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Attributes | |
ACN | 500289 |
Time | |
Date | 200102 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | ground : takeoff roll |
Route In Use | departure : other published ifr departure |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 18 |
ASRS Report | 500289 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 150 flight time total : 10555 flight time type : 2528 |
ASRS Report | 500304 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | flight crew : rejected takeoff |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : fault isolation performance deficiency : installation performance deficiency : logbook entry performance deficiency : testing |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
Was given an aircraft to work (xyz) along with 3 other mechanics. On the job card there were 3 items to complete. 1) a thru service 'a' check. 2) a borrowed escape slide needed to be replaced. 3) emergency exit window shade was inoperative. Upon checking aircraft log book there was 1 pilot item. Which was 'windshield wipers inoperative.' 2 men chose to work the 'a' check. I was working the other 2 job cards. I chose to work the pilot item. After trouble shooting I came to the conclusion that the wiper switch S-22 was at fault. I looked up the part in the ipc and then picked it up from stock. During the replacement of the switch. One of the other mechanics asked to borrow my screw driver for the job he was doing. After I finished installing the switch I performed an operational test of the wipers. Prior to the test I pushed the access panel up onto the safety latch. The wipers checked good. I then re-dropped the access panel to make sure the wires were not chaffing. I then put the access panel back on to the safety latch. I was going to put the cam locks (2) in to complete the job. When I realized that I did not have my screw driver as I had loaned it to the other mechanic. So I went to the back of the aircraft to get it. That mechanic and another were working on the emergency exit window shade. They needed some help holding the panel and getting the dust seal installed. This action probably took 20 min. After we finished getting the shade installed. We were informed that our aircraft had to be moved from gate xy to the ramp parking area. So I went down hooked up the tow bar and tractor with some help. We then moved the aircraft. I drove the tug and another mechanic rode the brakes. Then we went in and completed our log book sign-offs. After going home later in the day I received phone call informing me that the access panel was not secured properly and that it almost caused an accident when it came off the safety latch and fell down as the crew was getting ready for takeoff. When I was told this I immediately knew what I had forgotten. Supplemental information from acn 500304: on takeoff roll at about 90 KTS, the overhead instrument panel fell striking both pilots. We rejected the takeoff and returned to the gate for maintenance. Callback conversation with reporter revealed the following information: the reporter stated on takeoff roll at 80 knots the cockpit forward overhead panel P-5 dropped down and swung forward to just above and aft of the thrust levers. The reporter said when the panel dropped it struck both crew members on the shoulders injuring the first officer. The reporter said with the panel hanging down between the crew they lost sight of each other. The reporter stated had one or both of the crew been leaning toward the pedestal scanning the engine instruments the injuries would have most likely disabled the crew. The reporter said the primary panel cam locks witness marks to indicate locked panel were missing.
Original NASA ASRS Text
Title: A B737-300 REJECTED TKOF AT 80 KNOTS DUE TO FORWARD OVERHEAD PANEL P-5 DROPPED OPEN AND SWUNG FORWARD STRIKING THE FLC.
Narrative: WAS GIVEN AN ACFT TO WORK (XYZ) ALONG WITH 3 OTHER MECHANICS. ON THE JOB CARD THERE WERE 3 ITEMS TO COMPLETE. 1) A THRU SVC 'A' CHECK. 2) A BORROWED ESCAPE SLIDE NEEDED TO BE REPLACED. 3) EMER EXIT WINDOW SHADE WAS INOP. UPON CHKING ACFT LOG BOOK THERE WAS 1 PLT ITEM. WHICH WAS 'WINDSHIELD WIPERS INOP.' 2 MEN CHOSE TO WORK THE 'A' CHK. I WAS WORKING THE OTHER 2 JOB CARDS. I CHOSE TO WORK THE PLT ITEM. AFTER TROUBLE SHOOTING I CAME TO THE CONCLUSION THAT THE WIPER SWITCH S-22 WAS AT FAULT. I LOOKED UP THE PART IN THE IPC AND THEN PICKED IT UP FROM STOCK. DURING THE REPLACEMENT OF THE SWITCH. ONE OF THE OTHER MECHANICS ASKED TO BORROW MY SCREW DRIVER FOR THE JOB HE WAS DOING. AFTER I FINISHED INSTALLING THE SWITCH I PERFORMED AN OPERATIONAL TEST OF THE WIPERS. PRIOR TO THE TEST I PUSHED THE ACCESS PANEL UP ONTO THE SAFETY LATCH. THE WIPERS CHECKED GOOD. I THEN RE-DROPPED THE ACCESS PANEL TO MAKE SURE THE WIRES WERE NOT CHAFFING. I THEN PUT THE ACCESS PANEL BACK ON TO THE SAFETY LATCH. I WAS GOING TO PUT THE CAM LOCKS (2) IN TO COMPLETE THE JOB. WHEN I REALIZED THAT I DID NOT HAVE MY SCREW DRIVER AS I HAD LOANED IT TO THE OTHER MECHANIC. SO I WENT TO THE BACK OF THE ACFT TO GET IT. THAT MECH AND ANOTHER WERE WORKING ON THE EMER EXIT WINDOW SHADE. THEY NEEDED SOME HELP HOLDING THE PANEL AND GETTING THE DUST SEAL INSTALLED. THIS ACTION PROBABLY TOOK 20 MIN. AFTER WE FINISHED GETTING THE SHADE INSTALLED. WE WERE INFORMED THAT OUR ACFT HAD TO BE MOVED FROM GATE XY TO THE RAMP PARKING AREA. SO I WENT DOWN HOOKED UP THE TOW BAR AND TRACTOR WITH SOME HELP. WE THEN MOVED THE ACFT. I DROVE THE TUG AND ANOTHER MECH RODE THE BRAKES. THEN WE WENT IN AND COMPLETED OUR LOG BOOK SIGN-OFFS. AFTER GOING HOME LATER IN THE DAY I RECEIVED PHONE CALL INFORMING ME THAT THE ACCESS PANEL WAS NOT SECURED PROPERLY AND THAT IT ALMOST CAUSED AN ACCIDENT WHEN IT CAME OFF THE SAFETY LATCH AND FELL DOWN AS THE CREW WAS GETTING READY FOR TKOF. WHEN I WAS TOLD THIS I IMMEDIATELY KNEW WHAT I HAD FORGOTTEN. SUPPLEMENTAL INFO FROM ACN 500304: ON TKOF ROLL AT ABOUT 90 KTS, THE OVERHEAD INSTRUMENT PANEL FELL STRIKING BOTH PLTS. WE REJECTED THE TKOF AND RETURNED TO THE GATE FOR MAINT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED ON TKOF ROLL AT 80 KNOTS THE COCKPIT FORWARD OVERHEAD PANEL P-5 DROPPED DOWN AND SWUNG FORWARD TO JUST ABOVE AND AFT OF THE THRUST LEVERS. THE RPTR SAID WHEN THE PANEL DROPPED IT STRUCK BOTH CREW MEMBERS ON THE SHOULDERS INJURING THE FO. THE RPTR SAID WITH THE PANEL HANGING DOWN BTWN THE CREW THEY LOST SIGHT OF EACH OTHER. THE RPTR STATED HAD ONE OR BOTH OF THE CREW BEEN LEANING TOWARD THE PEDESTAL SCANNING THE ENG INSTRUMENTS THE INJURIES WOULD HAVE MOST LIKELY DISABLED THE CREW. THE RPTR SAID THE PRIMARY PANEL CAM LOCKS WITNESS MARKS TO INDICATE LOCKED PANEL WERE MISSING.
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.