37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 704334 |
Time | |
Date | 200607 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : ogg.airport |
State Reference | HI |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : preflight |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 150 flight time total : 11200 flight time type : 511 |
ASRS Report | 704334 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance |
Independent Detector | other flight crewa |
Resolutory Action | other |
Consequence | other |
Supplementary | |
Problem Areas | Company Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On preflight discovered that a blocker door at the 11 O'clock position in the left engine was not stowed properly. Examined maintenance history and saw that this defect had occurred on a prior leg the same day. At this point; the ETOPS-qualified mechanic had already released the airplane. I entered a log item and asked maintenance to look at the dropping blocker door. He replied that it was deferred; but this was incorrect. The engine had an additional blocker door in the 5 O'clock position that was deferred and physically removed. The 11 O'clock position blocker door was a separate issue. They ended up removing this second blocker door and we departed 1 hour 30 mins late. En route; we asked maintenance about the procedures the mechanic must follow when releasing an aircraft for an ETOPS leg. The maintenance controller said the controling air carrier maintenance document instructs the mechanic to 'perform a general walkaround inspection to check for obvious damage or irregularities;' with no specific instructions to look inside the engine. My concern is that this defect was immediately obvious to anyone who looked up the back of the engine; yet apparently the mechanic isn't required to do so. An additional concern is that this item had history; and the mechanic still wasn't required to inspect it. I was always under the impression that the ETOPS-qualified mechanic had more specific inspection procedures with respect to the engines prior to releasing an aircraft for a 180 min ETOPS flight. They are; after all; kind of important system. Safety was not compromised because the crew caught this defect during the walkaround; but I feel that the mechanic should have easily seen it. Not his fault; though; if he wasn't required to look there. Perhaps the air carrier ETOPS maintenance procedures need to be amended to provide specific guidance to the mechanics in this area. If a critical item has maintenance history; it should be inspected. I hope this isn't a case of oversight due to cost-cutting and inadequate manpwr.
Original NASA ASRS Text
Title: A B767-300 FLT CREW ON WALKAROUND PRIOR TO AN ETOPS FLT DISCOVERED A L ENG BLOCKER DOOR WAS IMPROPERLY STOWED. THE ACFT HAD ALREADY BEEN SIGNED OFF BY AN STOPS MECH.
Narrative: ON PREFLT DISCOVERED THAT A BLOCKER DOOR AT THE 11 O'CLOCK POS IN THE L ENG WAS NOT STOWED PROPERLY. EXAMINED MAINT HISTORY AND SAW THAT THIS DEFECT HAD OCCURRED ON A PRIOR LEG THE SAME DAY. AT THIS POINT; THE ETOPS-QUALIFIED MECH HAD ALREADY RELEASED THE AIRPLANE. I ENTERED A LOG ITEM AND ASKED MAINT TO LOOK AT THE DROPPING BLOCKER DOOR. HE REPLIED THAT IT WAS DEFERRED; BUT THIS WAS INCORRECT. THE ENG HAD AN ADDITIONAL BLOCKER DOOR IN THE 5 O'CLOCK POS THAT WAS DEFERRED AND PHYSICALLY REMOVED. THE 11 O'CLOCK POS BLOCKER DOOR WAS A SEPARATE ISSUE. THEY ENDED UP REMOVING THIS SECOND BLOCKER DOOR AND WE DEPARTED 1 HR 30 MINS LATE. ENRTE; WE ASKED MAINT ABOUT THE PROCS THE MECH MUST FOLLOW WHEN RELEASING AN ACFT FOR AN ETOPS LEG. THE MAINT CTLR SAID THE CTLING ACR MAINT DOCUMENT INSTRUCTS THE MECH TO 'PERFORM A GENERAL WALKAROUND INSPECTION TO CHK FOR OBVIOUS DAMAGE OR IRREGULARITIES;' WITH NO SPECIFIC INSTRUCTIONS TO LOOK INSIDE THE ENG. MY CONCERN IS THAT THIS DEFECT WAS IMMEDIATELY OBVIOUS TO ANYONE WHO LOOKED UP THE BACK OF THE ENG; YET APPARENTLY THE MECH ISN'T REQUIRED TO DO SO. AN ADDITIONAL CONCERN IS THAT THIS ITEM HAD HISTORY; AND THE MECH STILL WASN'T REQUIRED TO INSPECT IT. I WAS ALWAYS UNDER THE IMPRESSION THAT THE ETOPS-QUALIFIED MECH HAD MORE SPECIFIC INSPECTION PROCS WITH RESPECT TO THE ENGS PRIOR TO RELEASING AN ACFT FOR A 180 MIN ETOPS FLT. THEY ARE; AFTER ALL; KIND OF IMPORTANT SYS. SAFETY WAS NOT COMPROMISED BECAUSE THE CREW CAUGHT THIS DEFECT DURING THE WALKAROUND; BUT I FEEL THAT THE MECH SHOULD HAVE EASILY SEEN IT. NOT HIS FAULT; THOUGH; IF HE WASN'T REQUIRED TO LOOK THERE. PERHAPS THE ACR ETOPS MAINT PROCS NEED TO BE AMENDED TO PROVIDE SPECIFIC GUIDANCE TO THE MECHS IN THIS AREA. IF A CRITICAL ITEM HAS MAINT HISTORY; IT SHOULD BE INSPECTED. I HOPE THIS ISN'T A CASE OF OVERSIGHT DUE TO COST-CUTTING AND INADEQUATE MANPWR.
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.