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|
Attributes | |
ACN | 776025 |
Time | |
Date | 200802 |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 776025 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 776024 |
Events | |
Anomaly | 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 |
Factors | |
Maintenance | contributing factor : lighting contributing factor : tooling contributing factor : briefing performance deficiency : testing performance deficiency : training performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : installation |
Supplementary | |
Problem Areas | Company Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
I was assigned a maintenance service and the RAT check with another mechanic. We finished most of the service and began to set up for the RAT check. I installed the RAT cage and utilized a blanket for a pad to prevent abrasion to the lower fuselage. The blanket was secured with upward pressure from the RAT cage. The initial spin-up sucked the blanket and made contact with the blade. I went to inspect the RAT and found the edge/tip curled. The damage was immediately reported to my lead. The known factor on this shift is the continuous feeling of fatigue with a general poor lighting condition everywhere. The lack of formal training and infrequency led to uncertainty. The missing pad on the RAT cage led to a compromise with the blanket. Supplemental information from acn 776024: he then jacked the cage up and pinned the blanket against the fuselage with just an inch or two inside the cage. Somehow during RAT spin-up; the blanket was drawn into the cage and got caught in RAT and bent a blade tip. Also; I was not actually involved in the setup. I just happened to observe the cage after the setup was complete.
Original NASA ASRS Text
Title: AN AIRBUS A320 MECHANIC DESCRIBES THE EVENTS THAT LED TO THE ACFT'S EMERGENCY RAT MOTOR BLADES BEING DAMAGED DURING INITIAL SPIN UP BY A BLANKET BEING SUCKED INTO THE BLADES.
Narrative: I WAS ASSIGNED A MAINT SVC AND THE RAT CHK WITH ANOTHER MECH. WE FINISHED MOST OF THE SVC AND BEGAN TO SET UP FOR THE RAT CHK. I INSTALLED THE RAT CAGE AND UTILIZED A BLANKET FOR A PAD TO PREVENT ABRASION TO THE LOWER FUSELAGE. THE BLANKET WAS SECURED WITH UPWARD PRESSURE FROM THE RAT CAGE. THE INITIAL SPIN-UP SUCKED THE BLANKET AND MADE CONTACT WITH THE BLADE. I WENT TO INSPECT THE RAT AND FOUND THE EDGE/TIP CURLED. THE DAMAGE WAS IMMEDIATELY RPTED TO MY LEAD. THE KNOWN FACTOR ON THIS SHIFT IS THE CONTINUOUS FEELING OF FATIGUE WITH A GENERAL POOR LIGHTING CONDITION EVERYWHERE. THE LACK OF FORMAL TRAINING AND INFREQUENCY LED TO UNCERTAINTY. THE MISSING PAD ON THE RAT CAGE LED TO A COMPROMISE WITH THE BLANKET. SUPPLEMENTAL INFO FROM ACN 776024: HE THEN JACKED THE CAGE UP AND PINNED THE BLANKET AGAINST THE FUSELAGE WITH JUST AN INCH OR TWO INSIDE THE CAGE. SOMEHOW DURING RAT SPIN-UP; THE BLANKET WAS DRAWN INTO THE CAGE AND GOT CAUGHT IN RAT AND BENT A BLADE TIP. ALSO; I WAS NOT ACTUALLY INVOLVED IN THE SETUP. I JUST HAPPENED TO OBSERVE THE CAGE AFTER THE SETUP WAS COMPLETE.
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.