37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 535559 |
Time | |
Date | 200201 |
Day | Sun |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
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 supervisor : 10 |
ASRS Report | 535559 |
Person 2 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : company policies 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 : schedule pressure performance deficiency : logbook entry performance deficiency : scheduled maintenance performance deficiency : testing performance deficiency : inspection |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Company |
Primary Problem | Maintenance Human Performance |
Narrative:
During scheduled 'a' check maintenance, I opened #1 engine fan cowls and thrust reversers for engine oil, filter and chip detector servicing. Also removed plugs for non destructive testing borescope inspection. Also check and replacement of intermediate pressure check valve. Per the paperwork, I was supposed to install a lockout pin in the thrust reverser hydraulic control unit and initiate a logbook entry stating the same. After the engine maintenance was complete I closed the engine cowling. I failed to remove the hydraulic control unit lockout pin. The aircraft made a revenue flight. Upon landing, the thrust reverser did not deploy. Maintenance at the airport MEL'ed the thrust reverser and when the aircraft made the next flight to a hub city the thrust reverser was reactivated. During the course of maintenance, I failed to make a logbook entry. At the beginning of the night my crew chief told us that management said we had to have the A320 'a' checks done by XA00 regardless of the actual routing time, or we would lose the checks. Our crew was also short by 3-5 people that night. The factors that led to this in my opinion are small crew for the night which increased everybody's workload. Being pushed or rushed by management to have the aircraft done by XA00. Not staying focused on the job at hand. I knew I had to make a logbook entry, but I got sidetracked. I locked out the hydraulic control unit with a red streamer that was about 1/2 the length of the usual streamer we use. I closed the engine by myself so there wasn't an extra set of eyes checking things as the cowling was closed.
Original NASA ASRS Text
Title: AN AIRBUS WAS DISPATCHED IN NON COMPLIANCE WITH THE #1 ENG THRUST REVERSER SAFETY LOCKOUT PIN INSTALLED. #1 ENG FAILED TO REVERSE ON LNDG.
Narrative: DURING SCHEDULED 'A' CHK MAINT, I OPENED #1 ENG FAN COWLS AND THRUST REVERSERS FOR ENG OIL, FILTER AND CHIP DETECTOR SVCING. ALSO REMOVED PLUGS FOR NON DESTRUCTIVE TESTING BORESCOPE INSPECTION. ALSO CHK AND REPLACEMENT OF INTERMEDIATE PRESSURE CHK VALVE. PER THE PAPERWORK, I WAS SUPPOSED TO INSTALL A LOCKOUT PIN IN THE THRUST REVERSER HYD CTL UNIT AND INITIATE A LOGBOOK ENTRY STATING THE SAME. AFTER THE ENG MAINT WAS COMPLETE I CLOSED THE ENG COWLING. I FAILED TO REMOVE THE HYD CTL UNIT LOCKOUT PIN. THE ACFT MADE A REVENUE FLT. UPON LNDG, THE THRUST REVERSER DID NOT DEPLOY. MAINT AT THE ARPT MEL'ED THE THRUST REVERSER AND WHEN THE ACFT MADE THE NEXT FLT TO A HUB CITY THE THRUST REVERSER WAS REACTIVATED. DURING THE COURSE OF MAINT, I FAILED TO MAKE A LOGBOOK ENTRY. AT THE BEGINNING OF THE NIGHT MY CREW CHIEF TOLD US THAT MGMNT SAID WE HAD TO HAVE THE A320 'A' CHKS DONE BY XA00 REGARDLESS OF THE ACTUAL ROUTING TIME, OR WE WOULD LOSE THE CHKS. OUR CREW WAS ALSO SHORT BY 3-5 PEOPLE THAT NIGHT. THE FACTORS THAT LED TO THIS IN MY OPINION ARE SMALL CREW FOR THE NIGHT WHICH INCREASED EVERYBODY'S WORKLOAD. BEING PUSHED OR RUSHED BY MGMNT TO HAVE THE ACFT DONE BY XA00. NOT STAYING FOCUSED ON THE JOB AT HAND. I KNEW I HAD TO MAKE A LOGBOOK ENTRY, BUT I GOT SIDETRACKED. I LOCKED OUT THE HYD CTL UNIT WITH A RED STREAMER THAT WAS ABOUT 1/2 THE LENGTH OF THE USUAL STREAMER WE USE. I CLOSED THE ENG BY MYSELF SO THERE WASN'T AN EXTRA SET OF EYES CHKING THINGS AS THE COWLING WAS CLOSED.
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.