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|
Attributes | |
ACN | 657825 |
Time | |
Date | 200505 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : las.airport |
State Reference | NV |
Altitude | msl single value : 8000 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : las.tower |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff climbout : initial |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
Experience | maintenance technician : 17 |
ASRS Report | 657825 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 656791 |
Events | |
Anomaly | aircraft equipment problem : less severe maintenance problem : improper maintenance maintenance problem : non compliance with mel non adherence : far non adherence : company policies non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : ecam other flight crewa |
Resolutory Action | other |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : non compliance with legal requirements performance deficiency : repair |
Supplementary | |
Problem Areas | Aircraft Company Flight Crew Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I had a mandatory through-flight check on an airbus A320. I had an open write-up for a possible bird strike on the horizontal stabilizer. The tip was damaged and needed to be replaced. Per the maintenance manual; 3 circuit breakers needed to be pulled: ths mot 1; ths mot 2; ths mot 3. I pulled and tagged all 3 breakers. I also placed a sign on the flight deck door stating 'maintenance in progress do not run system.' I proceeded to change the tip. The new part didn't arrive till close to departure time and the end of my shift; but I completed the installation and signed off the bird strike write-up. I made a new write-up stating a cure time was required for the sealant. The mandatory through-flight write-up was also still open and the task card signed except for the block that states all logbook discrepancies are corrected. The next shift verified that the sealant was cured and signed off the logbook and returned it to the flight crew. I had failed to inform them that the breakers were pulled and tagged and the flight crew didn't see that the breakers were not reset. The aircraft took off and got numerous messages and returned to the airport. Maintenance met the aircraft and found that the breakers were still pulled and tagged. To prevent this from happening again; I am writing a task card to change the tip that will require an inspection buy-off for resetting the circuit breakers. This incident shows the importance of following the maintenance manuals; good turn-over and not getting into a hurry. Fortunately; the flight crew was able to get the plane down safely and no one was hurt. Supplemental information from acn 656791: on taxi out; all flight controls checked normal; everything was green on the flight control page; and the status page was blank. Our first indication that something was amiss was the ecams received while airborne. In retrospect; we obviously needed to slow down while everyone seemed to be pushing for departure. Furthermore; just because maintenance says clean bird and hands you the logbook; the burden of certainty remains with us.
Original NASA ASRS Text
Title: RUNNING BEHIND SCHEDULE DUE TO MAINT; A320 RETURNS TO DEP STATION AFTER RECEIVING MULTIPLE ECAM ERROR MESSAGES. DISCOVER CIRCUIT BREAKERS PULLED FOR MAINT PURPOSES WERE NOT RESET PRIOR TO DEP.
Narrative: I HAD A MANDATORY THROUGH-FLT CHK ON AN AIRBUS A320. I HAD AN OPEN WRITE-UP FOR A POSSIBLE BIRD STRIKE ON THE HORIZ STABILIZER. THE TIP WAS DAMAGED AND NEEDED TO BE REPLACED. PER THE MAINT MANUAL; 3 CIRCUIT BREAKERS NEEDED TO BE PULLED: THS MOT 1; THS MOT 2; THS MOT 3. I PULLED AND TAGGED ALL 3 BREAKERS. I ALSO PLACED A SIGN ON THE FLT DECK DOOR STATING 'MAINT IN PROGRESS DO NOT RUN SYS.' I PROCEEDED TO CHANGE THE TIP. THE NEW PART DIDN'T ARRIVE TILL CLOSE TO DEP TIME AND THE END OF MY SHIFT; BUT I COMPLETED THE INSTALLATION AND SIGNED OFF THE BIRD STRIKE WRITE-UP. I MADE A NEW WRITE-UP STATING A CURE TIME WAS REQUIRED FOR THE SEALANT. THE MANDATORY THROUGH-FLT WRITE-UP WAS ALSO STILL OPEN AND THE TASK CARD SIGNED EXCEPT FOR THE BLOCK THAT STATES ALL LOGBOOK DISCREPANCIES ARE CORRECTED. THE NEXT SHIFT VERIFIED THAT THE SEALANT WAS CURED AND SIGNED OFF THE LOGBOOK AND RETURNED IT TO THE FLT CREW. I HAD FAILED TO INFORM THEM THAT THE BREAKERS WERE PULLED AND TAGGED AND THE FLT CREW DIDN'T SEE THAT THE BREAKERS WERE NOT RESET. THE ACFT TOOK OFF AND GOT NUMEROUS MESSAGES AND RETURNED TO THE ARPT. MAINT MET THE ACFT AND FOUND THAT THE BREAKERS WERE STILL PULLED AND TAGGED. TO PREVENT THIS FROM HAPPENING AGAIN; I AM WRITING A TASK CARD TO CHANGE THE TIP THAT WILL REQUIRE AN INSPECTION BUY-OFF FOR RESETTING THE CIRCUIT BREAKERS. THIS INCIDENT SHOWS THE IMPORTANCE OF FOLLOWING THE MAINT MANUALS; GOOD TURN-OVER AND NOT GETTING INTO A HURRY. FORTUNATELY; THE FLT CREW WAS ABLE TO GET THE PLANE DOWN SAFELY AND NO ONE WAS HURT. SUPPLEMENTAL INFO FROM ACN 656791: ON TAXI OUT; ALL FLT CTLS CHKED NORMAL; EVERYTHING WAS GREEN ON THE FLT CTL PAGE; AND THE STATUS PAGE WAS BLANK. OUR FIRST INDICATION THAT SOMETHING WAS AMISS WAS THE ECAMS RECEIVED WHILE AIRBORNE. IN RETROSPECT; WE OBVIOUSLY NEEDED TO SLOW DOWN WHILE EVERYONE SEEMED TO BE PUSHING FOR DEP. FURTHERMORE; JUST BECAUSE MAINT SAYS CLEAN BIRD AND HANDS YOU THE LOGBOOK; THE BURDEN OF CERTAINTY REMAINS WITH US.
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.