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A B757-200 during a heavy check the trailing edge flaps were extended with a drive unit being replaced and flaps being lubed were suddenly activated.
| Attributes | |
| ACN | 645263 |
| Time | |
| Date | 200501 |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B757-200 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : maintenance ground : parked |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Qualification | technician : powerplant technician : fcc technician : airframe |
| Experience | maintenance avionics : 1 maintenance lead technician : 1 maintenance technician : 20 |
| ASRS Report | 645263 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | maintenance : technician |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
| Independent Detector | other other : 1 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : briefing contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : inspection performance deficiency : scheduled maintenance performance deficiency : testing |
| Supplementary | |
| Problem Areas | Maintenance Human Performance Company Aircraft Environmental Factor |
| Primary Problem | Maintenance Human Performance |
Narrative:
Circuit breakers for electrical pumps; flap control; and auxiliary hydraulic pumps were pulled and tagged with job cards. Flap power drive unit was pinned in inoperative mode. Technicians were assembling and lubricating trailing edge flaps. Someone pushed in circuit breakers and removed pdu lockout; then ran the hydraulic pumps; which caused the flaps to move since the lockout pin was removed. An alternate pin was inserted and tagged with a stamp from the corresponding job tags in the cockpit. The next morning; the pin was again removed. The circuit breakers were again activated (with tags still attached) and the flaps were retracted.
Original NASA ASRS Text
Title: A B757-200 DURING A HVY CHK THE TRAILING EDGE FLAPS WERE EXTENDED WITH A DRIVE UNIT BEING REPLACED AND FLAPS BEING LUBED WERE SUDDENLY ACTIVATED.
Narrative: CIRCUIT BREAKERS FOR ELECTRICAL PUMPS; FLAP CTL; AND AUX HYD PUMPS WERE PULLED AND TAGGED WITH JOB CARDS. FLAP PWR DRIVE UNIT WAS PINNED IN INOP MODE. TECHNICIANS WERE ASSEMBLING AND LUBRICATING TRAILING EDGE FLAPS. SOMEONE PUSHED IN CIRCUIT BREAKERS AND REMOVED PDU LOCKOUT; THEN RAN THE HYD PUMPS; WHICH CAUSED THE FLAPS TO MOVE SINCE THE LOCKOUT PIN WAS REMOVED. AN ALTERNATE PIN WAS INSERTED AND TAGGED WITH A STAMP FROM THE CORRESPONDING JOB TAGS IN THE COCKPIT. THE NEXT MORNING; THE PIN WAS AGAIN REMOVED. THE CIRCUIT BREAKERS WERE AGAIN ACTIVATED (WITH TAGS STILL ATTACHED) AND THE FLAPS WERE RETRACTED.
Data retrieved from NASA's ASRS site as of January 2009 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.