37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 663987 |
Time | |
Date | 200507 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl single value : 400 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B727-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : flight engineer technician : airframe technician : powerplant |
Experience | flight time total : 5000 flight time type : 275 |
ASRS Report | 663987 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : nose gear unsafe light other flight crewa other flight crewb other other : 1 |
Resolutory Action | flight crew : diverted to another airport other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : installation performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : inspection |
Supplementary | |
Problem Areas | Maintenance Human Performance Flight Crew Human Performance Chart Or Publication Aircraft Environmental Factor |
Primary Problem | Maintenance Human Performance |
Narrative:
We arrived to aircraft X at XA30 in ZZZ. Aircraft was on the gate and we went straight to the aircraft. It was noted that maintenance was still working on the aircraft and it might be a while before we could get going. The items in work were a low pressure light on the #2 'B' pump would not illuminate and they were chasing a hydraulic leak in the forward belly. They had the forward pit floor pulled up in sections and the a&east door removed to troubleshoot the leak. We were not able to do a preflight due to the amount of work being performed on the aircraft and so I decided to just do my flow upstairs and do the cockpit preflight without hydraulics. On the preflight we found the left wing anti-ice valve would not indicate closed. I advised maintenance; and they added it to the list. We also found the fire warning test on the engines would not ring the bell. I informed maintenance and they added it to the list. The senior found 2 items in the cabin that had to be fixed before loading passenger. I informed maintenance and they added it to the list. So to this point maintenance had their hands full and our flows were messed up because of the amount of system being worked. I still had not started the APU yet because of the troubleshooting on the wing ice valve. During my preflight; I had looked at the gear pins and pitot covers laying on the aircraft library. I had reviewed the logbook and noted the signoffs of the pins and covers and maintenance release of the aircraft. I did not notice that only 2 pins were wrapped up; I just looked and saw pins wrapped up. That was my first mistake. We were still trying for an on-time departure because it seemed feasible to us that it could still be done. We had maintenance defer the wing ice valve and close up the belly and defer the low pressure light and just accepted the fire bell and would write it up in ZZZ1. 10 mins till departure; I still had not done my walkaround because maintenance was still closing up. Finally; I proceeded to finish my external preflight because that was all that was left. I performed a normal external preflight and even remember looking at the nose gear; but at the time I was not looking for a pin because I saw the pins upstairs. Second mistake. Walkaround was completed; I finished my paperwork and we departed on time out of ZZZ. We could not get the nose gear up because the pin had not been removed and I missed it on my walkaround. We did an air turnback; landed in ZZZ; removed the pin and took on some more fuel and departed shortly after that. No other problems were noted. Maintenance had installed the nose pin while troubleshooting the hydraulic leak in the belly and never pulled it. I missed it on my walkaround. All I can say is; I learned another valuable lesson and I bet I will never take off again without all my pins.
Original NASA ASRS Text
Title: A B727-200 WAS DISPATCHED WITH THE NOSE LNDG GEAR LOCK PIN INSTALLED. RETURNED TO THE FIELD AND REMOVED PIN. CAUSED BY PREDEP DISTRS.
Narrative: WE ARRIVED TO ACFT X AT XA30 IN ZZZ. ACFT WAS ON THE GATE AND WE WENT STRAIGHT TO THE ACFT. IT WAS NOTED THAT MAINT WAS STILL WORKING ON THE ACFT AND IT MIGHT BE A WHILE BEFORE WE COULD GET GOING. THE ITEMS IN WORK WERE A LOW PRESSURE LIGHT ON THE #2 'B' PUMP WOULD NOT ILLUMINATE AND THEY WERE CHASING A HYD LEAK IN THE FORWARD BELLY. THEY HAD THE FORWARD PIT FLOOR PULLED UP IN SECTIONS AND THE A&E DOOR REMOVED TO TROUBLESHOOT THE LEAK. WE WERE NOT ABLE TO DO A PREFLT DUE TO THE AMOUNT OF WORK BEING PERFORMED ON THE ACFT AND SO I DECIDED TO JUST DO MY FLOW UPSTAIRS AND DO THE COCKPIT PREFLT WITHOUT HYDS. ON THE PREFLT WE FOUND THE L WING ANTI-ICE VALVE WOULD NOT INDICATE CLOSED. I ADVISED MAINT; AND THEY ADDED IT TO THE LIST. WE ALSO FOUND THE FIRE WARNING TEST ON THE ENGS WOULD NOT RING THE BELL. I INFORMED MAINT AND THEY ADDED IT TO THE LIST. THE SENIOR FOUND 2 ITEMS IN THE CABIN THAT HAD TO BE FIXED BEFORE LOADING PAX. I INFORMED MAINT AND THEY ADDED IT TO THE LIST. SO TO THIS POINT MAINT HAD THEIR HANDS FULL AND OUR FLOWS WERE MESSED UP BECAUSE OF THE AMOUNT OF SYS BEING WORKED. I STILL HAD NOT STARTED THE APU YET BECAUSE OF THE TROUBLESHOOTING ON THE WING ICE VALVE. DURING MY PREFLT; I HAD LOOKED AT THE GEAR PINS AND PITOT COVERS LAYING ON THE ACFT LIBRARY. I HAD REVIEWED THE LOGBOOK AND NOTED THE SIGNOFFS OF THE PINS AND COVERS AND MAINT RELEASE OF THE ACFT. I DID NOT NOTICE THAT ONLY 2 PINS WERE WRAPPED UP; I JUST LOOKED AND SAW PINS WRAPPED UP. THAT WAS MY FIRST MISTAKE. WE WERE STILL TRYING FOR AN ON-TIME DEP BECAUSE IT SEEMED FEASIBLE TO US THAT IT COULD STILL BE DONE. WE HAD MAINT DEFER THE WING ICE VALVE AND CLOSE UP THE BELLY AND DEFER THE LOW PRESSURE LIGHT AND JUST ACCEPTED THE FIRE BELL AND WOULD WRITE IT UP IN ZZZ1. 10 MINS TILL DEP; I STILL HAD NOT DONE MY WALKAROUND BECAUSE MAINT WAS STILL CLOSING UP. FINALLY; I PROCEEDED TO FINISH MY EXTERNAL PREFLT BECAUSE THAT WAS ALL THAT WAS LEFT. I PERFORMED A NORMAL EXTERNAL PREFLT AND EVEN REMEMBER LOOKING AT THE NOSE GEAR; BUT AT THE TIME I WAS NOT LOOKING FOR A PIN BECAUSE I SAW THE PINS UPSTAIRS. SECOND MISTAKE. WALKAROUND WAS COMPLETED; I FINISHED MY PAPERWORK AND WE DEPARTED ON TIME OUT OF ZZZ. WE COULD NOT GET THE NOSE GEAR UP BECAUSE THE PIN HAD NOT BEEN REMOVED AND I MISSED IT ON MY WALKAROUND. WE DID AN AIR TURNBACK; LANDED IN ZZZ; REMOVED THE PIN AND TOOK ON SOME MORE FUEL AND DEPARTED SHORTLY AFTER THAT. NO OTHER PROBS WERE NOTED. MAINT HAD INSTALLED THE NOSE PIN WHILE TROUBLESHOOTING THE HYD LEAK IN THE BELLY AND NEVER PULLED IT. I MISSED IT ON MY WALKAROUND. ALL I CAN SAY IS; I LEARNED ANOTHER VALUABLE LESSON AND I BET I WILL NEVER TAKE OFF AGAIN WITHOUT ALL MY PINS.
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.