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|
Attributes | |
ACN | 491535 |
Time | |
Date | 200011 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
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 | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 1 maintenance technician : 17 |
ASRS Report | 491535 |
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 |
Independent Detector | aircraft equipment other aircraft equipment : left eng pressure ratio other other : person 5 |
Resolutory Action | flight crew : diverted to another airport |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : work cards performance deficiency : training performance deficiency : inspection performance deficiency : scheduled maintenance performance deficiency : testing |
Supplementary | |
Problem Areas | Maintenance Human Performance Company Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Enclosed please find a copy of the statement I provided to the company concerning the diversion of an aircraft due to the trim stop not being lock-wired. The aircraft flew from ZZZ to abc. Upon leaving abc the aircraft could not achieve full power -- a derated takeoff was used at abc. It was determined by the flight crew to take off and they diverted to XXX. The mechanics in XXX discovered that the trim stop was not lock-wired. On the night of nov/wed/00 to nov/thu/00, ZZZ maintenance (us), we were assigned 20 work release items. This is an extraordinary amount of work for a station that is short staffed. That night we only had 2 leads and 3 mechanics on duty. We called the overtime list and only got 1 mechanic. This gave us a total compliment of 2 leads and 6 mechanics. The workload also consisted of 10 inbound pilot items and 1 tire change. I assigned aircraft xyz. I knew he was run-up and taxi qualified. I did it and he knows the airport, so when I finished my aircraft, I went to do the trim run on aircraft xyz. I was trying to help the 2 mechanics from xjx, 'hook' up the trim box and PT7 gauge set to #1 engine on aircraft xyz. We had some trouble with the adapters for the PT7 test box, but we finally figured that out, and got the aircraft ready for taxi out to the run-up block. (Name withheld) taxied the aircraft while I rode right seat. We got to the run-up block, did our trim, made all necessary adjustments to the engine, and came back to the gate. When they were removing the test equipment off the engine, it was discovered that some of the fittings we used to rig the PT7 test box up with were loose. So I told the mechanics to secure the fittings and we would go back to the run-up block and do a re-trim. The next trip to the run-up block, I taxied the aircraft. (Name withheld) sat in the right seat. Once again, all necessary adjustments were made and we returned to the gate. Upon returning to the gate, (name) set out to close up the engine. (Names) had to return while (name) was closing up. This took me away from aircraft xyz until (name) and I closed the cowling. Due to the number of tasks that I performed that night, I believed that the trim stop had been safetied.
Original NASA ASRS Text
Title: A B737-200 WAS DISPATCHED IN NON COMPLIANCE WITH THE TRIM ADJUSTMENT SCREW ON #1 ENG FUEL CTL NOT LOCKED RESULTING IN A DIVERSION.
Narrative: ENCLOSED PLEASE FIND A COPY OF THE STATEMENT I PROVIDED TO THE COMPANY CONCERNING THE DIVERSION OF AN ACFT DUE TO THE TRIM STOP NOT BEING LOCK-WIRED. THE ACFT FLEW FROM ZZZ TO ABC. UPON LEAVING ABC THE ACFT COULD NOT ACHIEVE FULL PWR -- A DERATED TKOF WAS USED AT ABC. IT WAS DETERMINED BY THE FLC TO TAKE OFF AND THEY DIVERTED TO XXX. THE MECHS IN XXX DISCOVERED THAT THE TRIM STOP WAS NOT LOCK-WIRED. ON THE NIGHT OF NOV/WED/00 TO NOV/THU/00, ZZZ MAINT (US), WE WERE ASSIGNED 20 WORK RELEASE ITEMS. THIS IS AN EXTRAORDINARY AMOUNT OF WORK FOR A STATION THAT IS SHORT STAFFED. THAT NIGHT WE ONLY HAD 2 LEADS AND 3 MECHS ON DUTY. WE CALLED THE OVERTIME LIST AND ONLY GOT 1 MECH. THIS GAVE US A TOTAL COMPLIMENT OF 2 LEADS AND 6 MECHS. THE WORKLOAD ALSO CONSISTED OF 10 INBOUND PLT ITEMS AND 1 TIRE CHANGE. I ASSIGNED ACFT XYZ. I KNEW HE WAS RUN-UP AND TAXI QUALIFIED. I DID IT AND HE KNOWS THE ARPT, SO WHEN I FINISHED MY ACFT, I WENT TO DO THE TRIM RUN ON ACFT XYZ. I WAS TRYING TO HELP THE 2 MECHS FROM XJX, 'HOOK' UP THE TRIM BOX AND PT7 GAUGE SET TO #1 ENG ON ACFT XYZ. WE HAD SOME TROUBLE WITH THE ADAPTERS FOR THE PT7 TEST BOX, BUT WE FINALLY FIGURED THAT OUT, AND GOT THE ACFT READY FOR TAXI OUT TO THE RUN-UP BLOCK. (NAME WITHHELD) TAXIED THE ACFT WHILE I RODE R SEAT. WE GOT TO THE RUN-UP BLOCK, DID OUR TRIM, MADE ALL NECESSARY ADJUSTMENTS TO THE ENG, AND CAME BACK TO THE GATE. WHEN THEY WERE REMOVING THE TEST EQUIP OFF THE ENG, IT WAS DISCOVERED THAT SOME OF THE FITTINGS WE USED TO RIG THE PT7 TEST BOX UP WITH WERE LOOSE. SO I TOLD THE MECHS TO SECURE THE FITTINGS AND WE WOULD GO BACK TO THE RUN-UP BLOCK AND DO A RE-TRIM. THE NEXT TRIP TO THE RUN-UP BLOCK, I TAXIED THE ACFT. (NAME WITHHELD) SAT IN THE R SEAT. ONCE AGAIN, ALL NECESSARY ADJUSTMENTS WERE MADE AND WE RETURNED TO THE GATE. UPON RETURNING TO THE GATE, (NAME) SET OUT TO CLOSE UP THE ENG. (NAMES) HAD TO RETURN WHILE (NAME) WAS CLOSING UP. THIS TOOK ME AWAY FROM ACFT XYZ UNTIL (NAME) AND I CLOSED THE COWLING. DUE TO THE NUMBER OF TASKS THAT I PERFORMED THAT NIGHT, I BELIEVED THAT THE TRIM STOP HAD BEEN SAFETIED.
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.