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|
Attributes | |
ACN | 563799 |
Time | |
Date | 200210 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | MD-11 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | other personnel other |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 563799 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other other : person 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : inspection |
Supplementary | |
Problem Areas | Maintenance Human Performance Chart Or Publication Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Aircraft X, flight ab, diverted from ZZZ2 to ZZZ due to #1 engine being shut down by the flight crew for a 'thrust reverser unlock' light on, per pom. Flight was diverted to ZZZ2. During maintenance, I instructed the mechanic on how to isolate the indication and lock out the reverser for dispatch under the MEL. After the aircraft departed ZZZ2, I discovered that I did not instruct them to do the engine windmill inspection. To correct this error, the aircraft was stopped at the arrival station to have the windmill inspection performed. To eliminate a recurrence, I will do the in-flight shutdown report before an aircraft departs. This report requires the windmill inspection has been reviewed.
Original NASA ASRS Text
Title: AN MD11 WAS DISPATCHED IN NON COMPLIANCE WITH AN INCOMPLETE ENG INFLT SHUTDOWN WINDMILL CHK. ENG SHUTDOWN DUE TO REVERSER UNLOCK LIGHT.
Narrative: ACFT X, FLT AB, DIVERTED FROM ZZZ2 TO ZZZ DUE TO #1 ENG BEING SHUT DOWN BY THE FLC FOR A 'THRUST REVERSER UNLOCK' LIGHT ON, PER POM. FLT WAS DIVERTED TO ZZZ2. DURING MAINT, I INSTRUCTED THE MECH ON HOW TO ISOLATE THE INDICATION AND LOCK OUT THE REVERSER FOR DISPATCH UNDER THE MEL. AFTER THE ACFT DEPARTED ZZZ2, I DISCOVERED THAT I DID NOT INSTRUCT THEM TO DO THE ENG WINDMILL INSPECTION. TO CORRECT THIS ERROR, THE ACFT WAS STOPPED AT THE ARR STATION TO HAVE THE WINDMILL INSPECTION PERFORMED. TO ELIMINATE A RECURRENCE, I WILL DO THE INFLT SHUTDOWN RPT BEFORE AN ACFT DEPARTS. THIS RPT REQUIRES THE WINDMILL INSPECTION HAS BEEN REVIEWED.
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.