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A DC9-30 was dispatched in non compliance with the emergency tailcone jettison system rendered inoperative.
| Attributes | |
| ACN | 477974 |
| Time | |
| Date | 200007 |
| Day | Wed |
| 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 | DC-9 30 |
| 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 : powerplant technician : airframe |
| Experience | maintenance technician : 20 |
| ASRS Report | 477974 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | oversight : supervisor |
| Qualification | technician : airframe technician : powerplant |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far non adherence : company policies |
| Independent Detector | other other : person 2 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : lighting performance deficiency : scheduled maintenance performance deficiency : inspection performance deficiency : testing |
| Supplementary | |
| Problem Areas | Company Maintenance Human Performance Chart Or Publication Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
Ad xx-22-44 allegedly complied with during 'C' check 6/mon/00. I inspected this general area 6/wed/00, but did not notice the safety wire on two tailcone release latches (evidently used in lieu of clamps specified as safety devices during modification process). Use of safety wire for this purpose is hazardous and evidently the post 'C' check tailcone drop test was not performed, as was alleged. Callback conversation with reporter revealed the following information: the reporter stated the air carrier contracts out the aircraft 'C' checks to a contract modification base who also does the airworthiness directives. The reporter said the tailcone airworthiness directive installs a third tailcone release handle just outside the aft bulkhead door on the right. The reporter stated this allows the person deploying the aft stair and tailcone to avoid walking on the catwalk. The reporter said the airplane was released to the carrier with all the tailcone airworthiness directive paperwork complete including a drop test of the tailcone. The reporter said because of sloppy workmanship and poor inspection on the part of the contract modification base the carrier inspects the released aircraft. The reporter stated during the inspection he missed the safety wiring on the tailcone latches which prevented deployment of the tailcone. The reporter said the wiring was later discovered and it brought into question the completed airworthiness directive paperwork and the drop test which could not have been accomplished with the latches wired.
Original NASA ASRS Text
Title: A DC9-30 WAS DISPATCHED IN NON COMPLIANCE WITH THE EMERGENCY TAILCONE JETTISON SYSTEM RENDERED INOPERATIVE.
Narrative: AD XX-22-44 ALLEGEDLY COMPLIED WITH DURING 'C' CHECK 6/MON/00. I INSPECTED THIS GENERAL AREA 6/WED/00, BUT DID NOT NOTICE THE SAFETY WIRE ON TWO TAILCONE RELEASE LATCHES (EVIDENTLY USED IN LIEU OF CLAMPS SPECIFIED AS SAFETY DEVICES DURING MODIFICATION PROCESS). USE OF SAFETY WIRE FOR THIS PURPOSE IS HAZARDOUS AND EVIDENTLY THE POST 'C' CHECK TAILCONE DROP TEST WAS NOT PERFORMED, AS WAS ALLEGED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE AIR CARRIER CONTRACTS OUT THE ACFT 'C' CHECKS TO A CONTRACT MODIFICATION BASE WHO ALSO DOES THE AIRWORTHINESS DIRECTIVES. THE REPORTER SAID THE TAILCONE AIRWORTHINESS DIRECTIVE INSTALLS A THIRD TAILCONE RELEASE HANDLE JUST OUTSIDE THE AFT BULKHEAD DOOR ON THE RIGHT. THE REPORTER STATED THIS ALLOWS THE PERSON DEPLOYING THE AFT STAIR AND TAILCONE TO AVOID WALKING ON THE CATWALK. THE REPORTER SAID THE AIRPLANE WAS RELEASED TO THE CARRIER WITH ALL THE TAILCONE AIRWORTHINESS DIRECTIVE PAPERWORK COMPLETE INCLUDING A DROP TEST OF THE TAILCONE. THE REPORTER SAID BECAUSE OF SLOPPY WORKMANSHIP AND POOR INSPECTION ON THE PART OF THE CONTRACT MODIFICATION BASE THE CARRIER INSPECTS THE RELEASED ACFT. THE REPORTER STATED DURING THE INSPECTION HE MISSED THE SAFETY WIRING ON THE TAILCONE LATCHES WHICH PREVENTED DEPLOYMENT OF THE TAILCONE. THE REPORTER SAID THE WIRING WAS LATER DISCOVERED AND IT BROUGHT INTO QUESTION THE COMPLETED AIRWORTHINESS DIRECTIVE PAPERWORK AND THE DROP TEST WHICH COULD NOT HAVE BEEN ACCOMPLISHED WITH THE LATCHES WIRED.
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.