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|
Attributes | |
ACN | 542386 |
Time | |
Date | 200203 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B727 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : multi engine pilot : instrument pilot : flight engineer pilot : commercial pilot : atp |
Experience | flight time last 90 days : 80 flight time total : 4500 flight time type : 100 |
ASRS Report | 542386 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa other other : person 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure contributing factor : engineering procedure performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Flight Crew Human Performance Environmental Factor Aircraft |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | MAINT MANUAL SAFETY PROCEDURE |
Narrative:
Upon arrival from hotel to company facility at ZZZ, captain and I proceeded to the aircraft. I performed my exterior safety check and the captain went up to the flight deck to stow his belongings. After completion of my exterior safety check, I went to the flight deck to continue preflight duties. After completing the checklist, through the standby power check, I advised the mechanic that I was going to start the APU to cool the flight deck. After starting and then xferring aircraft power to the APU, a mechanic came into the flight deck, closed the aircraft bleed air switches, and asked who had started the APU. I stated that I was unaware of anything wrong with the aircraft, let alone anyone working on it. The flight deck had no placards stating not to operate any aircraft system at the time of the incident. After the APU was shut down, I went to discuss the situation with the captain unaware of anyone being injured. At this point I learned that a mechanic had received an eye injury. After returning to the aircraft, someone had placed a piece of paper over the APU control panel that read 'no APU.' I believe a number of events leading up to this incident occurred starting with the following: no maintenance personnel relayed status of the aircraft with any of the flight crew. Dispatch also failed to notify flight crew of aircraft status as well as notifying us another aircraft had been dispatched. Failure to see anyone working on aircraft. Failure of mechanic in flight deck to stop APU from being used after being advised it was being started. Finally, absence of any placards stating that aircraft was and/or if any aircraft system were not to be operated. I believe better communications from all parties involved as well as placement of advisory placards over affected aircraft equipment could have prevented this unfortunate incident. Callback conversation with reporter revealed the following information: the reporter stated that unknown to anyone a technician was replacing the #3 engine start valve with the start valve duct opened. The reporter said when the preflight walkaround check was made a vehicle was parked under #3 engine but the cowling was closed and no maintenance technicians were in view. The reporter stated no placards were on the APU or pneumatic switches and no circuit breakers were pulled. The reporter stated the technician received a burn to the eye and was off several days before returning to work. The reporter said this maintenance station was always indifferent to safety procedures and believes management is at fault.
Original NASA ASRS Text
Title: A B727 PIC, WHILE PARKED, HAD THE SO START THE APU UNAWARE MAINT WAS WORKING IN OR NEAR THE UNIT. TECHNICIAN INCURRED AN EYE INJURY.
Narrative: UPON ARR FROM HOTEL TO COMPANY FACILITY AT ZZZ, CAPT AND I PROCEEDED TO THE ACFT. I PERFORMED MY EXTERIOR SAFETY CHK AND THE CAPT WENT UP TO THE FLT DECK TO STOW HIS BELONGINGS. AFTER COMPLETION OF MY EXTERIOR SAFETY CHK, I WENT TO THE FLT DECK TO CONTINUE PREFLT DUTIES. AFTER COMPLETING THE CHKLIST, THROUGH THE STANDBY PWR CHK, I ADVISED THE MECH THAT I WAS GOING TO START THE APU TO COOL THE FLT DECK. AFTER STARTING AND THEN XFERRING ACFT PWR TO THE APU, A MECH CAME INTO THE FLT DECK, CLOSED THE ACFT BLEED AIR SWITCHES, AND ASKED WHO HAD STARTED THE APU. I STATED THAT I WAS UNAWARE OF ANYTHING WRONG WITH THE ACFT, LET ALONE ANYONE WORKING ON IT. THE FLT DECK HAD NO PLACARDS STATING NOT TO OPERATE ANY ACFT SYS AT THE TIME OF THE INCIDENT. AFTER THE APU WAS SHUT DOWN, I WENT TO DISCUSS THE SIT WITH THE CAPT UNAWARE OF ANYONE BEING INJURED. AT THIS POINT I LEARNED THAT A MECH HAD RECEIVED AN EYE INJURY. AFTER RETURNING TO THE ACFT, SOMEONE HAD PLACED A PIECE OF PAPER OVER THE APU CTL PANEL THAT READ 'NO APU.' I BELIEVE A NUMBER OF EVENTS LEADING UP TO THIS INCIDENT OCCURRED STARTING WITH THE FOLLOWING: NO MAINT PERSONNEL RELAYED STATUS OF THE ACFT WITH ANY OF THE FLC. DISPATCH ALSO FAILED TO NOTIFY FLC OF ACFT STATUS AS WELL AS NOTIFYING US ANOTHER ACFT HAD BEEN DISPATCHED. FAILURE TO SEE ANYONE WORKING ON ACFT. FAILURE OF MECH IN FLT DECK TO STOP APU FROM BEING USED AFTER BEING ADVISED IT WAS BEING STARTED. FINALLY, ABSENCE OF ANY PLACARDS STATING THAT ACFT WAS AND/OR IF ANY ACFT SYS WERE NOT TO BE OPERATED. I BELIEVE BETTER COMS FROM ALL PARTIES INVOLVED AS WELL AS PLACEMENT OF ADVISORY PLACARDS OVER AFFECTED ACFT EQUIP COULD HAVE PREVENTED THIS UNFORTUNATE INCIDENT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THAT UNKNOWN TO ANYONE A TECHNICIAN WAS REPLACING THE #3 ENG START VALVE WITH THE START VALVE DUCT OPENED. THE RPTR SAID WHEN THE PREFLT WALKAROUND CHK WAS MADE A VEHICLE WAS PARKED UNDER #3 ENG BUT THE COWLING WAS CLOSED AND NO MAINT TECHNICIANS WERE IN VIEW. THE RPTR STATED NO PLACARDS WERE ON THE APU OR PNEUMATIC SWITCHES AND NO CIRCUIT BREAKERS WERE PULLED. THE RPTR STATED THE TECHNICIAN RECEIVED A BURN TO THE EYE AND WAS OFF SEVERAL DAYS BEFORE RETURNING TO WORK. THE RPTR SAID THIS MAINT STATION WAS ALWAYS INDIFFERENT TO SAFETY PROCS AND BELIEVES MGMNT IS AT 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.