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|
Attributes | |
ACN | 761199 |
Time | |
Date | 200711 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzzz.airport |
State Reference | FO |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | landing : roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 761199 |
Person 2 | |
Affiliation | other |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa other other : 2 |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : briefing contributing factor : tooling performance deficiency : scheduled maintenance performance deficiency : testing performance deficiency : non compliance with legal requirements performance deficiency : inspection |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
After landing in ZZZZ; the first officer (PNF) called out 'spoilers; no reverser #2.' I compensated for braking on the rollout. The tower advised us to do a 180 degree turn and back-taxi to the ramp; expediting for inbound landing traffic. Due to our time constraints; there was no time to try to see if #2 reverser would deploy on a ground test. Short taxi to the ramp left no time or safety for a ramp check. On engine second engine shutdown; we received a printed postflt report saying; 'fault message XXXX; thrust reverser sov/hcu/HC2.' we notified maintenance control via ACARS of the situation. We were told maintenance would be called to the airport. The station manager was able to locate the air carrier X mechanic who would be dealing with our problem and told us that he would be at our aircraft in less than 20 mins. Maintenance control asked; via ACARS; if we could start an engine and see if we could deploy the #2 thrust reverser. We advised him that we would be unable to perform the check; due to passenger boarding all surrounding aircraft via the ramp. We also stated that the mechanic was on his way to our aircraft. The mechanic was previously working on an A320 next to us. He spoke no english. So we used our station manager to translate our problem to him. We also had the MEL manual opened for reference and interpretation. Maintenance control faxed over maintenance procedures that they wanted the mechanic to perform. After opening the #2 engine cowl doors; he notified me that the hydraulic control unit lockout pin was 'still installed.' there also was no streamer attached to the pin. Obviously; this is what prompted the hcu #1 and #2 fault after engine shutdown and no reverser deployment. I spoke to maintenance control; via the station manager's cell phone; and had the mechanic accomplish all the checks required by maintenance; including visual confirmation of the reverser deployment on the #2 engine; and the closing and locking of the aircraft cowl doors. All proper logbook entries were entered verbatim; via maintenance control; with the air carrier X mechanic signing both log pages. Although the mechanic spoke no english; it was obvious that he was completely familiar with the A320 by the way he methodically moved through the mcdu during his system tests. Luckily; this aircraft was not dispatched with an unknown reverser locked out to an airport with a contaminated/short runway. The outcome would have been dramatically different. I suggest that; just as the landing gear pins when installed and removed; and the engine cowl flap doors when opened and latched closed; must be entered into the maintenance log; then so too should a hydraulic control unit lockout pin be entered into the logbook. Keep in mind that the streamer was missing from this pin; which I'm certain was a key factor to the oversight.
Original NASA ASRS Text
Title: AN AIRBUS A320 #2 ENGINE REVERSER DID NOT DEPLOY ON LANDING. THE HYD CONTROL UNIT LOCKOUT PIN WAS STILL INSTALLED WITHOUT A STREAMER ATTACHED.
Narrative: AFTER LNDG IN ZZZZ; THE FO (PNF) CALLED OUT 'SPOILERS; NO REVERSER #2.' I COMPENSATED FOR BRAKING ON THE ROLLOUT. THE TWR ADVISED US TO DO A 180 DEG TURN AND BACK-TAXI TO THE RAMP; EXPEDITING FOR INBOUND LNDG TFC. DUE TO OUR TIME CONSTRAINTS; THERE WAS NO TIME TO TRY TO SEE IF #2 REVERSER WOULD DEPLOY ON A GND TEST. SHORT TAXI TO THE RAMP LEFT NO TIME OR SAFETY FOR A RAMP CHK. ON ENG SECOND ENG SHUTDOWN; WE RECEIVED A PRINTED POSTFLT RPT SAYING; 'FAULT MESSAGE XXXX; THRUST REVERSER SOV/HCU/HC2.' WE NOTIFIED MAINT CTL VIA ACARS OF THE SITUATION. WE WERE TOLD MAINT WOULD BE CALLED TO THE ARPT. THE STATION MGR WAS ABLE TO LOCATE THE ACR X MECH WHO WOULD BE DEALING WITH OUR PROB AND TOLD US THAT HE WOULD BE AT OUR ACFT IN LESS THAN 20 MINS. MAINT CTL ASKED; VIA ACARS; IF WE COULD START AN ENG AND SEE IF WE COULD DEPLOY THE #2 THRUST REVERSER. WE ADVISED HIM THAT WE WOULD BE UNABLE TO PERFORM THE CHK; DUE TO PAX BOARDING ALL SURROUNDING ACFT VIA THE RAMP. WE ALSO STATED THAT THE MECH WAS ON HIS WAY TO OUR ACFT. THE MECH WAS PREVIOUSLY WORKING ON AN A320 NEXT TO US. HE SPOKE NO ENGLISH. SO WE USED OUR STATION MGR TO TRANSLATE OUR PROB TO HIM. WE ALSO HAD THE MEL MANUAL OPENED FOR REF AND INTERP. MAINT CTL FAXED OVER MAINT PROCS THAT THEY WANTED THE MECH TO PERFORM. AFTER OPENING THE #2 ENG COWL DOORS; HE NOTIFIED ME THAT THE HYD CTL UNIT LOCKOUT PIN WAS 'STILL INSTALLED.' THERE ALSO WAS NO STREAMER ATTACHED TO THE PIN. OBVIOUSLY; THIS IS WHAT PROMPTED THE HCU #1 AND #2 FAULT AFTER ENG SHUTDOWN AND NO REVERSER DEPLOYMENT. I SPOKE TO MAINT CTL; VIA THE STATION MGR'S CELL PHONE; AND HAD THE MECH ACCOMPLISH ALL THE CHKS REQUIRED BY MAINT; INCLUDING VISUAL CONFIRMATION OF THE REVERSER DEPLOYMENT ON THE #2 ENG; AND THE CLOSING AND LOCKING OF THE ACFT COWL DOORS. ALL PROPER LOGBOOK ENTRIES WERE ENTERED VERBATIM; VIA MAINT CTL; WITH THE ACR X MECH SIGNING BOTH LOG PAGES. ALTHOUGH THE MECH SPOKE NO ENGLISH; IT WAS OBVIOUS THAT HE WAS COMPLETELY FAMILIAR WITH THE A320 BY THE WAY HE METHODICALLY MOVED THROUGH THE MCDU DURING HIS SYS TESTS. LUCKILY; THIS ACFT WAS NOT DISPATCHED WITH AN UNKNOWN REVERSER LOCKED OUT TO AN ARPT WITH A CONTAMINATED/SHORT RWY. THE OUTCOME WOULD HAVE BEEN DRAMATICALLY DIFFERENT. I SUGGEST THAT; JUST AS THE LNDG GEAR PINS WHEN INSTALLED AND REMOVED; AND THE ENG COWL FLAP DOORS WHEN OPENED AND LATCHED CLOSED; MUST BE ENTERED INTO THE MAINT LOG; THEN SO TOO SHOULD A HYD CTL UNIT LOCKOUT PIN BE ENTERED INTO THE LOGBOOK. KEEP IN MIND THAT THE STREAMER WAS MISSING FROM THIS PIN; WHICH I'M CERTAIN WAS A KEY FACTOR TO THE OVERSIGHT.
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.