37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 581528 |
Time | |
Date | 200304 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A319 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 581528 |
Person 2 | |
Affiliation | company : air carrier |
Function | other personnel other |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel non adherence : far non adherence : published procedure |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : tooling performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : testing performance deficiency : training |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Company Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On apr/wed/03, I was contacted by air carrier to perform corrective action on an A319 flight arriving ZZZZ XA15 EST. I contacted air carrier, mcc, they stated that a facsimile was being sent to ZZZ with MEL procedures. A second call to air carrier mcc was made for more information. I spoke to coordination, mr Y, A319 desk. He told me they wanted sector 1 and sector 3 swapped. We discussed where they were located and how to access them. I, using the paperwork provided, pulled appropriate circuit breakers and swapped both second's. Mr X also informed me to use MEL ddg 27-64-01 to lock out spoiler pairs 1 and 2, because second was inoperative. I proceeded to obtain the procedures from the MEL manual in the flight deck. I made copies of them and began the procedure. I reached item east.1 on page 13 of DDG27. This item states: to deactivate the servo-control. I proceeded to the spoiler actuator, but I couldn't find the maintenance key stated on item (2). I called air carrier mcc to ask about item (2). Mr Y told me it may not be there, to just remove the hex-head control switch locking tab and turn the hex-head switch to the maintenance position, and re-safetied. Then I removed the cannon plugs and tie-wrapped them as stated. Item H states to make sure that the spoilers are in the retracted position, which they were. Item 1 states to reactivate the servo-control. At this point, being that I was deactivating the spoiler panels, I didn't think this pertained to the deactivating sequence and didn't complete item (1) and (2). I read the caution, but because of how it was written, again to me, it seemed as if it pertained to the reactivation of the spoiler panel, which I was not doing. At some point, while I was deactivating the spoiler control, I pushed up on the panel, and it didn't move. Since the hydraulic system was shut off and the cannon plugs were removed, I didn't think twice about it. After the inboard spoiler pairs were deactivated, I proceeded to call air carrier mcc and told him I was done. He asked if the chkout procedure had been done, I said no. I went to the flight deck, and with the help of the flight crew, we read and performed the chkout procedures for the computers and the spoiler lockout. When we reached item P on page 15, which states to push up on spoilers to check if they would float, I had checked them before, and they didn't so, I didn't return to the wing to push on them again. At this time, I called air carrier mcc and mr X passed me on to mr Y, the incoming coordinator. I stated what I had performed, and he proceeded to walk me through the logbook and MEL and signoff. On apr/wed/03, I received a call from mr Z, manager maintenance coordination air carrier asking me to write this letter, because the spoilers on A319 had floated in flight. Also, on may/thu/03, I spoke with mr a, air carrier, quality assurance. He was very helpful explaining the procedure, and the essence of the sequence and why the spoilers floated. I, in return, now understand the need for the reactivating procedure, and in no way intentionally failed to do it.
Original NASA ASRS Text
Title: AN AIRBUS 319 WAS DISPATCHED IN NON COMPLIANCE WITH SPOILER PAIRS DEFERRED AS INOP PER THE MEL, BUT SPOILERS NOT LOCKED OUT PER MEL PROCS. DEACTIVATED SPOILERS FLOATED IN FLT.
Narrative: ON APR/WED/03, I WAS CONTACTED BY ACR TO PERFORM CORRECTIVE ACTION ON AN A319 FLT ARRIVING ZZZZ XA15 EST. I CONTACTED ACR, MCC, THEY STATED THAT A FAX WAS BEING SENT TO ZZZ WITH MEL PROCS. A SECOND CALL TO ACR MCC WAS MADE FOR MORE INFO. I SPOKE TO COORD, MR Y, A319 DESK. HE TOLD ME THEY WANTED SECTOR 1 AND SECTOR 3 SWAPPED. WE DISCUSSED WHERE THEY WERE LOCATED AND HOW TO ACCESS THEM. I, USING THE PAPERWORK PROVIDED, PULLED APPROPRIATE CIRCUIT BREAKERS AND SWAPPED BOTH SEC'S. MR X ALSO INFORMED ME TO USE MEL DDG 27-64-01 TO LOCK OUT SPOILER PAIRS 1 AND 2, BECAUSE SEC WAS INOP. I PROCEEDED TO OBTAIN THE PROCS FROM THE MEL MANUAL IN THE FLT DECK. I MADE COPIES OF THEM AND BEGAN THE PROC. I REACHED ITEM E.1 ON PAGE 13 OF DDG27. THIS ITEM STATES: TO DEACTIVATE THE SERVO-CTL. I PROCEEDED TO THE SPOILER ACTUATOR, BUT I COULDN'T FIND THE MAINT KEY STATED ON ITEM (2). I CALLED ACR MCC TO ASK ABOUT ITEM (2). MR Y TOLD ME IT MAY NOT BE THERE, TO JUST REMOVE THE HEX-HEAD CTL SWITCH LOCKING TAB AND TURN THE HEX-HEAD SWITCH TO THE MAINT POS, AND RE-SAFETIED. THEN I REMOVED THE CANNON PLUGS AND TIE-WRAPPED THEM AS STATED. ITEM H STATES TO MAKE SURE THAT THE SPOILERS ARE IN THE RETRACTED POS, WHICH THEY WERE. ITEM 1 STATES TO REACTIVATE THE SERVO-CTL. AT THIS POINT, BEING THAT I WAS DEACTIVATING THE SPOILER PANELS, I DIDN'T THINK THIS PERTAINED TO THE DEACTIVATING SEQUENCE AND DIDN'T COMPLETE ITEM (1) AND (2). I READ THE CAUTION, BUT BECAUSE OF HOW IT WAS WRITTEN, AGAIN TO ME, IT SEEMED AS IF IT PERTAINED TO THE REACTIVATION OF THE SPOILER PANEL, WHICH I WAS NOT DOING. AT SOME POINT, WHILE I WAS DEACTIVATING THE SPOILER CTL, I PUSHED UP ON THE PANEL, AND IT DIDN'T MOVE. SINCE THE HYD SYSTEM WAS SHUT OFF AND THE CANNON PLUGS WERE REMOVED, I DIDN'T THINK TWICE ABOUT IT. AFTER THE INBOARD SPOILER PAIRS WERE DEACTIVATED, I PROCEEDED TO CALL ACR MCC AND TOLD HIM I WAS DONE. HE ASKED IF THE CHKOUT PROC HAD BEEN DONE, I SAID NO. I WENT TO THE FLT DECK, AND WITH THE HELP OF THE FLT CREW, WE READ AND PERFORMED THE CHKOUT PROCS FOR THE COMPUTERS AND THE SPOILER LOCKOUT. WHEN WE REACHED ITEM P ON PAGE 15, WHICH STATES TO PUSH UP ON SPOILERS TO CHK IF THEY WOULD FLOAT, I HAD CHKED THEM BEFORE, AND THEY DIDN'T SO, I DIDN'T RETURN TO THE WING TO PUSH ON THEM AGAIN. AT THIS TIME, I CALLED ACR MCC AND MR X PASSED ME ON TO MR Y, THE INCOMING COORDINATOR. I STATED WHAT I HAD PERFORMED, AND HE PROCEEDED TO WALK ME THROUGH THE LOGBOOK AND MEL AND SIGNOFF. ON APR/WED/03, I RECEIVED A CALL FROM MR Z, MGR MAINT COORD ACR ASKING ME TO WRITE THIS LETTER, BECAUSE THE SPOILERS ON A319 HAD FLOATED IN FLT. ALSO, ON MAY/THU/03, I SPOKE WITH MR A, ACR, QUALITY ASSURANCE. HE WAS VERY HELPFUL EXPLAINING THE PROC, AND THE ESSENCE OF THE SEQUENCE AND WHY THE SPOILERS FLOATED. I, IN RETURN, NOW UNDERSTAND THE NEED FOR THE REACTIVATING PROCEDURE, AND IN NO WAY INTENTIONALLY FAILED TO DO IT.
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.