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|
Attributes | |
ACN | 725371 |
Time | |
Date | 200701 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night Dawn |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | MD-80 Series (DC-9-80) Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 725371 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
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 : 5 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : schedule pressure performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : logbook entry performance deficiency : inspection |
Supplementary | |
Problem Areas | Chart Or Publication Environmental Factor Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Upon completion of a check on aircraft I was left alone to sign off what was not already signed off of the package. Since the gate time for the airplane was fast approaching I took care of what needed to be signed off and took the plane to the gate. After we left it at the gate it was found that one of the thrust reverser's isolation valves had its pin in; leaving the thrust reverser inoperative. It's common practice to do so when doing work around the engine as was done that night. I however was not the one who worked on those engines; nor did I install the pins in the isolation valves. I have been told that I signed off on something to do with removal of those pins; but I was not shown exactly what it was. The only thing I can think of that would involve my stamp would be the final close card in which you verify that all panels; doors; etc; are closed on the airplane; which I did; and I don't recall seeing the access panel for the thrust reverser isolation valve to be open. I don't recall any other signoff specifically naming the thrust reversers. I am sure that there was a requirement on whatever task that required installation of those pins also required the removal of the same. I hope the paperwork can be examined to see where exactly the fault; or multiple faults were with this incident.
Original NASA ASRS Text
Title: AN MD80 CHK WAS PERFORMED BY 4 TECHNICIANS. CHK ROUTINE REQUIRES THRUST REVERSER ISOLATION VALVES BE PINNED FOR SAFETY. ACFT RELEASED FOR SVC WITH 1 THRUST REVERSER PINNED INOP.
Narrative: UPON COMPLETION OF A CHK ON ACFT I WAS LEFT ALONE TO SIGN OFF WHAT WAS NOT ALREADY SIGNED OFF OF THE PACKAGE. SINCE THE GATE TIME FOR THE AIRPLANE WAS FAST APCHING I TOOK CARE OF WHAT NEEDED TO BE SIGNED OFF AND TOOK THE PLANE TO THE GATE. AFTER WE LEFT IT AT THE GATE IT WAS FOUND THAT ONE OF THE THRUST REVERSER'S ISOLATION VALVES HAD ITS PIN IN; LEAVING THE THRUST REVERSER INOP. IT'S COMMON PRACTICE TO DO SO WHEN DOING WORK AROUND THE ENG AS WAS DONE THAT NIGHT. I HOWEVER WAS NOT THE ONE WHO WORKED ON THOSE ENGS; NOR DID I INSTALL THE PINS IN THE ISOLATION VALVES. I HAVE BEEN TOLD THAT I SIGNED OFF ON SOMETHING TO DO WITH REMOVAL OF THOSE PINS; BUT I WAS NOT SHOWN EXACTLY WHAT IT WAS. THE ONLY THING I CAN THINK OF THAT WOULD INVOLVE MY STAMP WOULD BE THE FINAL CLOSE CARD IN WHICH YOU VERIFY THAT ALL PANELS; DOORS; ETC; ARE CLOSED ON THE AIRPLANE; WHICH I DID; AND I DON'T RECALL SEEING THE ACCESS PANEL FOR THE THRUST REVERSER ISOLATION VALVE TO BE OPEN. I DON'T RECALL ANY OTHER SIGNOFF SPECIFICALLY NAMING THE THRUST REVERSERS. I AM SURE THAT THERE WAS A REQUIREMENT ON WHATEVER TASK THAT REQUIRED INSTALLATION OF THOSE PINS ALSO REQUIRED THE REMOVAL OF THE SAME. I HOPE THE PAPERWORK CAN BE EXAMINED TO SEE WHERE EXACTLY THE FAULT; OR MULTIPLE FAULTS WERE WITH THIS INCIDENT.
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.