37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 513861 |
Time | |
Date | 200106 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | MD-90 Series (DC-9-90) Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 4 |
ASRS Report | 513861 |
Person 2 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : mech 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : tooling contributing factor : engineering procedure performance deficiency : inspection performance deficiency : training performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft Company |
Primary Problem | Chart Or Publication |
Situations | |
Publication | Maint Manual Procs |
Narrative:
Recently I completed a horizontal stabilizer/jackscrew inspection on an MD90 aircraft. The operation requires a restraining fixture to be affixed to the airplane. The mounts for the restraining fixture are upper and lower. After review, the upper mount should be removed before aircraft release. The mount could cause structural damage. I did not remove the upper mount. I also didn't install the upper mount. It was already on the airplane -- due to lighting and access I could not see the typical damage location. Of course I didn't know the fitting or the damage were possible. I believe more training should be given for such an important inspection. I didn't know there was a problem with the upper mount because this was my first inspection. Nobody else that night had ever done the inspection either. I notified maintenance to inspect our MD80 and MD90 fleet for more test fittings installed on aircraft. Callback conversation with reporter revealed the following information: the reporter stated the airplane came into the maintenance check with the upper mount installed by a previous station doing the stabilizer inspection. The reporter said the inspection is quite new and few people were aware of the special tooling to lock the horizontal stabilizer for the inspection. The reporter said no training was given on the inspection and tooling required. The reporter stated the job card to perform the inspection is inadequate as the last statement on the card directs removal of all tooling installed. The reporter said procedures were introduced to correct the job card with diagrams and paint all required tooling a bright color with six foot streamers. The reporter said this solves their problem but how about other MD90 operators?
Original NASA ASRS Text
Title: AN MD90 DURING MAINT CHECK WAS DISCOVERED TO HAVE A STABILIZER UPPER LOCK MOUNT INSPECTION FITTING INSTALLED WHICH CAUSED STRUCTURAL DAMAGE.
Narrative: RECENTLY I COMPLETED A HORIZONTAL STABILIZER/JACKSCREW INSPECTION ON AN MD90 ACFT. THE OPERATION REQUIRES A RESTRAINING FIXTURE TO BE AFFIXED TO THE AIRPLANE. THE MOUNTS FOR THE RESTRAINING FIXTURE ARE UPPER AND LOWER. AFTER REVIEW, THE UPPER MOUNT SHOULD BE REMOVED BEFORE ACFT RELEASE. THE MOUNT COULD CAUSE STRUCTURAL DAMAGE. I DID NOT REMOVE THE UPPER MOUNT. I ALSO DIDN'T INSTALL THE UPPER MOUNT. IT WAS ALREADY ON THE AIRPLANE -- DUE TO LIGHTING AND ACCESS I COULD NOT SEE THE TYPICAL DAMAGE LOCATION. OF COURSE I DIDN'T KNOW THE FITTING OR THE DAMAGE WERE POSSIBLE. I BELIEVE MORE TRAINING SHOULD BE GIVEN FOR SUCH AN IMPORTANT INSPECTION. I DIDN'T KNOW THERE WAS A PROB WITH THE UPPER MOUNT BECAUSE THIS WAS MY FIRST INSPECTION. NOBODY ELSE THAT NIGHT HAD EVER DONE THE INSPECTION EITHER. I NOTIFIED MAINT TO INSPECT OUR MD80 AND MD90 FLEET FOR MORE TEST FITTINGS INSTALLED ON ACFT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE AIRPLANE CAME INTO THE MAINT CHECK WITH THE UPPER MOUNT INSTALLED BY A PREVIOUS STATION DOING THE STABILIZER INSPECTION. THE RPTR SAID THE INSPECTION IS QUITE NEW AND FEW PEOPLE WERE AWARE OF THE SPECIAL TOOLING TO LOCK THE HORIZONTAL STABILIZER FOR THE INSPECTION. THE RPTR SAID NO TRAINING WAS GIVEN ON THE INSPECTION AND TOOLING REQUIRED. THE RPTR STATED THE JOB CARD TO PERFORM THE INSPECTION IS INADEQUATE AS THE LAST STATEMENT ON THE CARD DIRECTS REMOVAL OF ALL TOOLING INSTALLED. THE RPTR SAID PROCS WERE INTRODUCED TO CORRECT THE JOB CARD WITH DIAGRAMS AND PAINT ALL REQUIRED TOOLING A BRIGHT COLOR WITH SIX FOOT STREAMERS. THE RPTR SAID THIS SOLVES THEIR PROB BUT HOW ABOUT OTHER MD90 OPERATORS?
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.