37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 639017 |
Time | |
Date | 200412 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance lead technician : 4 maintenance technician : 15 |
ASRS Report | 639017 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : lead 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 : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : work cards performance deficiency : repair performance deficiency : logbook entry performance deficiency : testing performance deficiency : non compliance with legal requirements performance deficiency : inspection |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Maint Manual Chap 27 |
Narrative:
Aircraft X was in for routine visit. During an inspection, plugs were found on the elevator feel pitot static turbine. 2 had red streamers attached. A log history search did not reveal any elevator feel write-ups. April/2004 during a hangar psv check, I performed a routine test of the elevator feel pitot static turbine. The test failed due to a leak beyond limits. My lead mechanic wrote a non routine card against the failed test so further troubleshooting, repair, and subsequent retest could be performed. I signed the routine card and the non routine was worked by a mechanic on the next shift. He replaced a cracked elbow in the line and signed the card off as 'replaced elbow and tested per maintenance manual.' the maintenance manual test states to plug the lines and tape over the drain holes in the line, leak test the system, then remove the caps and tape, then reconnect the lines, same as the routine card. On dec/sat/04, there was no tape on the drain holes, and 2 of the plugs were not in the specified area. I was given the job to retest the system and restore the system to normal. The retest revealed a leak at a very high rate. This was at the end of my shift so I short-signed the logbook, and the next crew completed the job. I can only guess what actual events took place for this to have occurred. The mechanic that signed off the non routine card works the shift after me, so I was not there at the completion of the test. An inspector also signed off the non routine card. The psv check done in apr/04 most likely had a card to inspect and close the hatch to the tail compartment. Could the leak found on dec/tue/04 have generated a crew verbal sometime after apr/04, then work started and not completed? If the aircraft left the hangar apr/04 with the caps on, then I feel the best way to prevent a recurrence would be a more detailed set of instructions as to what must be done to complete a non routine discrepancy written against a failed routine test. And if there is not a routine card with an 'ok to close' with an inspector, or a second set of eyes to survey the area, we should create one.
Original NASA ASRS Text
Title: A B757-200 WAS DISCOVERED ON A ROUTINE CHK TO HAVE THE ELEVATOR FEEL PITOT LINES PLUGGED WITH RED STREAMERS ATTACHED. NO RPTED ELEVATOR FEEL RPTS OR WARNINGS.
Narrative: ACFT X WAS IN FOR ROUTINE VISIT. DURING AN INSPECTION, PLUGS WERE FOUND ON THE ELEVATOR FEEL PITOT STATIC TURBINE. 2 HAD RED STREAMERS ATTACHED. A LOG HISTORY SEARCH DID NOT REVEAL ANY ELEVATOR FEEL WRITE-UPS. APRIL/2004 DURING A HANGAR PSV CHK, I PERFORMED A ROUTINE TEST OF THE ELEVATOR FEEL PITOT STATIC TURBINE. THE TEST FAILED DUE TO A LEAK BEYOND LIMITS. MY LEAD MECH WROTE A NON ROUTINE CARD AGAINST THE FAILED TEST SO FURTHER TROUBLESHOOTING, REPAIR, AND SUBSEQUENT RETEST COULD BE PERFORMED. I SIGNED THE ROUTINE CARD AND THE NON ROUTINE WAS WORKED BY A MECH ON THE NEXT SHIFT. HE REPLACED A CRACKED ELBOW IN THE LINE AND SIGNED THE CARD OFF AS 'REPLACED ELBOW AND TESTED PER MAINT MANUAL.' THE MAINT MANUAL TEST STATES TO PLUG THE LINES AND TAPE OVER THE DRAIN HOLES IN THE LINE, LEAK TEST THE SYS, THEN REMOVE THE CAPS AND TAPE, THEN RECONNECT THE LINES, SAME AS THE ROUTINE CARD. ON DEC/SAT/04, THERE WAS NO TAPE ON THE DRAIN HOLES, AND 2 OF THE PLUGS WERE NOT IN THE SPECIFIED AREA. I WAS GIVEN THE JOB TO RETEST THE SYS AND RESTORE THE SYS TO NORMAL. THE RETEST REVEALED A LEAK AT A VERY HIGH RATE. THIS WAS AT THE END OF MY SHIFT SO I SHORT-SIGNED THE LOGBOOK, AND THE NEXT CREW COMPLETED THE JOB. I CAN ONLY GUESS WHAT ACTUAL EVENTS TOOK PLACE FOR THIS TO HAVE OCCURRED. THE MECH THAT SIGNED OFF THE NON ROUTINE CARD WORKS THE SHIFT AFTER ME, SO I WAS NOT THERE AT THE COMPLETION OF THE TEST. AN INSPECTOR ALSO SIGNED OFF THE NON ROUTINE CARD. THE PSV CHK DONE IN APR/04 MOST LIKELY HAD A CARD TO INSPECT AND CLOSE THE HATCH TO THE TAIL COMPARTMENT. COULD THE LEAK FOUND ON DEC/TUE/04 HAVE GENERATED A CREW VERBAL SOMETIME AFTER APR/04, THEN WORK STARTED AND NOT COMPLETED? IF THE ACFT LEFT THE HANGAR APR/04 WITH THE CAPS ON, THEN I FEEL THE BEST WAY TO PREVENT A RECURRENCE WOULD BE A MORE DETAILED SET OF INSTRUCTIONS AS TO WHAT MUST BE DONE TO COMPLETE A NON ROUTINE DISCREPANCY WRITTEN AGAINST A FAILED ROUTINE TEST. AND IF THERE IS NOT A ROUTINE CARD WITH AN 'OK TO CLOSE' WITH AN INSPECTOR, OR A SECOND SET OF EYES TO SURVEY THE AREA, WE SHOULD CREATE ONE.
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.