37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 769781 |
Time | |
Date | 200801 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A319 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked |
Person 1 | |
Affiliation | other |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 769781 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | other other : 1 |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : briefing performance deficiency : installation performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
My co-worker (mr X) and I volunteered to work on aircraft X. The work package on that aircraft had multiple job assigned to it. One of the jobs were replacing the N1 sensor on engine #2. After replacing the sensor; mr X and I dropped the cowling. However; we never latched it closed. I advised mr X that the latches should be closed while we were running the engine. Mr X suggested we leave it unlatched since we still needed to check for leaks on the sensor after the run. At this point; mr Y and I went to run the engine while mr X was giving us clearance. After a satisfactory run; we shut the engine down and I gave mr X a thumbs up from the cockpit. Mr X then started walking towards the engine. I took this to mean that he was checking for leaks and latching the cowls closed. Mr Y and I stayed in the cockpit and began the FMGC load; since we were already up there. Mr X came up to the cockpit as we were finishing up the FMGC load. As we were xferring data from FMC1 to FMC2; our co-worker; mr Z; came from gate Z asking for some assistance. All 3 of us left aircraft X on gate B and proceeded to aircraft Y on gate a. After about 1 hour; I went back to retrieve the FMGC loader. It was XA20 and knowing that the flight was to depart at XB00 I quickly went to the office and began signing off all the necessary paperwork. As I was signing off the logbooks with my employee number; the captain started to call for his books. I was supposed to wake up the aircraft and deliver the logbooks to the captain but we got another gate call. My lead decided that he would take the books up to gate B; while I went ahead to answer the captain on the new gate. I came back to the office and was asked to tow the airplanes at overnight parking to the gates. At this point it's XC30; and 1/2 hour past my scheduled shift; so I punched out and left the airport. At approximately XD30; I began to wonder whether or not mr X did in fact close the latches. I called the station and asked for mr X's number so I could confirm with him and when I spoke to mr X he couldn't confirm that he closed them. I then went ahead and tried to call mr Y to see if the pilot had picked it up on his walkaround and if mr Y himself had closed them or not. Mr Y didn't pick up; so I left a message for him to call me right away because it was very important. At this point; I called our station supervisor and told him what had happened. I asked him to track aircraft X to make sure that it made it to its destination safely and have a mechanic check on the latches to confirm they were securely closed. He advised me that he hadn't heard anything yet but that he'd check to make sure and call me right back. 1 hour later; the supervisor returned my phone call. He stated that the aircraft did make it to its destination safely; however; the cowlings snapped off and caused major aircraft damage. After assessing the whole situation; I strongly believe that distraction and miscom led to this unfortunate incident. In the future; I think that the following corrective actions may help prevent similar incidents: walkarounds (which are routine checks on the interior and exterior of the aircraft prior to departure); are a must regardless of the situation. Always complete your assigned tasks prior to helping your fellow co-workers. Doublechk/triplechk the work before signing with your employee number. Callback conversation with reporter revealed the following information: reporter stated they are contract maintenance employees performing overnight maintenance for a 121 carrier. The whole chain of events began with distractions and mis-communication between himself and his work partner. As a result; the engine fan cowl latches were never fully closed and secured after they replaced the N-1 sensor on #2 engine. Reporter also stated he was told by management that a passenger had informed a flight attendant after takeoff that the engine cowl was loose and moving. Shortly thereafter; one section of the fan cowl departed the engine. Flight continued and on landing the remaining cowl tore loose and was believed to be the cowl that caused major damage to the horizontal stabilizer of the A319.this same cowl also landed back on the same runway and was promptly run over by a B757; blowing out two tires on the B757 that was following the A319. The eec for the #2 engine on the A319 was also damaged and required replacement. Reporter added the post maintenance walk around procedure is a routine check of the aircraft's interior and exterior that is supposed to be done by a mechanic who has not worked the same aircraft. This standard company procedure had not been accomplished. The flight crew walk around also missed the hanging fan cowl latches. Reporter was the only sign-off on the maintenance paperwork.
Original NASA ASRS Text
Title: BOTH FAN COWLINGS ON AN AIRBUS A319 ACFT DEPARTED #2 ENG CAUSING MAJOR HORIZ STAB DAMAGE ON THE A319 AND BLOWN TIRES ON A FOLLOWING B757 ACFT.
Narrative: MY CO-WORKER (MR X) AND I VOLUNTEERED TO WORK ON ACFT X. THE WORK PACKAGE ON THAT ACFT HAD MULTIPLE JOB ASSIGNED TO IT. ONE OF THE JOBS WERE REPLACING THE N1 SENSOR ON ENG #2. AFTER REPLACING THE SENSOR; MR X AND I DROPPED THE COWLING. HOWEVER; WE NEVER LATCHED IT CLOSED. I ADVISED MR X THAT THE LATCHES SHOULD BE CLOSED WHILE WE WERE RUNNING THE ENG. MR X SUGGESTED WE LEAVE IT UNLATCHED SINCE WE STILL NEEDED TO CHK FOR LEAKS ON THE SENSOR AFTER THE RUN. AT THIS POINT; MR Y AND I WENT TO RUN THE ENG WHILE MR X WAS GIVING US CLRNC. AFTER A SATISFACTORY RUN; WE SHUT THE ENG DOWN AND I GAVE MR X A THUMBS UP FROM THE COCKPIT. MR X THEN STARTED WALKING TOWARDS THE ENG. I TOOK THIS TO MEAN THAT HE WAS CHKING FOR LEAKS AND LATCHING THE COWLS CLOSED. MR Y AND I STAYED IN THE COCKPIT AND BEGAN THE FMGC LOAD; SINCE WE WERE ALREADY UP THERE. MR X CAME UP TO THE COCKPIT AS WE WERE FINISHING UP THE FMGC LOAD. AS WE WERE XFERRING DATA FROM FMC1 TO FMC2; OUR CO-WORKER; MR Z; CAME FROM GATE Z ASKING FOR SOME ASSISTANCE. ALL 3 OF US LEFT ACFT X ON GATE B AND PROCEEDED TO ACFT Y ON GATE A. AFTER ABOUT 1 HR; I WENT BACK TO RETRIEVE THE FMGC LOADER. IT WAS XA20 AND KNOWING THAT THE FLT WAS TO DEPART AT XB00 I QUICKLY WENT TO THE OFFICE AND BEGAN SIGNING OFF ALL THE NECESSARY PAPERWORK. AS I WAS SIGNING OFF THE LOGBOOKS WITH MY EMPLOYEE NUMBER; THE CAPT STARTED TO CALL FOR HIS BOOKS. I WAS SUPPOSED TO WAKE UP THE ACFT AND DELIVER THE LOGBOOKS TO THE CAPT BUT WE GOT ANOTHER GATE CALL. MY LEAD DECIDED THAT HE WOULD TAKE THE BOOKS UP TO GATE B; WHILE I WENT AHEAD TO ANSWER THE CAPT ON THE NEW GATE. I CAME BACK TO THE OFFICE AND WAS ASKED TO TOW THE AIRPLANES AT OVERNIGHT PARKING TO THE GATES. AT THIS POINT IT'S XC30; AND 1/2 HR PAST MY SCHEDULED SHIFT; SO I PUNCHED OUT AND LEFT THE ARPT. AT APPROX XD30; I BEGAN TO WONDER WHETHER OR NOT MR X DID IN FACT CLOSE THE LATCHES. I CALLED THE STATION AND ASKED FOR MR X'S NUMBER SO I COULD CONFIRM WITH HIM AND WHEN I SPOKE TO MR X HE COULDN'T CONFIRM THAT HE CLOSED THEM. I THEN WENT AHEAD AND TRIED TO CALL MR Y TO SEE IF THE PLT HAD PICKED IT UP ON HIS WALKAROUND AND IF MR Y HIMSELF HAD CLOSED THEM OR NOT. MR Y DIDN'T PICK UP; SO I LEFT A MESSAGE FOR HIM TO CALL ME RIGHT AWAY BECAUSE IT WAS VERY IMPORTANT. AT THIS POINT; I CALLED OUR STATION SUPVR AND TOLD HIM WHAT HAD HAPPENED. I ASKED HIM TO TRACK ACFT X TO MAKE SURE THAT IT MADE IT TO ITS DEST SAFELY AND HAVE A MECH CHK ON THE LATCHES TO CONFIRM THEY WERE SECURELY CLOSED. HE ADVISED ME THAT HE HADN'T HEARD ANYTHING YET BUT THAT HE'D CHK TO MAKE SURE AND CALL ME RIGHT BACK. 1 HR LATER; THE SUPVR RETURNED MY PHONE CALL. HE STATED THAT THE ACFT DID MAKE IT TO ITS DEST SAFELY; HOWEVER; THE COWLINGS SNAPPED OFF AND CAUSED MAJOR ACFT DAMAGE. AFTER ASSESSING THE WHOLE SITUATION; I STRONGLY BELIEVE THAT DISTR AND MISCOM LED TO THIS UNFORTUNATE INCIDENT. IN THE FUTURE; I THINK THAT THE FOLLOWING CORRECTIVE ACTIONS MAY HELP PREVENT SIMILAR INCIDENTS: WALKAROUNDS (WHICH ARE ROUTINE CHKS ON THE INTERIOR AND EXTERIOR OF THE ACFT PRIOR TO DEP); ARE A MUST REGARDLESS OF THE SITUATION. ALWAYS COMPLETE YOUR ASSIGNED TASKS PRIOR TO HELPING YOUR FELLOW CO-WORKERS. DOUBLECHK/TRIPLECHK THE WORK BEFORE SIGNING WITH YOUR EMPLOYEE NUMBER. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED THEY ARE CONTRACT MAINT EMPLOYEES PERFORMING OVERNIGHT MAINT FOR A 121 CARRIER. THE WHOLE CHAIN OF EVENTS BEGAN WITH DISTRACTIONS AND MIS-COMMUNICATION BETWEEN HIMSELF AND HIS WORK PARTNER. AS A RESULT; THE ENG FAN COWL LATCHES WERE NEVER FULLY CLOSED AND SECURED AFTER THEY REPLACED THE N-1 SENSOR ON #2 ENG. REPORTER ALSO STATED HE WAS TOLD BY MANAGEMENT THAT A PASSENGER HAD INFORMED A FLIGHT ATTENDANT AFTER TKOF THAT THE ENG COWL WAS LOOSE AND MOVING. SHORTLY THEREAFTER; ONE SECTION OF THE FAN COWL DEPARTED THE ENGINE. FLIGHT CONTINUED AND ON LANDING THE REMAINING COWL TORE LOOSE AND WAS BELIEVED TO BE THE COWL THAT CAUSED MAJOR DAMAGE TO THE HORIZONTAL STAB OF THE A319.THIS SAME COWL ALSO LANDED BACK ON THE SAME RUNWAY AND WAS PROMPTLY RUN OVER BY A B757; BLOWING OUT TWO TIRES ON THE B757 THAT WAS FOLLOWING THE A319. THE EEC FOR THE #2 ENG ON THE A319 WAS ALSO DAMAGED AND REQUIRED REPLACEMENT. REPORTER ADDED THE POST MAINT WALK AROUND PROCEDURE IS A ROUTINE CHECK OF THE ACFT'S INTERIOR AND EXTERIOR THAT IS SUPPOSED TO BE DONE BY A MECHANIC WHO HAS NOT WORKED THE SAME ACFT. THIS STANDARD COMPANY PROCEDURE HAD NOT BEEN ACCOMPLISHED. THE FLIGHT CREW WALK AROUND ALSO MISSED THE HANGING FAN COWL LATCHES. REPORTER WAS THE ONLY SIGN-OFF ON THE MAINT PAPERWORK.
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.