37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 474713 |
Time | |
Date | 200006 |
Day | Sun |
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 2 | |
Operator | common carrier : air carrier |
Make Model Name | L-1011 Tri-Star All Series |
Operating Under FAR Part | Part 91 |
Flight Phase | ground : maintenance ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : fcc technician : airframe |
Experience | maintenance lead technician : 20 maintenance technician : 30 |
ASRS Report | 474713 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 5 |
ASRS Report | 474714 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : non compliance with mel non adherence : published procedure |
Independent Detector | other other : person 2 |
Resolutory Action | none taken : anomaly accepted |
Consequence | other other |
Factors | |
Maintenance | contributing factor : engineering procedure contributing factor : manuals contributing factor : non availability of parts performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Company Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Air carrier's aircraft xyz APU was deactivated per MEL. While troubleshooting another problem at departure time, aircraft on delay we were going to reactivate the APU when a circuit breaker cap popped off. I sought to have the wire removed from the back of the circuit breaker, insulated the terminal and secure it. The circuit was completely deactivated and safe for flight. However, this procedure could not be located in our manuals. This same procedure has been previously been used and I believed it to be covered in standard practices of the L1011 maintenance manual or our company's auths. This was reported to wxx vxv in maintenance at about the time of departure with no objection noted. The item was updated in text and a new circuit breaker was ordered for XXX. The circuit breaker was changed at the termination of ferry flight abc on jun/sun/00. I believe the above could be prevented if there had been less pressure to move the aircraft. I was told there was no spare aircraft. Had auths been available at the station or maintenance or someone flagged us as this practice is no longer covered, I would not have considered it. I have suggested to ZZZ maintenance manager to have air carrier's engineering department write relief into our manual, maintenance manuals or have auths available to the people working on the aircraft. Note: this was a ferry flight with cockpit crew only. No problems resulted from the aforementioned procedure. The affected part was replaced in XXX at the termination of this flight.
Original NASA ASRS Text
Title: AN L1011-500 WAS DISPATCHED IN ERROR WITH A FAILED CIRCUIT BREAKER INCORRECTLY DEACTIVATED.
Narrative: ACR'S ACFT XYZ APU WAS DEACTIVATED PER MEL. WHILE TROUBLESHOOTING ANOTHER PROB AT DEP TIME, ACFT ON DELAY WE WERE GOING TO REACTIVATE THE APU WHEN A CIRCUIT BREAKER CAP POPPED OFF. I SOUGHT TO HAVE THE WIRE REMOVED FROM THE BACK OF THE CIRCUIT BREAKER, INSULATED THE TERMINAL AND SECURE IT. THE CIRCUIT WAS COMPLETELY DEACTIVATED AND SAFE FOR FLT. HOWEVER, THIS PROC COULD NOT BE LOCATED IN OUR MANUALS. THIS SAME PROC HAS BEEN PREVIOUSLY BEEN USED AND I BELIEVED IT TO BE COVERED IN STANDARD PRACTICES OF THE L1011 MAINT MANUAL OR OUR COMPANY'S AUTHS. THIS WAS RPTED TO WXX VXV IN MAINT AT ABOUT THE TIME OF DEP WITH NO OBJECTION NOTED. THE ITEM WAS UPDATED IN TEXT AND A NEW CIRCUIT BREAKER WAS ORDERED FOR XXX. THE CIRCUIT BREAKER WAS CHANGED AT THE TERMINATION OF FERRY FLT ABC ON JUN/SUN/00. I BELIEVE THE ABOVE COULD BE PREVENTED IF THERE HAD BEEN LESS PRESSURE TO MOVE THE ACFT. I WAS TOLD THERE WAS NO SPARE ACFT. HAD AUTHS BEEN AVAILABLE AT THE STATION OR MAINT OR SOMEONE FLAGGED US AS THIS PRACTICE IS NO LONGER COVERED, I WOULD NOT HAVE CONSIDERED IT. I HAVE SUGGESTED TO ZZZ MAINT MGR TO HAVE ACR'S ENGINEERING DEPT WRITE RELIEF INTO OUR MANUAL, MAINT MANUALS OR HAVE AUTHS AVAILABLE TO THE PEOPLE WORKING ON THE ACFT. NOTE: THIS WAS A FERRY FLT WITH COCKPIT CREW ONLY. NO PROBS RESULTED FROM THE AFOREMENTIONED PROC. THE AFFECTED PART WAS REPLACED IN XXX AT THE TERMINATION OF THIS FLT.
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.