37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 697159 |
Time | |
Date | 200605 |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Dash 8-400 |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 697159 |
Events | |
Anomaly | ground encounters : vehicle non adherence : published procedure non adherence : far other anomaly |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | performance deficiency : unqualified personnel performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
Received notification from our maintenance controller that aircraft had a pilot report of problems with the nosewheel steering system. At around xa:20 I heard the mechanics call for the tow team to pull the aircraft forward onto grease plates for troubleshooting. At around xa:15 I heard the mechanic call again asking for tow team support. At around xa:20 I instructed my lead and mechanics to use the aircraft engines to move the aircraft forward onto the grease plates so the troubleshooting could continue. The mechanics cleared the immediate area around the aircraft of obstructions and began a pre-start walkaround of the aircraft. At the time the aircraft was approximately 2 ft short of the normal parking stop line and need to be repositioned approximately 12 inches forward so there was sufficient clearance for movement. Mechanic 1 went into the flight deck and started the pre-start checklist; mechanic 2 went to the nose to act as an observer; and mechanic 3 was inside or near a maintenance van parked approximately 30 ft forward of the #1 engine. I noticed the #2 engine come to the start and feather condition and then to what appeared to be the flight idle min position. The aircraft started to move very slowly and at about 12 inches I noticed the observer signal the mechanic in the pilot seat to stop. The aircraft did stop after about another 12 inches but slipped to the right about 2 ft while on the grease pads. The aircraft then briefly stopped but started to roll backwards for about 5 ft; stopped again; and then started moving very slowly forward. About 15 ft after the aircraft started moving forward it appeared that the mechanic in the pilot seat shut down the #2 engine. The aircraft continued to roll very slowly with the #2 propeller still turning. At about 25 ft; the #2 propeller struck a maintenance stand while it was still turning. Additionally the #1 propeller was static but contacted a maintenance van that had been about 30 ft in front of the aircraft. Other damage included damage to the gpu power receptacle caused by the ground cord being pulled out during the aircraft movement. It appears that the mechanic running the engines did not follow established procedures and complete the engine start checklist before starting engines. He released the parking brake before starting the #1 engine and did not have the #1 spu on. This condition resulted in not having normal brake system pressure. The mechanic also failed to react to the situation quickly and did not reset the parking brake until after impacting the stand and maintenance vehicle.
Original NASA ASRS Text
Title: A DHC-8-400 WITH A PILOT REPORT OF NOSE STEERING TROUBLE. SUPERVISOR INSTRUCTS TECHNICIANS TO MOVE AIRCRAFT WITH ENGINE POWER. LOSS OF AIRCRAFT CONTROL INCURRED DAMAGE TO AIRCRAFT AND GROUND EQUIPMENT.
Narrative: RECEIVED NOTIFICATION FROM OUR MAINT CTLR THAT ACFT HAD A PLT REPORT OF PROBS WITH THE NOSEWHEEL STEERING SYSTEM. AT AROUND XA:20 I HEARD THE MECHS CALL FOR THE TOW TEAM TO PULL THE ACFT FORWARD ONTO GREASE PLATES FOR TROUBLESHOOTING. AT AROUND XA:15 I HEARD THE MECH CALL AGAIN ASKING FOR TOW TEAM SUPPORT. AT AROUND XA:20 I INSTRUCTED MY LEAD AND MECHS TO USE THE ACFT ENGS TO MOVE THE ACFT FORWARD ONTO THE GREASE PLATES SO THE TROUBLESHOOTING COULD CONTINUE. THE MECHS CLEARED THE IMMEDIATE AREA AROUND THE ACFT OF OBSTRUCTIONS AND BEGAN A PRE-START WALKAROUND OF THE ACFT. AT THE TIME THE ACFT WAS APPROX 2 FT SHORT OF THE NORMAL PARKING STOP LINE AND NEED TO BE REPOSITIONED APPROX 12 INCHES FORWARD SO THERE WAS SUFFICIENT CLRNC FOR MOVEMENT. MECH 1 WENT INTO THE FLT DECK AND STARTED THE PRE-START CHKLIST; MECH 2 WENT TO THE NOSE TO ACT AS AN OBSERVER; AND MECH 3 WAS INSIDE OR NEAR A MAINT VAN PARKED APPROX 30 FT FORWARD OF THE #1 ENG. I NOTICED THE #2 ENG COME TO THE START AND FEATHER CONDITION AND THEN TO WHAT APPEARED TO BE THE FLT IDLE MIN POSITION. THE ACFT STARTED TO MOVE VERY SLOWLY AND AT ABOUT 12 INCHES I NOTICED THE OBSERVER SIGNAL THE MECH IN THE PLT SEAT TO STOP. THE ACFT DID STOP AFTER ABOUT ANOTHER 12 INCHES BUT SLIPPED TO THE RIGHT ABOUT 2 FT WHILE ON THE GREASE PADS. THE ACFT THEN BRIEFLY STOPPED BUT STARTED TO ROLL BACKWARDS FOR ABOUT 5 FT; STOPPED AGAIN; AND THEN STARTED MOVING VERY SLOWLY FORWARD. ABOUT 15 FT AFTER THE ACFT STARTED MOVING FORWARD IT APPEARED THAT THE MECH IN THE PLT SEAT SHUT DOWN THE #2 ENG. THE ACFT CONTINUED TO ROLL VERY SLOWLY WITH THE #2 PROP STILL TURNING. AT ABOUT 25 FT; THE #2 PROP STRUCK A MAINT STAND WHILE IT WAS STILL TURNING. ADDITIONALLY THE #1 PROP WAS STATIC BUT CONTACTED A MAINT VAN THAT HAD BEEN ABOUT 30 FT IN FRONT OF THE ACFT. OTHER DAMAGE INCLUDED DAMAGE TO THE GPU POWER RECEPTACLE CAUSED BY THE GND CORD BEING PULLED OUT DURING THE ACFT MOVEMENT. IT APPEARS THAT THE MECH RUNNING THE ENGS DID NOT FOLLOW ESTABLISHED PROCS AND COMPLETE THE ENG START CHKLIST BEFORE STARTING ENGS. HE RELEASED THE PARKING BRAKE BEFORE STARTING THE #1 ENG AND DID NOT HAVE THE #1 SPU ON. THIS CONDITION RESULTED IN NOT HAVING NORMAL BRAKE SYSTEM PRESSURE. THE MECH ALSO FAILED TO REACT TO THE SITUATION QUICKLY AND DID NOT RESET THE PARKING BRAKE UNTIL AFTER IMPACTING THE STAND AND MAINT VEHICLE.
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.