37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 470987 |
Time | |
Date | 200004 |
Day | Fri |
Local Time Of Day | 0001 To 0600 |
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 | B757-200 |
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 : airframe technician : powerplant |
Experience | maintenance technician : 19 |
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 : published procedure |
Independent Detector | other other : person 1 |
Resolutory Action | other |
Factors | |
Maintenance | contributing factor : lighting performance deficiency : inspection performance deficiency : repair performance deficiency : testing performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
While performing troubleshooting and repair of an elevator feel problem, 2 circuit breakers were pulled to deactivate the ram air turbine. They were pulled because the alternate pitot system was pressurized. Deactivating the ram air turbine prevented inadvertent deployment. Work on the elevator feel system began at approximately XA00 on apr/xa/00. We didn't finish troubleshooting and repair until XH00. I was working with a partner and each of us took turns operating controls on the flight deck and adjusting sensors in the tail. When our work was completed, I failed to re-engage the ram air turbine circuit breakers. I did not put 'danger tags' on the affected breakers. I admit this shortcut is what prevented me from noticing when I finally left the flight deck. Without the tags, my partner also did not notice the pulled breakers. On our commute home, I remembered the breakers. I immediately called the day shift lead technician to report it and ask for assistance in getting the breakers reactivated.
Original NASA ASRS Text
Title: A B757-200 WAS RELEASED FOR SVC IN NON COMPLIANCE WITH THE RAM AIR TURBINE CIRCUIT BREAKERS OPENED FOR MAINT BUT NOT RESET AT JOB COMPLETION.
Narrative: WHILE PERFORMING TROUBLESHOOTING AND REPAIR OF AN ELEVATOR FEEL PROB, 2 CIRCUIT BREAKERS WERE PULLED TO DEACTIVATE THE RAM AIR TURBINE. THEY WERE PULLED BECAUSE THE ALTERNATE PITOT SYS WAS PRESSURIZED. DEACTIVATING THE RAM AIR TURBINE PREVENTED INADVERTENT DEPLOYMENT. WORK ON THE ELEVATOR FEEL SYS BEGAN AT APPROX XA00 ON APR/XA/00. WE DIDN'T FINISH TROUBLESHOOTING AND REPAIR UNTIL XH00. I WAS WORKING WITH A PARTNER AND EACH OF US TOOK TURNS OPERATING CTLS ON THE FLT DECK AND ADJUSTING SENSORS IN THE TAIL. WHEN OUR WORK WAS COMPLETED, I FAILED TO RE-ENGAGE THE RAM AIR TURBINE CIRCUIT BREAKERS. I DID NOT PUT 'DANGER TAGS' ON THE AFFECTED BREAKERS. I ADMIT THIS SHORTCUT IS WHAT PREVENTED ME FROM NOTICING WHEN I FINALLY LEFT THE FLT DECK. WITHOUT THE TAGS, MY PARTNER ALSO DID NOT NOTICE THE PULLED BREAKERS. ON OUR COMMUTE HOME, I REMEMBERED THE BREAKERS. I IMMEDIATELY CALLED THE DAY SHIFT LEAD TECHNICIAN TO RPT IT AND ASK FOR ASSISTANCE IN GETTING THE BREAKERS REACTIVATED.
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.