37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 572276 |
Time | |
Date | 200301 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | MD-88 |
Operating Under FAR Part | Part 121 |
Flight Phase | landing : roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : instrument pilot : commercial pilot : atp |
Experience | flight time last 90 days : 193 flight time total : 13000 flight time type : 5900 |
ASRS Report | 572276 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 572148 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel 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 : manuals contributing factor : schedule pressure performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
When we reviewed aircraft's logbook in ZZZ, we noted that the left thrust reverser was on deferred list. A review of the maintenance deferral manual revealed that circuit breaker T-29 (reverser accumulator low message) should be pulled and collared. It was not. We called maintenance and had T-29 properly secured. The flight to YYY was normal. The approach was briefed and planned for an inoperative left thrust reverser. Upon landing, the left thrust reverser unlocked and deployed when the reverser levers were raised. After I conferred with flight control and the maintenance coordination about the situation, contract maintenance was called. His investigation revealed that the thrust reverser had not been properly locked out at the engine. The flight back to ZZZ finally departed about 1 hour late, after the reverser had been properly secured. I found this entire situation very troubling. Not only had the original maintenance been performed improperly, the unsecured circuit breaker indicated that maintenance deferral manual procedures had not been followed. Callback conversation with reporter revealed the following information: the reporter stated the crew found the circuit breaker not pulled and locked out and maintenance corrected this discrepancy, but no thought was given to the mechanical lockout of the reverser at the engine. The reporter said on landing the reverser was activated and deployed.
Original NASA ASRS Text
Title: A MD88 WAS DISPATCHED IN NON COMPLIANCE WITH #1 REVERSER DEFERRED AS INOP PER THE MEL, BUT NOT MECHANICALLY LOCKED OUT AS REQUIRED.
Narrative: WHEN WE REVIEWED ACFT'S LOGBOOK IN ZZZ, WE NOTED THAT THE L THRUST REVERSER WAS ON DEFERRED LIST. A REVIEW OF THE MAINT DEFERRAL MANUAL REVEALED THAT CIRCUIT BREAKER T-29 (REVERSER ACCUMULATOR LOW MESSAGE) SHOULD BE PULLED AND COLLARED. IT WAS NOT. WE CALLED MAINT AND HAD T-29 PROPERLY SECURED. THE FLT TO YYY WAS NORMAL. THE APCH WAS BRIEFED AND PLANNED FOR AN INOP L THRUST REVERSER. UPON LNDG, THE L THRUST REVERSER UNLOCKED AND DEPLOYED WHEN THE REVERSER LEVERS WERE RAISED. AFTER I CONFERRED WITH FLT CTL AND THE MAINT COORD ABOUT THE SIT, CONTRACT MAINT WAS CALLED. HIS INVESTIGATION REVEALED THAT THE THRUST REVERSER HAD NOT BEEN PROPERLY LOCKED OUT AT THE ENG. THE FLT BACK TO ZZZ FINALLY DEPARTED ABOUT 1 HR LATE, AFTER THE REVERSER HAD BEEN PROPERLY SECURED. I FOUND THIS ENTIRE SIT VERY TROUBLING. NOT ONLY HAD THE ORIGINAL MAINT BEEN PERFORMED IMPROPERLY, THE UNSECURED CIRCUIT BREAKER INDICATED THAT MAINT DEFERRAL MANUAL PROCS HAD NOT BEEN FOLLOWED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE CREW FOUND THE CIRCUIT BREAKER NOT PULLED AND LOCKED OUT AND MAINT CORRECTED THIS DISCREPANCY, BUT NO THOUGHT WAS GIVEN TO THE MECHANICAL LOCKOUT OF THE REVERSER AT THE ENG. THE RPTR SAID ON LNDG THE REVERSER WAS ACTIVATED AND DEPLOYED.
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.