37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 543625 |
Time | |
Date | 200204 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl single value : 15000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 11 |
ASRS Report | 543625 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 10120 flight time type : 3027 |
ASRS Report | 543624 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | flight crew : diverted to another airport |
Consequence | faa : investigated other other |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
While performing predeparture check of the APU everything appeared to be in good condition. The technician assisting me then closed the APU doors and the aircraft was released for service. The aircraft departed and approximately 40 miles out the doors came off and damaged the elevators. The aircraft did an air turnback and returned to ZZZ without incident. I am not sure what caused this but I suspect latches were faulty or somehow did not get latched properly as there is no way to physically check latch for go or no go condition except if door stays closed. I believe a sight glass at each latch or a florescent no go indicator on the side of the latches could have possibly prevented this or latch that latches into the forward bulkhead like on the L1011's APU doors would have been a positive latch to the fuselage and doors would not have been able to open into the airstream. Callback conversation with reporter revealed the following information: the reporter stated the APU cowling was opened by the gate tech with the help of the reporter to service the unit. The reporter said the cowling was closed and latched by the gate technician and was observed by the reporter as being faired with the fuselage. The reporter stated in latching and locking this cowling everyone has their own method of closure to avoid false latching. The reporter said the rptrs technique is latching the most forward latch first and observing it fairing with the fuselage skin then continue aft latching the cowling and checking the tabs for positive locking. The reporter said the locking tab is .50 inch wide X .250 inch long and protrudes out of the cowling .250 inch and is the same material and color as the latch mechanism. The reporter suggests coloring the tabs may assist in observing the tabs from the ground. The reporter said the tabs are approximately 15 to 17 ft from ground level depending on strut extension and tough to see on a walk around check. Callback from acn 543624: the reporter stated climbing through 15000 ft the flight crew felt a 'bump' and then an airframe vibration which decreased with lower speed. The reporter said the APU was not operating at this time. The reporter stated the flight was diverted and on the ground the APU cowling was found missing and a hole was discovered in each elevator. The reporter said the cowling was recovered from a private residence backyard.
Original NASA ASRS Text
Title: A B767-300ER AFTER TKOF AT 15000 FT DIVERTED DUE TO EXPERIENCING A BUMP THEN A CONSTANT VIBRATION. CAUSED BY THE APU COWLING DEPARTING ACFT.
Narrative: WHILE PERFORMING PREDEPARTURE CHK OF THE APU EVERYTHING APPEARED TO BE IN GOOD CONDITION. THE TECHNICIAN ASSISTING ME THEN CLOSED THE APU DOORS AND THE ACFT WAS RELEASED FOR SVC. THE ACFT DEPARTED AND APPROX 40 MILES OUT THE DOORS CAME OFF AND DAMAGED THE ELEVATORS. THE ACFT DID AN AIR TURNBACK AND RETURNED TO ZZZ WITHOUT INCIDENT. I AM NOT SURE WHAT CAUSED THIS BUT I SUSPECT LATCHES WERE FAULTY OR SOMEHOW DID NOT GET LATCHED PROPERLY AS THERE IS NO WAY TO PHYSICALLY CHK LATCH FOR GO OR NO GO CONDITION EXCEPT IF DOOR STAYS CLOSED. I BELIEVE A SIGHT GLASS AT EACH LATCH OR A FLORESCENT NO GO INDICATOR ON THE SIDE OF THE LATCHES COULD HAVE POSSIBLY PREVENTED THIS OR LATCH THAT LATCHES INTO THE FORWARD BULKHEAD LIKE ON THE L1011'S APU DOORS WOULD HAVE BEEN A POSITIVE LATCH TO THE FUSELAGE AND DOORS WOULD NOT HAVE BEEN ABLE TO OPEN INTO THE AIRSTREAM. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE APU COWLING WAS OPENED BY THE GATE TECH WITH THE HELP OF THE RPTR TO SVC THE UNIT. THE RPTR SAID THE COWLING WAS CLOSED AND LATCHED BY THE GATE TECHNICIAN AND WAS OBSERVED BY THE RPTR AS BEING FAIRED WITH THE FUSELAGE. THE RPTR STATED IN LATCHING AND LOCKING THIS COWLING EVERYONE HAS THEIR OWN METHOD OF CLOSURE TO AVOID FALSE LATCHING. THE RPTR SAID THE RPTRS TECHNIQUE IS LATCHING THE MOST FORWARD LATCH FIRST AND OBSERVING IT FAIRING WITH THE FUSELAGE SKIN THEN CONTINUE AFT LATCHING THE COWLING AND CHECKING THE TABS FOR POSITIVE LOCKING. THE RPTR SAID THE LOCKING TAB IS .50 INCH WIDE X .250 INCH LONG AND PROTRUDES OUT OF THE COWLING .250 INCH AND IS THE SAME MATERIAL AND COLOR AS THE LATCH MECHANISM. THE RPTR SUGGESTS COLORING THE TABS MAY ASSIST IN OBSERVING THE TABS FROM THE GND. THE RPTR SAID THE TABS ARE APPROXIMATELY 15 TO 17 FT FROM GND LEVEL DEPENDING ON STRUT EXTENSION AND TOUGH TO SEE ON A WALK AROUND CHK. CALLBACK FROM ACN 543624: THE RPTR STATED CLBING THROUGH 15000 FT THE FLT CREW FELT A 'BUMP' AND THEN AN AIRFRAME VIBRATION WHICH DECREASED WITH LOWER SPEED. THE RPTR SAID THE APU WAS NOT OPERATING AT THIS TIME. THE RPTR STATED THE FLT WAS DIVERTED AND ON THE GND THE APU COWLING WAS FOUND MISSING AND A HOLE WAS DISCOVERED IN EACH ELEVATOR. THE RPTR SAID THE COWLING WAS RECOVERED FROM A PRIVATE RESIDENCE BACKYARD.
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.