repairman : 15 maintenance technician : 15 |
ASRS Report | 466490 |
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 other anomaly other |
Independent Detector | other other : 936 |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : testing performance deficiency : repair performance deficiency : installation |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I, abc zxzx on mar/wed/00, dispatched aircraft xyz. On pushback to taxiway the crew and passenger reported a grinding noise in mid-cabin area, rows 12-18. The pushback amt (aircraft maintenance technician) wxvv told the crew to return to the gate so we could investigate the noise. At the gate we spoke to the crew. Amt's wxvv, xwxw and myself. I went to the cockpit and talked with the crew and told them I suspected a loose cargo container to be the source of the noise. I then called the smc (station maintenance controller) to have ramp open the forward pit, and left the cockpit and all 3 of us met in the forward pit, we found the containers secured and then removed the aft air mix manifold cover to gain access to the recirculation fans. At this time I went outside and thought we might have a pack problem, or something loose in the left air conditioning bay. As I started to unlatch the left air conditioning door forward and aft latches I got called to go and shut the APU bleed off, because amt's wxvv and xwxw heard a noise coming from the air mix manifold. As I left to go to the cockpit with the air conditioning bay door halfway unlatched to shut the bleeds off, I returned to the forward pit to see what they found. They found a 2 inch by 2 ft long bracket that was in the mix manifold. At this time we didn't know what we had, so I went to the ipc (illustrated parts catalog) to find out and we called the engineers for assistance. They called the line maintenance controller and had us defer the bracket which is a screen stiffener, to be replaced at denver. So we closed up and dispatched the aircraft. I didn't realize that I did not relatch the air conditioning door panel until the crew called and said they heard an explosion and returned to ZZZ.
Original NASA ASRS Text
Title: A B777 WAS DISPATCHED IN NON COMPLIANCE WITH THE L AIR CONDITIONING PACK DOOR UNLATCHED WHICH DEPARTED THE ACFT REQUIRING A RETURN TO THE FIELD.
Narrative: I, ABC ZXZX ON MAR/WED/00, DISPATCHED ACFT XYZ. ON PUSHBACK TO TXWY THE CREW AND PAX RPTED A GRINDING NOISE IN MID-CABIN AREA, ROWS 12-18. THE PUSHBACK AMT (ACFT MAINT TECHNICIAN) WXVV TOLD THE CREW TO RETURN TO THE GATE SO WE COULD INVESTIGATE THE NOISE. AT THE GATE WE SPOKE TO THE CREW. AMT'S WXVV, XWXW AND MYSELF. I WENT TO THE COCKPIT AND TALKED WITH THE CREW AND TOLD THEM I SUSPECTED A LOOSE CARGO CONTAINER TO BE THE SOURCE OF THE NOISE. I THEN CALLED THE SMC (STATION MAINT CTLR) TO HAVE RAMP OPEN THE FORWARD PIT, AND LEFT THE COCKPIT AND ALL 3 OF US MET IN THE FORWARD PIT, WE FOUND THE CONTAINERS SECURED AND THEN REMOVED THE AFT AIR MIX MANIFOLD COVER TO GAIN ACCESS TO THE RECIRCULATION FANS. AT THIS TIME I WENT OUTSIDE AND THOUGHT WE MIGHT HAVE A PACK PROB, OR SOMETHING LOOSE IN THE L AIR CONDITIONING BAY. AS I STARTED TO UNLATCH THE L AIR CONDITIONING DOOR FORWARD AND AFT LATCHES I GOT CALLED TO GO AND SHUT THE APU BLEED OFF, BECAUSE AMT'S WXVV AND XWXW HEARD A NOISE COMING FROM THE AIR MIX MANIFOLD. AS I LEFT TO GO TO THE COCKPIT WITH THE AIR CONDITIONING BAY DOOR HALFWAY UNLATCHED TO SHUT THE BLEEDS OFF, I RETURNED TO THE FORWARD PIT TO SEE WHAT THEY FOUND. THEY FOUND A 2 INCH BY 2 FT LONG BRACKET THAT WAS IN THE MIX MANIFOLD. AT THIS TIME WE DIDN'T KNOW WHAT WE HAD, SO I WENT TO THE IPC (ILLUSTRATED PARTS CATALOG) TO FIND OUT AND WE CALLED THE ENGINEERS FOR ASSISTANCE. THEY CALLED THE LINE MAINT CTLR AND HAD US DEFER THE BRACKET WHICH IS A SCREEN STIFFENER, TO BE REPLACED AT DENVER. SO WE CLOSED UP AND DISPATCHED THE ACFT. I DIDN'T REALIZE THAT I DID NOT RELATCH THE AIR CONDITIONING DOOR PANEL UNTIL THE CREW CALLED AND SAID THEY HEARD AN EXPLOSION AND RETURNED TO ZZZ.
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.