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|
Attributes | |
ACN | 475917 |
Time | |
Date | 200006 |
Day | Fri |
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 | |
Operator | common carrier : air carrier |
Make Model Name | DC-9 Undifferentiated or Other Model |
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 | 475917 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | 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 : cabin altitude indicator other other : person 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : inspection |
Supplementary | |
Problem Areas | Company Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I was working a ferry flight aircraft xyz, a B737-300 which was having an APU bus problem and a pack overheat problem at the time. A B737-400 was at the next gate getting loaded, then flight XXX (a DC9) returned to the gate next to that. I went back to first plane xyz (a B737-300), got it fixed and pushed it out. Went up on DC9 to check its problem which was cockpit to cabin call bell were inoperative and PA system was on MEL. I went in east&east to check PA. Amp tested and adjusted it. Went back upstairs. Everything was working fine. As I was signing off logbook my pushback partner informed me the B737-400 was ready to go. The captain of the DC9 said 'so are we.' since they were late coming in and going out, I decided we would push the DC9 first to try to help get them back on time, which we did. Then I went in to do paperwork. I looked out the window and saw a DC9 from our company landing. Then I heard flight XXX was back on the ground. They had a pressurization problem. When it got to the gate, I discovered and remembered that I left the east&east door open. Upon inspection, I found that the cannon plug was off on the door light switch. I resecured it and it operations checked good. Pilot wrote up forward cargo door light illuminated and said when it would not pressurize and door light lit he thought he lost cargo door. One factor that contributed to this is the fact that 1 person is stretched so thin when things are normal. It's not too bad, but when things get backed up and 1 mechanic is trying to fix a problem and another plane needs to be pushed, one can get distraction as to where he is on his problem.
Original NASA ASRS Text
Title: A DC9 WAS DISPATCHED AND RETURNED TO THE FIELD DUE TO INABILITY TO PRESSURIZE THE CABIN CAUSED BY THE E&E COMPARTMENT DOOR BEING LEFT OPEN.
Narrative: I WAS WORKING A FERRY FLT ACFT XYZ, A B737-300 WHICH WAS HAVING AN APU BUS PROB AND A PACK OVERHEAT PROB AT THE TIME. A B737-400 WAS AT THE NEXT GATE GETTING LOADED, THEN FLT XXX (A DC9) RETURNED TO THE GATE NEXT TO THAT. I WENT BACK TO FIRST PLANE XYZ (A B737-300), GOT IT FIXED AND PUSHED IT OUT. WENT UP ON DC9 TO CHK ITS PROB WHICH WAS COCKPIT TO CABIN CALL BELL WERE INOP AND PA SYS WAS ON MEL. I WENT IN E&E TO CHK PA. AMP TESTED AND ADJUSTED IT. WENT BACK UPSTAIRS. EVERYTHING WAS WORKING FINE. AS I WAS SIGNING OFF LOGBOOK MY PUSHBACK PARTNER INFORMED ME THE B737-400 WAS READY TO GO. THE CAPT OF THE DC9 SAID 'SO ARE WE.' SINCE THEY WERE LATE COMING IN AND GOING OUT, I DECIDED WE WOULD PUSH THE DC9 FIRST TO TRY TO HELP GET THEM BACK ON TIME, WHICH WE DID. THEN I WENT IN TO DO PAPERWORK. I LOOKED OUT THE WINDOW AND SAW A DC9 FROM OUR COMPANY LNDG. THEN I HEARD FLT XXX WAS BACK ON THE GND. THEY HAD A PRESSURIZATION PROB. WHEN IT GOT TO THE GATE, I DISCOVERED AND REMEMBERED THAT I LEFT THE E&E DOOR OPEN. UPON INSPECTION, I FOUND THAT THE CANNON PLUG WAS OFF ON THE DOOR LIGHT SWITCH. I RESECURED IT AND IT OPS CHKED GOOD. PLT WROTE UP FORWARD CARGO DOOR LIGHT ILLUMINATED AND SAID WHEN IT WOULD NOT PRESSURIZE AND DOOR LIGHT LIT HE THOUGHT HE LOST CARGO DOOR. ONE FACTOR THAT CONTRIBUTED TO THIS IS THE FACT THAT 1 PERSON IS STRETCHED SO THIN WHEN THINGS ARE NORMAL. IT'S NOT TOO BAD, BUT WHEN THINGS GET BACKED UP AND 1 MECH IS TRYING TO FIX A PROB AND ANOTHER PLANE NEEDS TO BE PUSHED, ONE CAN GET DISTR AS TO WHERE HE IS ON HIS 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.