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|
Attributes | |
ACN | 653618 |
Time | |
Date | 200504 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet 200 ER&LR |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 2 |
ASRS Report | 653618 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : company policies non adherence : published procedure |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : tooling performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication Environmental Factor |
Primary Problem | Maintenance Human Performance |
Narrative:
The morning of apr/sat/05; I was working several work orders on aircraft xxxxx. Other mechanics were changing aileron cable pulleys. I was working an ultrasound inspection of the r-hand main landing gear. This involves bringing the gear in the up position. The other mechanics said they were done with the pulleys and down to close up. We then proceeded to jack the aircraft and commence the ultrasound inspection. I was at the point of swinging the gear and I looked around and found no mechanics near the flight controls. I told everyone around I was going to pressurize the #3 hydraulic system. I went into the cockpit and found no placards and all circuit breakers in. I announced the hydraulics about to be pressurized and again noticed no one near any of the flight controls. I proceeded to turn on the pump and in about 1 second I heard a voice to shut off the pump. Upon inspection; I found toilet paper wedged between the ailerons and the outboard flaps. Both ailerons and the r-hand outboard flap were damaged. The flight controls on this aircraft return to neutral when hydraulic pressure is turned on. I discovered the mechanics working on the ailerons used the rolls of toilet paper to hold the aileron up for ease of installation. They removed the paper when they did the freedom of movement tests along with the placard in the cockpit. When they went to close up; they wedged the ailerons up and forgot the pulled circuit breakers and to replace the placard. Of the many things that contributed to this; complacency is about the biggest. I can't remember how many times I have turned on system without incident. The maintenance manuals did play a part in this. There was several references to the aileron pulley replacement. Along with the maintenance manual; there is a service bulletin out; too. They are different as far as setting up the job. The next shift ended up changing both ailerons and the r-hand outboard flap. Callback conversation with reporter revealed the following information: the airplane was a CRJ200 and undergoing an aileron cable change and the technicians not having the correct tooling to deflect the ailerons up while replacing the cables wedged toilet paper rolls between the ailerons and flaps. No non routine cards were written about the toilet paper rolls insertion in the ailerons and nothing in the cockpit was tagged 'do not operate.'
Original NASA ASRS Text
Title: A CRJ200 PARKED IN HANGAR INCURRED DAMAGE WHEN #3 HYD SYS WAS PRESSURIZED. L AND R AILERONS AND R OUTBOARD FLAP DAMAGED.
Narrative: THE MORNING OF APR/SAT/05; I WAS WORKING SEVERAL WORK ORDERS ON ACFT XXXXX. OTHER MECHS WERE CHANGING AILERON CABLE PULLEYS. I WAS WORKING AN ULTRASOUND INSPECTION OF THE R-HAND MAIN LNDG GEAR. THIS INVOLVES BRINGING THE GEAR IN THE UP POS. THE OTHER MECHS SAID THEY WERE DONE WITH THE PULLEYS AND DOWN TO CLOSE UP. WE THEN PROCEEDED TO JACK THE ACFT AND COMMENCE THE ULTRASOUND INSPECTION. I WAS AT THE POINT OF SWINGING THE GEAR AND I LOOKED AROUND AND FOUND NO MECHS NEAR THE FLT CTLS. I TOLD EVERYONE AROUND I WAS GOING TO PRESSURIZE THE #3 HYD SYS. I WENT INTO THE COCKPIT AND FOUND NO PLACARDS AND ALL CIRCUIT BREAKERS IN. I ANNOUNCED THE HYDS ABOUT TO BE PRESSURIZED AND AGAIN NOTICED NO ONE NEAR ANY OF THE FLT CTLS. I PROCEEDED TO TURN ON THE PUMP AND IN ABOUT 1 SECOND I HEARD A VOICE TO SHUT OFF THE PUMP. UPON INSPECTION; I FOUND TOILET PAPER WEDGED BTWN THE AILERONS AND THE OUTBOARD FLAPS. BOTH AILERONS AND THE R-HAND OUTBOARD FLAP WERE DAMAGED. THE FLT CTLS ON THIS ACFT RETURN TO NEUTRAL WHEN HYD PRESSURE IS TURNED ON. I DISCOVERED THE MECHS WORKING ON THE AILERONS USED THE ROLLS OF TOILET PAPER TO HOLD THE AILERON UP FOR EASE OF INSTALLATION. THEY REMOVED THE PAPER WHEN THEY DID THE FREEDOM OF MOVEMENT TESTS ALONG WITH THE PLACARD IN THE COCKPIT. WHEN THEY WENT TO CLOSE UP; THEY WEDGED THE AILERONS UP AND FORGOT THE PULLED CIRCUIT BREAKERS AND TO REPLACE THE PLACARD. OF THE MANY THINGS THAT CONTRIBUTED TO THIS; COMPLACENCY IS ABOUT THE BIGGEST. I CAN'T REMEMBER HOW MANY TIMES I HAVE TURNED ON SYS WITHOUT INCIDENT. THE MAINT MANUALS DID PLAY A PART IN THIS. THERE WAS SEVERAL REFS TO THE AILERON PULLEY REPLACEMENT. ALONG WITH THE MAINT MANUAL; THERE IS A SVC BULLETIN OUT; TOO. THEY ARE DIFFERENT AS FAR AS SETTING UP THE JOB. THE NEXT SHIFT ENDED UP CHANGING BOTH AILERONS AND THE R-HAND OUTBOARD FLAP. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE AIRPLANE WAS A CRJ200 AND UNDERGOING AN AILERON CABLE CHANGE AND THE TECHNICIANS NOT HAVING THE CORRECT TOOLING TO DEFLECT THE AILERONS UP WHILE REPLACING THE CABLES WEDGED TOILET PAPER ROLLS BTWN THE AILERONS AND FLAPS. NO NON ROUTINE CARDS WERE WRITTEN ABOUT THE TOILET PAPER ROLLS INSERTION IN THE AILERONS AND NOTHING IN THE COCKPIT WAS TAGGED 'DO NOT OPERATE.'
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.