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Attributes | |
ACN | 789592 |
Time | |
Date | 200805 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : takeoff roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 789592 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Resolutory Action | flight crew : diverted to another airport |
Consequence | other |
Factors | |
Maintenance | contributing factor : briefing performance deficiency : installation performance deficiency : non compliance with legal requirements performance deficiency : testing performance deficiency : inspection |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Approximately XA00 am I received a call that aircraft X was returning to the field due to a floating right #1 spoiler. The aircraft was flying en route to ZZZ1. There was a spoiler fault indicated. Passenger noted the spoiler somewhat raised. A 5 degree roll was indicated in the cockpit. Aircraft returned to the field because of the right #1 spoiler 'floating' in-flight and inducing a 5 degree bank angle. This was visually confirmed. I pulled up the amm procedures for right and right of the spoiler to give the mechanics some initial reference to the job at hand. Hearing that the aircraft was in range I went to hangar to obtain the special tool. I was given the tool as well as a homemade tool many mechanics used. I was also alerted to the fact many mechanics in base would lock the spoiler in bypass while replacing a main landing gear. Upon arriving back at the gate; the mechanics advised me that in fact the spoiler was still in bypass. I gave the mechanic the proper tool but it could not be inserted with the spoiler in bypass. I then gave the mechanic the homemade tool to use to take the spoiler out of bypass. Several mechanics then took turns using the correct tool to lock and unlock the spoiler to get the feel of it. So while the homemade tool was used to take the spoiler out of bypass; the correct tool was used to make the final step in locking the spoiler in the proper position. I then went inside to pull up the reference from the MEL book for MEL'ing a spoiler; but barely got inside the door when the mechanics called on the radio that the job was complete. I had them confirm the spoiler operation was visually correct outside; on ECAM and that no faults displayed. I also had them try to physically lift that right #1 spoiler but it remained down as it should have. I then scanned through the maintenance manual spoiler activation/deactivation pages and determined all necessary steps had been accomplished. When I told person X we did not use the referenced maintenance manual pages; it was because we did not have it at the aircraft or follow it step by step. I did use it to verify the necessary steps to confirm proper operation of the spoilers. I simply neglected to include the task reference in my sign off. The aircraft had been in heavy maintenance for main landing gear replacement. An unknown mechanic used a homemade tool to put the right #1 spoiler in bypass to facilitate the gear replacement. No paperwork was generated to call this to anyone's attention. The spoiler was never restored to flight condition. There is no foolproof way of preventing such incidents aside from modifying the spoiler actuator to create a fault signal whenever the spoiler actuator is not in the flight position.
Original NASA ASRS Text
Title: AN AIRBUS A320 ACFT RETURNED TO FIELD DUE TO THE R #1 SPOILER 'FLOATING' AND INDUCING A 5-DEGREE BANK ANGLE DUE TO ACTUATOR STILL IN 'BYPASS' POS. LEAD MECHANIC SUGGESTS AIRBUS CONSIDER MODIFYING SPOILER ACTUATORS.
Narrative: APPROX XA00 AM I RECEIVED A CALL THAT ACFT X WAS RETURNING TO THE FIELD DUE TO A FLOATING R #1 SPOILER. THE ACFT WAS FLYING ENRTE TO ZZZ1. THERE WAS A SPOILER FAULT INDICATED. PAX NOTED THE SPOILER SOMEWHAT RAISED. A 5 DEG ROLL WAS INDICATED IN THE COCKPIT. ACFT RETURNED TO THE FIELD BECAUSE OF THE R #1 SPOILER 'FLOATING' INFLT AND INDUCING A 5 DEG BANK ANGLE. THIS WAS VISUALLY CONFIRMED. I PULLED UP THE AMM PROCS FOR R AND R OF THE SPOILER TO GIVE THE MECHS SOME INITIAL REF TO THE JOB AT HAND. HEARING THAT THE ACFT WAS IN RANGE I WENT TO HANGAR TO OBTAIN THE SPECIAL TOOL. I WAS GIVEN THE TOOL AS WELL AS A HOMEMADE TOOL MANY MECHS USED. I WAS ALSO ALERTED TO THE FACT MANY MECHS IN BASE WOULD LOCK THE SPOILER IN BYPASS WHILE REPLACING A MAIN LNDG GEAR. UPON ARRIVING BACK AT THE GATE; THE MECHS ADVISED ME THAT IN FACT THE SPOILER WAS STILL IN BYPASS. I GAVE THE MECH THE PROPER TOOL BUT IT COULD NOT BE INSERTED WITH THE SPOILER IN BYPASS. I THEN GAVE THE MECH THE HOMEMADE TOOL TO USE TO TAKE THE SPOILER OUT OF BYPASS. SEVERAL MECHS THEN TOOK TURNS USING THE CORRECT TOOL TO LOCK AND UNLOCK THE SPOILER TO GET THE FEEL OF IT. SO WHILE THE HOMEMADE TOOL WAS USED TO TAKE THE SPOILER OUT OF BYPASS; THE CORRECT TOOL WAS USED TO MAKE THE FINAL STEP IN LOCKING THE SPOILER IN THE PROPER POS. I THEN WENT INSIDE TO PULL UP THE REF FROM THE MEL BOOK FOR MEL'ING A SPOILER; BUT BARELY GOT INSIDE THE DOOR WHEN THE MECHS CALLED ON THE RADIO THAT THE JOB WAS COMPLETE. I HAD THEM CONFIRM THE SPOILER OP WAS VISUALLY CORRECT OUTSIDE; ON ECAM AND THAT NO FAULTS DISPLAYED. I ALSO HAD THEM TRY TO PHYSICALLY LIFT THAT R #1 SPOILER BUT IT REMAINED DOWN AS IT SHOULD HAVE. I THEN SCANNED THROUGH THE MAINT MANUAL SPOILER ACTIVATION/DEACTIVATION PAGES AND DETERMINED ALL NECESSARY STEPS HAD BEEN ACCOMPLISHED. WHEN I TOLD PERSON X WE DID NOT USE THE REFED MAINT MANUAL PAGES; IT WAS BECAUSE WE DID NOT HAVE IT AT THE ACFT OR FOLLOW IT STEP BY STEP. I DID USE IT TO VERIFY THE NECESSARY STEPS TO CONFIRM PROPER OP OF THE SPOILERS. I SIMPLY NEGLECTED TO INCLUDE THE TASK REF IN MY SIGN OFF. THE ACFT HAD BEEN IN HVY MAINT FOR MAIN LNDG GEAR REPLACEMENT. AN UNKNOWN MECH USED A HOMEMADE TOOL TO PUT THE R #1 SPOILER IN BYPASS TO FACILITATE THE GEAR REPLACEMENT. NO PAPERWORK WAS GENERATED TO CALL THIS TO ANYONE'S ATTN. THE SPOILER WAS NEVER RESTORED TO FLT CONDITION. THERE IS NO FOOLPROOF WAY OF PREVENTING SUCH INCIDENTS ASIDE FROM MODIFYING THE SPOILER ACTUATOR TO CREATE A FAULT SIGNAL WHENEVER THE SPOILER ACTUATOR IS NOT IN THE FLT POS.
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.