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|
Attributes | |
ACN | 768722 |
Time | |
Date | 200801 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : taxi ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 768722 |
Person 2 | |
Affiliation | company : air carrier |
Function | oversight : supervisor |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact other |
Consequence | other |
Factors | |
Maintenance | contributing factor : briefing performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : repair |
Supplementary | |
Problem Areas | Company Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
When we landed we had maintenance fix the stall protection panel. It was not fully secure because the fastener was broken. The mechanic came out with 2 other mechanics. The lead mechanic sat in the first officer seat while I was in the captain seat. I sat and watched the mechanic bring in the cockpit a yellow dewalt drill with a small bit; a rivet tool; a personal leatherman; a screwdriver with a black handle; a flashlight; and a small ziplock bag with new backing plates and rivets in it. He placed all of these items on the center pedestal and started working on the panel by drilling out the old backing plates. After a while I left the cockpit and the lead mechanic doing all the work said it will be done when you get back. I came back approximately 30 mins later and I reviewed the logbook and we departed on time for ZZZ. While taxiing out to runway 13 we heard a clunking sound coming from the rudder pedal area every time we made a turn. We got to the runway and asked to return to the gate. When we got back to the gate I debriefed the mechanic in detail and wrote it up in the maintenance log. We sat and waited approximately 15-20 mins and they decided to swap the aircraft. We deplaned and after everyone got off and while we were packing our kit bags I got a flashlight to check and make sure we removed everything and also take a quick look at the rudder pedal area because I noticed none of the mechanics never even looked in that area while they were troubleshooting. Then I noticed a shiny object in back of the captain's right rudder pedal and when I looked closer; it was the screwdriver that the mechanic was using to fix the stall panel that he put on the center pedestal. I had operations send out the maintenance supervisor to show him what I had found. My whole crew also saw this black handle screwdriver. The maintenance supervisor along with the 2 mechanics who were troubleshooting aircraft X saw the screwdriver. The maintenance supervisor said he would get to the bottom of it and apologized. The next day we were assigned the same aircraft. While I was reviewing the logbook as per company policy I noticed what was written in the corrective action box of my write-up and it floored me. Maintenance replaced both nose landing gear tires. Maintenance made no entry as to the sound was caused by FOD in the cockpit because of a mechanic's screwdriver that was left behind mistakenly. They wasted thousands of dollars of company resources to cover up a mechanic's gross negligence and unsafe maintenance practices that could have resulted in a flight control jam and caused the aircraft to be uncontrollable and crash. I was very clear with maintenance with what I described to them about the clunking sound. I did not state that I had vibration coming from the nose landing gear. I did not state that I heard a clunking sound coming from the strut or nose landing gear area. I told the passenger when we got to the next aircraft exactly what happened because they were very upset at the delay and wanted to know what the problem was. Unsatisfactory maintenance practices caused by negligence and unethical behavior. Also; a very poor maintenance tool inventory program or a non existent one. Mandate that air carrier maintenance start a tool inventory program that has a tool crib monitor with chits for all mechanics like the military line maintenance organizations do. Also outlaw all personal tools like leathermans etc. Mandate that after any work is done all tools must be turned back in to the tool crib for inventory and if anything is missing then the aircraft that the mechanic was working on is grounded until the tool is found and accounted for.
Original NASA ASRS Text
Title: AN EMB135LR (ERJ135LR) PILOT BELIEVES MAINT COVERED-UP GROSS NEGLIGENCE AND UNSAFE MAINT PRACTICES BY UNNECESSARILY CHANGING BOTH NOSE TIRES WHEN MECHANIC'S SCREWDRIVER FOUND FWD OF CAPT'S PEDALS.
Narrative: WHEN WE LANDED WE HAD MAINT FIX THE STALL PROTECTION PANEL. IT WAS NOT FULLY SECURE BECAUSE THE FASTENER WAS BROKEN. THE MECH CAME OUT WITH 2 OTHER MECHS. THE LEAD MECH SAT IN THE FO SEAT WHILE I WAS IN THE CAPT SEAT. I SAT AND WATCHED THE MECH BRING IN THE COCKPIT A YELLOW DEWALT DRILL WITH A SMALL BIT; A RIVET TOOL; A PERSONAL LEATHERMAN; A SCREWDRIVER WITH A BLACK HANDLE; A FLASHLIGHT; AND A SMALL ZIPLOCK BAG WITH NEW BACKING PLATES AND RIVETS IN IT. HE PLACED ALL OF THESE ITEMS ON THE CTR PEDESTAL AND STARTED WORKING ON THE PANEL BY DRILLING OUT THE OLD BACKING PLATES. AFTER A WHILE I LEFT THE COCKPIT AND THE LEAD MECH DOING ALL THE WORK SAID IT WILL BE DONE WHEN YOU GET BACK. I CAME BACK APPROX 30 MINS LATER AND I REVIEWED THE LOGBOOK AND WE DEPARTED ON TIME FOR ZZZ. WHILE TAXIING OUT TO RWY 13 WE HEARD A CLUNKING SOUND COMING FROM THE RUDDER PEDAL AREA EVERY TIME WE MADE A TURN. WE GOT TO THE RWY AND ASKED TO RETURN TO THE GATE. WHEN WE GOT BACK TO THE GATE I DEBRIEFED THE MECH IN DETAIL AND WROTE IT UP IN THE MAINT LOG. WE SAT AND WAITED APPROX 15-20 MINS AND THEY DECIDED TO SWAP THE ACFT. WE DEPLANED AND AFTER EVERYONE GOT OFF AND WHILE WE WERE PACKING OUR KIT BAGS I GOT A FLASHLIGHT TO CHK AND MAKE SURE WE REMOVED EVERYTHING AND ALSO TAKE A QUICK LOOK AT THE RUDDER PEDAL AREA BECAUSE I NOTICED NONE OF THE MECHS NEVER EVEN LOOKED IN THAT AREA WHILE THEY WERE TROUBLESHOOTING. THEN I NOTICED A SHINY OBJECT IN BACK OF THE CAPT'S R RUDDER PEDAL AND WHEN I LOOKED CLOSER; IT WAS THE SCREWDRIVER THAT THE MECH WAS USING TO FIX THE STALL PANEL THAT HE PUT ON THE CTR PEDESTAL. I HAD OPS SEND OUT THE MAINT SUPVR TO SHOW HIM WHAT I HAD FOUND. MY WHOLE CREW ALSO SAW THIS BLACK HANDLE SCREWDRIVER. THE MAINT SUPVR ALONG WITH THE 2 MECHS WHO WERE TROUBLESHOOTING ACFT X SAW THE SCREWDRIVER. THE MAINT SUPVR SAID HE WOULD GET TO THE BOTTOM OF IT AND APOLOGIZED. THE NEXT DAY WE WERE ASSIGNED THE SAME ACFT. WHILE I WAS REVIEWING THE LOGBOOK AS PER COMPANY POLICY I NOTICED WHAT WAS WRITTEN IN THE CORRECTIVE ACTION BOX OF MY WRITE-UP AND IT FLOORED ME. MAINT REPLACED BOTH NOSE LNDG GEAR TIRES. MAINT MADE NO ENTRY AS TO THE SOUND WAS CAUSED BY FOD IN THE COCKPIT BECAUSE OF A MECH'S SCREWDRIVER THAT WAS LEFT BEHIND MISTAKENLY. THEY WASTED THOUSANDS OF DOLLARS OF COMPANY RESOURCES TO COVER UP A MECH'S GROSS NEGLIGENCE AND UNSAFE MAINT PRACTICES THAT COULD HAVE RESULTED IN A FLT CTL JAM AND CAUSED THE ACFT TO BE UNCONTROLLABLE AND CRASH. I WAS VERY CLR WITH MAINT WITH WHAT I DESCRIBED TO THEM ABOUT THE CLUNKING SOUND. I DID NOT STATE THAT I HAD VIBRATION COMING FROM THE NOSE LNDG GEAR. I DID NOT STATE THAT I HEARD A CLUNKING SOUND COMING FROM THE STRUT OR NOSE LNDG GEAR AREA. I TOLD THE PAX WHEN WE GOT TO THE NEXT ACFT EXACTLY WHAT HAPPENED BECAUSE THEY WERE VERY UPSET AT THE DELAY AND WANTED TO KNOW WHAT THE PROB WAS. UNSATISFACTORY MAINT PRACTICES CAUSED BY NEGLIGENCE AND UNETHICAL BEHAVIOR. ALSO; A VERY POOR MAINT TOOL INVENTORY PROGRAM OR A NON EXISTENT ONE. MANDATE THAT ACR MAINT START A TOOL INVENTORY PROGRAM THAT HAS A TOOL CRIB MONITOR WITH CHITS FOR ALL MECHS LIKE THE MIL LINE MAINT ORGANIZATIONS DO. ALSO OUTLAW ALL PERSONAL TOOLS LIKE LEATHERMANS ETC. MANDATE THAT AFTER ANY WORK IS DONE ALL TOOLS MUST BE TURNED BACK IN TO THE TOOL CRIB FOR INVENTORY AND IF ANYTHING IS MISSING THEN THE ACFT THAT THE MECH WAS WORKING ON IS GROUNDED UNTIL THE TOOL IS FOUND AND ACCOUNTED FOR.
Data retrieved from NASA's ASRS site as of May 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.