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|
Attributes | |
ACN | 576063 |
Time | |
Date | 200303 |
Day | Sun |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tower : pns.tower |
Operator | common carrier : air carrier |
Make Model Name | DC-9 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician maintenance : lead technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 3 maintenance technician : 18 |
ASRS Report | 576063 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Independent Detector | other other : maint 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals performance deficiency : installation performance deficiency : scheduled maintenance performance deficiency : testing performance deficiency : inspection |
Supplementary | |
Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Maint Manual Chap 30 |
Narrative:
Mechanic #1 and I began the day with a full plate of 'non-routines' to accomplish, one of which was to test the spoiler automatic system. Together, we had accomplished this test 2 days before and the aircraft failed the test. A part had been ordered that same day and its arrival was expected on the morning of mar/sun/03. As the part was not to arrive until after XA30 am, mechanic #1 instructed me to accomplish as many of the other 'non-routines' as possible. I was in the midst of a maddening search for a filler, when mechanic #1 approached me for my assistance to install the part for the spoiler system, as it had finally arrived. Together, we installed the part and began the test of the system as we had done 2 days before. Mechanic #1 had the paperwork for the test in the cockpit and I was on the ground with a radio listening for instructions. As mechanic #1 read the instructions from the maintenance manual, I responded with the appropriate action. As the test proceeded, the request was given to place the nose oleo switch in the ground position. (The ground shift link had been previously disconnected). I complied, as this switch is placed in various position throughout the test. After mechanic #1 emerged from the cockpit, with one of us on each outboard brake transducer, we spun the transducers simultaneously to ensure spoiler deployment. Mechanic #1 returned to the cockpit to complete the test, which passed. I was then instructed to install the hubcaps on the wheels. This concluded the maintenance manual procedures on this particular test. The maintenance manual instructed us to disconnect the link on the ground shift, but never instructed us to reconnect the link. Clearly, common sense would dictate that a link disconnected would then need reconnecting. Unfortunately, in the mayhem of the day, I installed the hubcaps and immediately returned to my search for the filler to repair the leading edge slat. Regrettably, my thoughts never returned to the disconnected ground shift link. Had the maintenance manual had instructed us to connect the link, I am certain the link would have been connected. On mar/mon/03, aircraft X left ZZZ and could not retract the landing gear. The aircraft never went into flight mode because the link was disconnected. The aircraft landed safely in ZZZ1. A logbook entry was made and the mechanic on ground found the link disconnected.
Original NASA ASRS Text
Title: A DC9-30 WAS UNABLE TO RETRACT THE LNDG GEAR DUE TO FAILURE TO RECONNECT THE GND SHIFT LINK AFTER SPOILER MAINT.
Narrative: MECH #1 AND I BEGAN THE DAY WITH A FULL PLATE OF 'NON-ROUTINES' TO ACCOMPLISH, ONE OF WHICH WAS TO TEST THE SPOILER AUTOMATIC SYS. TOGETHER, WE HAD ACCOMPLISHED THIS TEST 2 DAYS BEFORE AND THE ACFT FAILED THE TEST. A PART HAD BEEN ORDERED THAT SAME DAY AND ITS ARR WAS EXPECTED ON THE MORNING OF MAR/SUN/03. AS THE PART WAS NOT TO ARRIVE UNTIL AFTER XA30 AM, MECH #1 INSTRUCTED ME TO ACCOMPLISH AS MANY OF THE OTHER 'NON-ROUTINES' AS POSSIBLE. I WAS IN THE MIDST OF A MADDENING SEARCH FOR A FILLER, WHEN MECH #1 APCHED ME FOR MY ASSISTANCE TO INSTALL THE PART FOR THE SPOILER SYS, AS IT HAD FINALLY ARRIVED. TOGETHER, WE INSTALLED THE PART AND BEGAN THE TEST OF THE SYS AS WE HAD DONE 2 DAYS BEFORE. MECH #1 HAD THE PAPERWORK FOR THE TEST IN THE COCKPIT AND I WAS ON THE GND WITH A RADIO LISTENING FOR INSTRUCTIONS. AS MECH #1 READ THE INSTRUCTIONS FROM THE MAINT MANUAL, I RESPONDED WITH THE APPROPRIATE ACTION. AS THE TEST PROCEEDED, THE REQUEST WAS GIVEN TO PLACE THE NOSE OLEO SWITCH IN THE GND POS. (THE GND SHIFT LINK HAD BEEN PREVIOUSLY DISCONNECTED). I COMPLIED, AS THIS SWITCH IS PLACED IN VARIOUS POS THROUGHOUT THE TEST. AFTER MECH #1 EMERGED FROM THE COCKPIT, WITH ONE OF US ON EACH OUTBOARD BRAKE TRANSDUCER, WE SPUN THE TRANSDUCERS SIMULTANEOUSLY TO ENSURE SPOILER DEPLOYMENT. MECH #1 RETURNED TO THE COCKPIT TO COMPLETE THE TEST, WHICH PASSED. I WAS THEN INSTRUCTED TO INSTALL THE HUBCAPS ON THE WHEELS. THIS CONCLUDED THE MAINT MANUAL PROCS ON THIS PARTICULAR TEST. THE MAINT MANUAL INSTRUCTED US TO DISCONNECT THE LINK ON THE GND SHIFT, BUT NEVER INSTRUCTED US TO RECONNECT THE LINK. CLRLY, COMMON SENSE WOULD DICTATE THAT A LINK DISCONNECTED WOULD THEN NEED RECONNECTING. UNFORTUNATELY, IN THE MAYHEM OF THE DAY, I INSTALLED THE HUBCAPS AND IMMEDIATELY RETURNED TO MY SEARCH FOR THE FILLER TO REPAIR THE LEADING EDGE SLAT. REGRETTABLY, MY THOUGHTS NEVER RETURNED TO THE DISCONNECTED GND SHIFT LINK. HAD THE MAINT MANUAL HAD INSTRUCTED US TO CONNECT THE LINK, I AM CERTAIN THE LINK WOULD HAVE BEEN CONNECTED. ON MAR/MON/03, ACFT X LEFT ZZZ AND COULD NOT RETRACT THE LNDG GEAR. THE ACFT NEVER WENT INTO FLT MODE BECAUSE THE LINK WAS DISCONNECTED. THE ACFT LANDED SAFELY IN ZZZ1. A LOGBOOK ENTRY WAS MADE AND THE MECH ON GND FOUND THE LINK DISCONNECTED.
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.