37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 630943 |
Time | |
Date | 200408 |
Day | Fri |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 4 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-500 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 23 |
ASRS Report | 630943 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 22 |
ASRS Report | 630803 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : manuals performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Maintenance Human Performance |
Primary Problem | Chart Or Publication |
Situations | |
Publication | Maint Manual |
Narrative:
Replaced standby hydraulic module in medium large transport wheel well per maintenance manual on aug/fri/2004. On sept/fri/2004, hydraulic line for reverse was found not hooked up to module. Maintenance manual does not reference a plug to be removed or an adapter to be installed on the standby hydraulic module for reverser line to be connected. Maintenance manual does not reference an operational test of the reversers upon completion of standby hydraulic module replacement. Had either item been stated in the maintenance manual, I believe the error would not have taken place. Supplemental information from acn 630803: accomplished leak check of module after unit replaced. Accomplished operational test of standby module. Test passed reference maintenance manual. Reference illustrated parts catalog. This job was accomplished after a turnover from previous crew, which had already changed module, but new module was bad (cracked) same place original was. We continued on with new part. Callback conversation with reporter acn 630943 revealed the following information: the reporter stated the reverser line that should have been attached to the standby hydraulic power unit was disconnected by another shift during the module removal and pushed back behind the 'B' pumps out of sight. The reporter said the standby hydraulic power unit was installed per the maintenance manual and tested ok for service. The reporter stated the manual does not call out the installation of the adapter for the reverser line. The reporter said the reverser was not on the operational test in the maintenance manual. The reporter stated the illustrated parts catalog pictorial view of the standby hydraulic module shows the reverser port having a plug installed not an adapter fitting for a line connection. The reporter said the reverser line adapter fittings and 'O' ring seals were to be included with the unit received from stores but were not with the module.
Original NASA ASRS Text
Title: A B737-500 WAS DISPATCHED IN NON COMPLIANCE WITH A REVERSER LINE NOT CONNECTED TO THE STANDBY HYDRAULIC POWER MODULE.
Narrative: REPLACED STANDBY HYDRAULIC MODULE IN MLG WHEEL WELL PER MAINT MANUAL ON AUG/FRI/2004. ON SEPT/FRI/2004, HYDRAULIC LINE FOR REVERSE WAS FOUND NOT HOOKED UP TO MODULE. MAINT MANUAL DOES NOT REFERENCE A PLUG TO BE REMOVED OR AN ADAPTER TO BE INSTALLED ON THE STANDBY HYDRAULIC MODULE FOR REVERSER LINE TO BE CONNECTED. MAINT MANUAL DOES NOT REFERENCE AN OPERATIONAL TEST OF THE REVERSERS UPON COMPLETION OF STANDBY HYDRAULIC MODULE REPLACEMENT. HAD EITHER ITEM BEEN STATED IN THE MAINT MANUAL, I BELIEVE THE ERROR WOULD NOT HAVE TAKEN PLACE. SUPPLEMENTAL INFO FROM ACN 630803: ACCOMPLISHED LEAK CHECK OF MODULE AFTER UNIT REPLACED. ACCOMPLISHED OPERATIONAL TEST OF STANDBY MODULE. TEST PASSED REFERENCE MAINT MANUAL. REFERENCE ILLUSTRATED PARTS CATALOG. THIS JOB WAS ACCOMPLISHED AFTER A TURNOVER FROM PREVIOUS CREW, WHICH HAD ALREADY CHANGED MODULE, BUT NEW MODULE WAS BAD (CRACKED) SAME PLACE ORIGINAL WAS. WE CONTINUED ON WITH NEW PART. CALLBACK CONVERSATION WITH RPTR ACN 630943 REVEALED THE FOLLOWING INFO: THE RPTR STATED THE REVERSER LINE THAT SHOULD HAVE BEEN ATTACHED TO THE STANDBY HYDRAULIC POWER UNIT WAS DISCONNECTED BY ANOTHER SHIFT DURING THE MODULE REMOVAL AND PUSHED BACK BEHIND THE 'B' PUMPS OUT OF SIGHT. THE RPTR SAID THE STANDBY HYDRAULIC PWR UNIT WAS INSTALLED PER THE MAINT MANUAL AND TESTED OK FOR SERVICE. THE RPTR STATED THE MANUAL DOES NOT CALL OUT THE INSTALLATION OF THE ADAPTER FOR THE REVERSER LINE. THE RPTR SAID THE REVERSER WAS NOT ON THE OPERATIONAL TEST IN THE MAINT MANUAL. THE RPTR STATED THE ILLUSTRATED PARTS CATALOG PICTORIAL VIEW OF THE STANDBY HYDRAULIC MODULE SHOWS THE REVERSER PORT HAVING A PLUG INSTALLED NOT AN ADAPTER FITTING FOR A LINE CONNECTION. THE RPTR SAID THE REVERSER LINE ADAPTER FITTINGS AND 'O' RING SEALS WERE TO BE INCLUDED WITH THE UNIT RECEIVED FROM STORES BUT WERE NOT WITH THE MODULE.
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.