37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 622722 |
Time | |
Date | 200406 |
Day | Mon |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : inspector |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 5.5 |
ASRS Report | 622722 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : company policies non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | flight crew : overcame equipment problem flight crew : regained aircraft control |
Consequence | other other |
Factors | |
Maintenance | contributing factor : briefing contributing factor : schedule pressure contributing factor : work cards performance deficiency : scheduled maintenance performance deficiency : testing performance deficiency : inspection performance deficiency : installation performance deficiency : logbook entry performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Environmental Factor Chart Or Publication Aircraft |
Primary Problem | Chart Or Publication |
Situations | |
Publication | Maint Manual |
Narrative:
On mon june 2004, I inspected the reconnection of the brake pedal bus pushrods that had been disconnected for maintenance. The mechanic told me he reconnected them on the right side of the aircraft. I saw that everything was hooked up correctly as per the maintenance manual. This is where the maintenance manual tells you to disconnect the rods, and also adjust them if required. Apparently whoever disconnected the forward rod did it in the middle of the rod where it is separated, so it can be removed from the aircraft. This rod being left loose when the aircraft was returned to service, jammed up on a flight on or about mon june 2004. When the captain applied the brakes they didn't work, but they did work on the first officer's side. I believe the whole situation would have been avoided if the item had been written up differently on the non-routine card, and documented better. The item was written up as, 'hydraulic brake quadrant cross-over rods disconnected for maintenance.' it should have said, 'disconnect the brake pedal bus pushrods for maintenance.' the way it was written up nobody documented where they were disconnected, or who disconnected them. If this work had been better documented, this would have never happened. Nowhere in the maintenance manual does it mention the bolt in the middle of the forward rod. Callback conversation with reporter revealed the following information: the reporter stated the rods were disconnected at the rod ends except the most forward rod, which was disconnected at the center disconnect. The reporter said neither the maintenance manual nor the non-routine write up describes the center disconnect. The reporter stated the inspection of the installation was made at both left and right rod ends, overlooking the center connection. The reporter said the corrections to the maintenance manual have been sent to technical publications. The reporter stated more training must be given to technicians writing non-routine cards to clearly describe the job, what was done, and location.
Original NASA ASRS Text
Title: A B737-700 WHILE TAXIING THE CAPT HAD NO BRAKE CTL. MAINT FOUND FORWARD BRAKE CROSS-OVER ROD DISCONNECTED AT CENTER DISCONNECT.
Narrative: ON MON JUNE 2004, I INSPECTED THE RECONNECTION OF THE BRAKE PEDAL BUS PUSHRODS THAT HAD BEEN DISCONNECTED FOR MAINT. THE MECHANIC TOLD ME HE RECONNECTED THEM ON THE R SIDE OF THE ACFT. I SAW THAT EVERYTHING WAS HOOKED UP CORRECTLY AS PER THE MAINT MANUAL. THIS IS WHERE THE MAINT MANUAL TELLS YOU TO DISCONNECT THE RODS, AND ALSO ADJUST THEM IF REQUIRED. APPARENTLY WHOEVER DISCONNECTED THE FORWARD ROD DID IT IN THE MIDDLE OF THE ROD WHERE IT IS SEPARATED, SO IT CAN BE REMOVED FROM THE ACFT. THIS ROD BEING LEFT LOOSE WHEN THE ACFT WAS RETURNED TO SERVICE, JAMMED UP ON A FLT ON OR ABOUT MON JUNE 2004. WHEN THE CAPT APPLIED THE BRAKES THEY DIDN'T WORK, BUT THEY DID WORK ON THE FO'S SIDE. I BELIEVE THE WHOLE SIT WOULD HAVE BEEN AVOIDED IF THE ITEM HAD BEEN WRITTEN UP DIFFERENTLY ON THE NON-ROUTINE CARD, AND DOCUMENTED BETTER. THE ITEM WAS WRITTEN UP AS, 'HYD BRAKE QUADRANT CROSS-OVER RODS DISCONNECTED FOR MAINT.' IT SHOULD HAVE SAID, 'DISCONNECT THE BRAKE PEDAL BUS PUSHRODS FOR MAINT.' THE WAY IT WAS WRITTEN UP NOBODY DOCUMENTED WHERE THEY WERE DISCONNECTED, OR WHO DISCONNECTED THEM. IF THIS WORK HAD BEEN BETTER DOCUMENTED, THIS WOULD HAVE NEVER HAPPENED. NOWHERE IN THE MAINT MANUAL DOES IT MENTION THE BOLT IN THE MIDDLE OF THE FORWARD ROD. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE RODS WERE DISCONNECTED AT THE ROD ENDS EXCEPT THE MOST FORWARD ROD, WHICH WAS DISCONNECTED AT THE CENTER DISCONNECT. THE RPTR SAID NEITHER THE MAINT MANUAL NOR THE NON-ROUTINE WRITE UP DESCRIBES THE CENTER DISCONNECT. THE RPTR STATED THE INSPECTION OF THE INSTALLATION WAS MADE AT BOTH L AND R ROD ENDS, OVERLOOKING THE CENTER CONNECTION. THE RPTR SAID THE CORRECTIONS TO THE MAINT MANUAL HAVE BEEN SENT TO TECHNICAL PUBLICATIONS. THE RPTR STATED MORE TRAINING MUST BE GIVEN TO TECHNICIANS WRITING NON-ROUTINE CARDS TO CLEARLY DESCRIBE THE JOB, WHAT WAS DONE, AND LOCATION.
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.