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Attributes | |
ACN | 702114 |
Time | |
Date | 200606 |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
ASRS Report | 702114 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 701499 |
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 : position indication light other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : manuals performance deficiency : installation performance deficiency : inspection performance deficiency : testing performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Cabin Crew Human Performance |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | Flt Crew Manual |
Narrative:
This report is in reference to my operation of aircraft X on jun/wed/06; with the right main landing gear auxiliary down and locked sensor not installed. This occurred because maintenance personnel failed to reinstall the sensor unit after replacement of the right main gear. The auxiliary landing gear lights are only checked during a lights test; during which the auxiliary gear lights illuminated properly. There is no normal procedure or flow in the B737-200 manual that has either crew member check the auxiliary gear lights other than the lights test. During the flight deck safety inspection; the crew member doing the flow checks that the gear lever is in the down position; and the forward panel down and locked lights are illuminated. In addition the flight handbook that the manual replaced references 3 green lights during the flow versus 5 green lights. The B737NG series aircraft references 3 green lights versus the 6 down and locked lights that are installed. During the yrs that I've been operating and teaching the B737-200; the auxiliary gear lights have only been checked during the lights test; or when there was an abnormal indication with the forward panel down and locked lights. In order to prevent this from occurring in the future; I would suggest that the manual be modified to include all 5 green gear lights be illuminated; and make this change an emphasis item during recurrent training. Kudos should be given to the crew member who found this issue; even though it was not part of their flow or check.
Original NASA ASRS Text
Title: A B737-200 WAS RELEASED FOR SVC WITH THE R MAIN GEAR AUX DOWN AND LOCK SENSOR NOT INSTALLED. NO NORMAL FLOW PROC IN FLT MANUAL FOR LIGHT TEST AND ONLY REFS 3 GREEN.
Narrative: THIS RPT IS IN REF TO MY OP OF ACFT X ON JUN/WED/06; WITH THE R MAIN LNDG GEAR AUX DOWN AND LOCKED SENSOR NOT INSTALLED. THIS OCCURRED BECAUSE MAINT PERSONNEL FAILED TO REINSTALL THE SENSOR UNIT AFTER REPLACEMENT OF THE R MAIN GEAR. THE AUX LNDG GEAR LIGHTS ARE ONLY CHKED DURING A LIGHTS TEST; DURING WHICH THE AUX GEAR LIGHTS ILLUMINATED PROPERLY. THERE IS NO NORMAL PROC OR FLOW IN THE B737-200 MANUAL THAT HAS EITHER CREW MEMBER CHK THE AUX GEAR LIGHTS OTHER THAN THE LIGHTS TEST. DURING THE FLT DECK SAFETY INSPECTION; THE CREW MEMBER DOING THE FLOW CHKS THAT THE GEAR LEVER IS IN THE DOWN POS; AND THE FORWARD PANEL DOWN AND LOCKED LIGHTS ARE ILLUMINATED. IN ADDITION THE FLT HANDBOOK THAT THE MANUAL REPLACED REFS 3 GREEN LIGHTS DURING THE FLOW VERSUS 5 GREEN LIGHTS. THE B737NG SERIES ACFT REFS 3 GREEN LIGHTS VERSUS THE 6 DOWN AND LOCKED LIGHTS THAT ARE INSTALLED. DURING THE YRS THAT I'VE BEEN OPERATING AND TEACHING THE B737-200; THE AUX GEAR LIGHTS HAVE ONLY BEEN CHKED DURING THE LIGHTS TEST; OR WHEN THERE WAS AN ABNORMAL INDICATION WITH THE FORWARD PANEL DOWN AND LOCKED LIGHTS. IN ORDER TO PREVENT THIS FROM OCCURRING IN THE FUTURE; I WOULD SUGGEST THAT THE MANUAL BE MODIFIED TO INCLUDE ALL 5 GREEN GEAR LIGHTS BE ILLUMINATED; AND MAKE THIS CHANGE AN EMPHASIS ITEM DURING RECURRENT TRAINING. KUDOS SHOULD BE GIVEN TO THE CREW MEMBER WHO FOUND THIS ISSUE; EVEN THOUGH IT WAS NOT PART OF THEIR FLOW OR CHK.
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.