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Attributes | |
ACN | 723676 |
Time | |
Date | 200701 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 723676 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 723997 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals contributing factor : schedule pressure contributing factor : work cards performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : scheduled maintenance performance deficiency : inspection |
Supplementary | |
Problem Areas | Aircraft Chart Or Publication Environmental Factor Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I was asked to assist with a stall warning task card. I had been assigned 2 services by myself and our crew was overloaded with work including numerous aircraft repos. When I arrived at aircraft; XA00; mr X and mr Y had already installed the pitot probe adapters to both upper pitots. The aoa (angle of attack) protractors were also installed. I applied tape to the l-hand lower pitot. Mr X applied tape to the r-hand pitot. When I applied the tape I did not leave a tail or streamer on the end. It had been about 8 yrs since I last taped a pitot. We performed the test uninterrupted and once passed had begun to remove the test equipment. I removed the pitot adapter first; then the aoa protractor. To avoid dropping the aoa protractor; I stepped down from the ladder and put it in its box. At this time my lead mechanic stopped by to take the protractors back to the hangar. My lead had been telling me that another mechanic on my crew; might need help. While we were talking; mr X said he would put the 2 screws back in the aoa mounting flange on my side (l-hand) that were removed to install the protractors. I left to assist on other aircraft. Obviously; I assumed lead would remove the tape and he probably thought I would remove it or he didn't see it without the tail; and I'm sure he thought either myself or mr X had removed it and he probably would never had seen it without shining a light on the probe. Ultimately I was informed about this incident on the next night by my manager. I feel this incident could have been avoided if there had been better communication between all involved and had I been using brightly colored tape with a 'tail' on it. I am fully aware how serious this situation is; and am grateful no one was harmed considering what the possible outcome could have been. I will be sure to never assume my teammates will complete a task. I will verify myself and better communicate with fellow teammates in the future. I will also never use black tape with or without a tail on a pitot again. We do stock yellow and red/white vinyl tape and my golf cart is now stocked with both. Callback conversation with reporter revealed the following information: the job assigned was to assist in a stall warning test job card. The reporter applied tape to static ports on the lower left pitot probe and began the test procedure. As the job was closing up the reporter removed the pitot tube adapter and the angle of attack sensor but failed to remove the tape covering the probe static port. The reporter talked to the system engineer and the job cards and maintenance manual will be revised for a step added to remove the tape and add a bright colored tape for visibility. Callback conversation with reporter acn 723997 revealed the following information: the workload was very heavy and as the stall warning test was finishing and the test equipment removal was in progress; the lead technician assigned two of us (the mechanics) to another aircraft. The reporter had taped the upper right pitot static probe static ports and remembers removing the black tape. The job card has a step to tape the ports but nothing to remove the tape. It is reported the job card will be revised.
Original NASA ASRS Text
Title: A B737-300 WAS DISPATCHED WITH THE L LOWER PITOT AND STATIC PORTS TAPED. ACFT RETURNED TO THE DEP ARPT.
Narrative: I WAS ASKED TO ASSIST WITH A STALL WARNING TASK CARD. I HAD BEEN ASSIGNED 2 SVCS BY MYSELF AND OUR CREW WAS OVERLOADED WITH WORK INCLUDING NUMEROUS ACFT REPOS. WHEN I ARRIVED AT ACFT; XA00; MR X AND MR Y HAD ALREADY INSTALLED THE PITOT PROBE ADAPTERS TO BOTH UPPER PITOTS. THE AOA (ANGLE OF ATTACK) PROTRACTORS WERE ALSO INSTALLED. I APPLIED TAPE TO THE L-HAND LOWER PITOT. MR X APPLIED TAPE TO THE R-HAND PITOT. WHEN I APPLIED THE TAPE I DID NOT LEAVE A TAIL OR STREAMER ON THE END. IT HAD BEEN ABOUT 8 YRS SINCE I LAST TAPED A PITOT. WE PERFORMED THE TEST UNINTERRUPTED AND ONCE PASSED HAD BEGUN TO REMOVE THE TEST EQUIP. I REMOVED THE PITOT ADAPTER FIRST; THEN THE AOA PROTRACTOR. TO AVOID DROPPING THE AOA PROTRACTOR; I STEPPED DOWN FROM THE LADDER AND PUT IT IN ITS BOX. AT THIS TIME MY LEAD MECH STOPPED BY TO TAKE THE PROTRACTORS BACK TO THE HANGAR. MY LEAD HAD BEEN TELLING ME THAT ANOTHER MECH ON MY CREW; MIGHT NEED HELP. WHILE WE WERE TALKING; MR X SAID HE WOULD PUT THE 2 SCREWS BACK IN THE AOA MOUNTING FLANGE ON MY SIDE (L-HAND) THAT WERE REMOVED TO INSTALL THE PROTRACTORS. I LEFT TO ASSIST ON OTHER ACFT. OBVIOUSLY; I ASSUMED LEAD WOULD REMOVE THE TAPE AND HE PROBABLY THOUGHT I WOULD REMOVE IT OR HE DIDN'T SEE IT WITHOUT THE TAIL; AND I'M SURE HE THOUGHT EITHER MYSELF OR MR X HAD REMOVED IT AND HE PROBABLY WOULD NEVER HAD SEEN IT WITHOUT SHINING A LIGHT ON THE PROBE. ULTIMATELY I WAS INFORMED ABOUT THIS INCIDENT ON THE NEXT NIGHT BY MY MGR. I FEEL THIS INCIDENT COULD HAVE BEEN AVOIDED IF THERE HAD BEEN BETTER COM BTWN ALL INVOLVED AND HAD I BEEN USING BRIGHTLY COLORED TAPE WITH A 'TAIL' ON IT. I AM FULLY AWARE HOW SERIOUS THIS SITUATION IS; AND AM GRATEFUL NO ONE WAS HARMED CONSIDERING WHAT THE POSSIBLE OUTCOME COULD HAVE BEEN. I WILL BE SURE TO NEVER ASSUME MY TEAMMATES WILL COMPLETE A TASK. I WILL VERIFY MYSELF AND BETTER COMMUNICATE WITH FELLOW TEAMMATES IN THE FUTURE. I WILL ALSO NEVER USE BLACK TAPE WITH OR WITHOUT A TAIL ON A PITOT AGAIN. WE DO STOCK YELLOW AND RED/WHITE VINYL TAPE AND MY GOLF CART IS NOW STOCKED WITH BOTH. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE JOB ASSIGNED WAS TO ASSIST IN A STALL WARNING TEST JOB CARD. THE RPTR APPLIED TAPE TO STATIC PORTS ON THE LOWER L PITOT PROBE AND BEGAN THE TEST PROC. AS THE JOB WAS CLOSING UP THE RPTR REMOVED THE PITOT TUBE ADAPTER AND THE ANGLE OF ATTACK SENSOR BUT FAILED TO REMOVE THE TAPE COVERING THE PROBE STATIC PORT. THE RPTR TALKED TO THE SYS ENGINEER AND THE JOB CARDS AND MAINT MANUAL WILL BE REVISED FOR A STEP ADDED TO REMOVE THE TAPE AND ADD A BRIGHT COLORED TAPE FOR VISIBILITY. CALLBACK CONVERSATION WITH RPTR ACN 723997 REVEALED THE FOLLOWING INFO: THE WORKLOAD WAS VERY HVY AND AS THE STALL WARNING TEST WAS FINISHING AND THE TEST EQUIP REMOVAL WAS IN PROGRESS; THE LEAD TECHNICIAN ASSIGNED TWO OF US (THE MECHS) TO ANOTHER ACFT. THE RPTR HAD TAPED THE UPPER R PITOT STATIC PROBE STATIC PORTS AND REMEMBERS REMOVING THE BLACK TAPE. THE JOB CARD HAS A STEP TO TAPE THE PORTS BUT NOTHING TO REMOVE THE TAPE. IT IS RPTED THE JOB CARD WILL BE REVISED.
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.