37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 690870 |
Time | |
Date | 200603 |
Place | |
Locale Reference | airport : mia.airport |
State Reference | FL |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-800 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 690870 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | other other : 3 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : inspection performance deficiency : logbook entry performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Flight Crew Human Performance Environmental Factor Company Chart Or Publication Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I was informed that after my flts on this airplane the standby hydraulic system was found pinned in the off position. I preflted this airplane. I always do a thorough exterior preflight. My philosophy is that I want to find problems on the ground; not airborne. The union informed me that the standby hydraulic system was found pinned off and the pin had a flag on it. I guarantee the flag was not visible on any of my preflts. The pin may have been in place and the flag tucked out of view. I have a lot of time on the airplane and know it well but am unaware of this maintenance procedure and its pitfalls. I was also unaware/untrained that the standby system could even be pinned off. It is difficult to come up with a recommendation on how to prevent this kind of thing in the future. It is impossible to come up with a method by which a pilot can catch every possible maintenance failure. Surely there are procedures in place to check and double check work? There were redundant check procedures in place during my time in military aviation maintenance work. From a pilot perspective; the best recommendation that I can suggest is that all maintenance pins should have foolproof visibility device attached to it that cannot render itself indiscernible from a normal aircraft appearance.callback conversation with reporter revealed the following information: the reporter stated the flag must have been rolled up and hidden behind the hydraulic components in the fwd wall of the main wheel well. There is no cockpit test that would reveal the blocked hydraulic system. All of the walk around inspections were performed in a professional manner.
Original NASA ASRS Text
Title: A B737-800 WAS RETURNED TO SVC AND OPERATED FOR SEVERAL DAYS WITH THE STANDBY HYDRAULIC SYSTEM FOUND PINNED IN THE 'OFF' POSITION.
Narrative: I WAS INFORMED THAT AFTER MY FLTS ON THIS AIRPLANE THE STANDBY HYD SYSTEM WAS FOUND PINNED IN THE OFF POSITION. I PREFLTED THIS AIRPLANE. I ALWAYS DO A THOROUGH EXTERIOR PREFLT. MY PHILOSOPHY IS THAT I WANT TO FIND PROBLEMS ON THE GND; NOT AIRBORNE. THE UNION INFORMED ME THAT THE STANDBY HYDRAULIC SYSTEM WAS FOUND PINNED OFF AND THE PIN HAD A FLAG ON IT. I GUARANTEE THE FLAG WAS NOT VISIBLE ON ANY OF MY PREFLTS. THE PIN MAY HAVE BEEN IN PLACE AND THE FLAG TUCKED OUT OF VIEW. I HAVE A LOT OF TIME ON THE AIRPLANE AND KNOW IT WELL BUT AM UNAWARE OF THIS MAINT PROC AND ITS PITFALLS. I WAS ALSO UNAWARE/UNTRAINED THAT THE STANDBY SYSTEM COULD EVEN BE PINNED OFF. IT IS DIFFICULT TO COME UP WITH A RECOMMENDATION ON HOW TO PREVENT THIS KIND OF THING IN THE FUTURE. IT IS IMPOSSIBLE TO COME UP WITH A METHOD BY WHICH A PLT CAN CATCH EVERY POSSIBLE MAINT FAILURE. SURELY THERE ARE PROCS IN PLACE TO CHK AND DOUBLE CHK WORK? THERE WERE REDUNDANT CHK PROCS IN PLACE DURING MY TIME IN MIL AVIATION MAINT WORK. FROM A PLT PERSPECTIVE; THE BEST RECOMMENDATION THAT I CAN SUGGEST IS THAT ALL MAINT PINS SHOULD HAVE FOOLPROOF VISIBILITY DEVICE ATTACHED TO IT THAT CANNOT RENDER ITSELF INDISCERNIBLE FROM A NORMAL ACFT APPEARANCE.CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE FLAG MUST HAVE BEEN ROLLED UP AND HIDDEN BEHIND THE HYDRAULIC COMPONENTS IN THE FWD WALL OF THE MAIN WHEEL WELL. THERE IS NO COCKPIT TEST THAT WOULD REVEAL THE BLOCKED HYDRAULIC SYSTEM. ALL OF THE WALK AROUND INSPECTIONS WERE PERFORMED IN A PROFESSIONAL MANNER.
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.