37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 501651 |
Time | |
Date | 200102 |
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 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 11 |
ASRS Report | 501651 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 501646 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : adi indicator other other : person 3 |
Resolutory Action | other |
Consequence | other other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : schedule pressure performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : inspection |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
On feb/xa/01, I was assigned aircraft xyz, which had a chronic pressurization problem. In the troubleshooting process, the #1 vertical gyro was removed to facilitate the E1-1 rack removal. When the E1-1 was reinstalled, the #1 vertical gyro was left unsecured. The paperwork showed the rack needed securing but not the gyro -- it was left out. The aircraft was put back together and all noted system disturbed were operations checked. The aircraft was needed for revenue service as soon as possible. Subsequent inspection of east&east compartment missed the gyro and preflight crew also missed it before test flight crew was called in. Our flight crew immediately spotted the problem. Maintenance ordered a new gyro, found the loose one without paperwork noting its removal. Maintenance installed new one and generated all necessary paperwork to properly close paper package for its release back into service.
Original NASA ASRS Text
Title: A B737-200 WAS RELEASED FOR SVC AFTER MAINT WITH THE #1 VERT GYRO NOT INSTALLED.
Narrative: ON FEB/XA/01, I WAS ASSIGNED ACFT XYZ, WHICH HAD A CHRONIC PRESSURIZATION PROB. IN THE TROUBLESHOOTING PROCESS, THE #1 VERT GYRO WAS REMOVED TO FACILITATE THE E1-1 RACK REMOVAL. WHEN THE E1-1 WAS REINSTALLED, THE #1 VERT GYRO WAS LEFT UNSECURED. THE PAPERWORK SHOWED THE RACK NEEDED SECURING BUT NOT THE GYRO -- IT WAS LEFT OUT. THE ACFT WAS PUT BACK TOGETHER AND ALL NOTED SYS DISTURBED WERE OPS CHKED. THE ACFT WAS NEEDED FOR REVENUE SVC ASAP. SUBSEQUENT INSPECTION OF E&E COMPARTMENT MISSED THE GYRO AND PREFLT CREW ALSO MISSED IT BEFORE TEST FLC WAS CALLED IN. OUR FLC IMMEDIATELY SPOTTED THE PROB. MAINT ORDERED A NEW GYRO, FOUND THE LOOSE ONE WITHOUT PAPERWORK NOTING ITS REMOVAL. MAINT INSTALLED NEW ONE AND GENERATED ALL NECESSARY PAPERWORK TO PROPERLY CLOSE PAPER PACKAGE FOR ITS RELEASE BACK INTO SVC.
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.