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|
Attributes | |
ACN | 531378 |
Time | |
Date | 200111 |
Day | Sun |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
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 : 13 |
ASRS Report | 531378 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Independent Detector | aircraft equipment other aircraft equipment : gear position indication other flight crewa other flight crewb |
Resolutory Action | flight crew : diverted to another airport |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : lighting performance deficiency : installation performance deficiency : inspection performance deficiency : testing performance deficiency : logbook entry |
Supplementary | |
Problem Areas | Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft X came into ZZZ for overnight maintenance (routine). One deferral on the aircraft was a faulty GPWS. While troubleshooting the system per the maintenance manual, one step was to install gear pins. Not having any in the immediate area I chose to use my 6 inch 1/4 inch drive ratchet extension for the nose gear down lock pin. After all the troubleshooting and testing per the maintenance manual, I returned the GPWS back to airworthy condition and released the aircraft back to service, failing to remove the 6 inch extension from the nose gear down lock assembly. Unfortunately, the aircraft was unable to retract the nose gear after takeoff, thus returning to the airfield, back to the gate. At that point it was inspected and the 6 inch extension was discovered in the specified area. Contributing factors to this event are: poor choice in not following maintenance manual procedures, maintenance was accomplished at the gate overnight, thus lighting was inefficient, frustration in trying to familiarize myself with this system so as to fix it due to the fact that it would be grounded at the end of the flying day (my shift starts at XA00 and I leave at XK15, I really tried to put a full effort into finding the fault).
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED IN NON COMPLIANCE WITH THE NOSE GEAR PINNED IN THE DOWN POS. CAUSED BY A SUBSTITUTE GEAR PIN INSTALLED DURING MAINT.
Narrative: ACFT X CAME INTO ZZZ FOR OVERNIGHT MAINT (ROUTINE). ONE DEFERRAL ON THE ACFT WAS A FAULTY GPWS. WHILE TROUBLESHOOTING THE SYS PER THE MAINT MANUAL, ONE STEP WAS TO INSTALL GEAR PINS. NOT HAVING ANY IN THE IMMEDIATE AREA I CHOSE TO USE MY 6 INCH 1/4 INCH DRIVE RATCHET EXTENSION FOR THE NOSE GEAR DOWN LOCK PIN. AFTER ALL THE TROUBLESHOOTING AND TESTING PER THE MAINT MANUAL, I RETURNED THE GPWS BACK TO AIRWORTHY CONDITION AND RELEASED THE ACFT BACK TO SVC, FAILING TO REMOVE THE 6 INCH EXTENSION FROM THE NOSE GEAR DOWN LOCK ASSEMBLY. UNFORTUNATELY, THE ACFT WAS UNABLE TO RETRACT THE NOSE GEAR AFTER TKOF, THUS RETURNING TO THE AIRFIELD, BACK TO THE GATE. AT THAT POINT IT WAS INSPECTED AND THE 6 INCH EXTENSION WAS DISCOVERED IN THE SPECIFIED AREA. CONTRIBUTING FACTORS TO THIS EVENT ARE: POOR CHOICE IN NOT FOLLOWING MAINT MANUAL PROCS, MAINT WAS ACCOMPLISHED AT THE GATE OVERNIGHT, THUS LIGHTING WAS INEFFICIENT, FRUSTRATION IN TRYING TO FAMILIARIZE MYSELF WITH THIS SYS SO AS TO FIX IT DUE TO THE FACT THAT IT WOULD BE GNDED AT THE END OF THE FLYING DAY (MY SHIFT STARTS AT XA00 AND I LEAVE AT XK15, I REALLY TRIED TO PUT A FULL EFFORT INTO FINDING THE FAULT).
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.