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|
Attributes | |
ACN | 524553 |
Time | |
Date | 200109 |
Day | Sun |
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 | |
Controlling Facilities | tower : dfw.tower |
Operator | common carrier : air carrier |
Make Model Name | MD-88 |
Operating Under FAR Part | Part 121 |
Flight Phase | landing : roll |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance technician : 1 |
ASRS Report | 524553 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
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 | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : weather contributing factor : tooling contributing factor : work cards performance deficiency : inspection |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | CHECK JOB CARD |
Narrative:
Aircraft X came into ZZZ early morning requiring a transit check. I was responsible for performing the engine inspection portion of the work card. I bypassed and pinned the r-hand thrust reverser controller to perform the inspection of the tail section of the engine. Upon completion of the inspection I failed to unbypass the thrust reverser. The aircraft then left ZZZ and landed in san francisco, where the r-hand thrust reverser failed to deploy because it was still bypassed. The transit check work card does not have a step for pinning or unpinning the thrust reverser control valve for the inspection, however, it is done for safety concerns. That night it was windy and the ladder I had to perform my inspection with felt unstable, which in turn made me nervous. Callback conversation with reporter revealed the following information: the reporter stated the pin to lock out the reverser was installed for safety as the inspection requires actual entry into the reverser for inspection. The reporter said after the inspection job card was signed off the lock pin was forgotten. The reporter stated since this event another reverser lockout occurred at the station and the carrier made job card changes. The reporter said the job card has a signoff for installing the lockout pin and a signoff for removal of the pin and a write-up must be made any time any lockout pin is installed in any system. The reporter stated this change is now in effect and the job cards corrected to indicate this new procedure.
Original NASA ASRS Text
Title: AN MD88 WAS DISPATCHED IN NON COMPLIANCE WITH THE R THRUST REVERSER LOCKED INOP FOR MAINT INSPECTION AND NOT ACTIVATED.
Narrative: ACFT X CAME INTO ZZZ EARLY MORNING REQUIRING A TRANSIT CHK. I WAS RESPONSIBLE FOR PERFORMING THE ENG INSPECTION PORTION OF THE WORK CARD. I BYPASSED AND PINNED THE R-HAND THRUST REVERSER CONTROLLER TO PERFORM THE INSPECTION OF THE TAIL SECTION OF THE ENG. UPON COMPLETION OF THE INSPECTION I FAILED TO UNBYPASS THE THRUST REVERSER. THE ACFT THEN LEFT ZZZ AND LANDED IN SAN FRANCISCO, WHERE THE R-HAND THRUST REVERSER FAILED TO DEPLOY BECAUSE IT WAS STILL BYPASSED. THE TRANSIT CHK WORK CARD DOES NOT HAVE A STEP FOR PINNING OR UNPINNING THE THRUST REVERSER CTL VALVE FOR THE INSPECTION, HOWEVER, IT IS DONE FOR SAFETY CONCERNS. THAT NIGHT IT WAS WINDY AND THE LADDER I HAD TO PERFORM MY INSPECTION WITH FELT UNSTABLE, WHICH IN TURN MADE ME NERVOUS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE PIN TO LOCK OUT THE REVERSER WAS INSTALLED FOR SAFETY AS THE INSPECTION REQUIRES ACTUAL ENTRY INTO THE REVERSER FOR INSPECTION. THE RPTR SAID AFTER THE INSPECTION JOB CARD WAS SIGNED OFF THE LOCK PIN WAS FORGOTTEN. THE RPTR STATED SINCE THIS EVENT ANOTHER REVERSER LOCKOUT OCCURRED AT THE STATION AND THE CARRIER MADE JOB CARD CHANGES. THE RPTR SAID THE JOB CARD HAS A SIGNOFF FOR INSTALLING THE LOCKOUT PIN AND A SIGNOFF FOR REMOVAL OF THE PIN AND A WRITE-UP MUST BE MADE ANY TIME ANY LOCKOUT PIN IS INSTALLED IN ANY SYS. THE RPTR STATED THIS CHANGE IS NOW IN EFFECT AND THE JOB CARDS CORRECTED TO INDICATE THIS NEW PROC.
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.