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A maintenance supervisor reports that a B717-200 left engine thrust reverser did not deploy on landing. The reverser did not have the lockout 'remove before flight' streamer hanging out of the thrust reverser control panel.
| Attributes | |
| ACN | 794528 |
| Time | |
| Date | 200807 |
| 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 | B717 (Formerly MD-95) |
| Operating Under FAR Part | Part 121 |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | other personnel other oversight : supervisor |
| ASRS Report | 794528 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
| Independent Detector | other other : 1 |
| Resolutory Action | none taken : detected after the fact |
| Consequence | other |
| Factors | |
| Maintenance | contributing factor : briefing performance deficiency : logbook entry performance deficiency : inspection performance deficiency : non compliance with legal requirements |
| Supplementary | |
| Problem Areas | Aircraft Company Flight Crew Human Performance Maintenance Human Performance |
| Primary Problem | Maintenance Human Performance |
Narrative:
In the early morning; aircraft X's maintenance logbook was being closed out and the maintenance work was being completed. There had been log discrepancies for the right thrust reverser being locked out; those discrepancies were signed off. An additional block in the logbook had been initialed that the thrust reversers were locked out. Assuming that it had been used as an additional log for the right; I signed them off not aware that it had also been used to lock out the left thrust reverser. Upon landing; the thrust reverser did not deploy. Maintenance control was notified and the thrust reverser was un-bypassed. The thrust reverser did not have the lockout 'remove before flight' streamer hanging out of the door. This would have caught the attention of the maintenance crew working on the aircraft that morning as well as the flight crew during preflight. Maintenance personnel should ensure that any streamers attached to lockout pins should be visible when components are locked out and all maintenance actions should be investigated before signing them off and not assumed that they were a part of other maintenance that was closed out.
Original NASA ASRS Text
Title: A MAINT SUPERVISOR REPORTS THAT A B717-200 LEFT ENGINE THRUST REVERSER DID NOT DEPLOY ON LANDING. THE REVERSER DID NOT HAVE THE LOCKOUT 'REMOVE BEFORE FLIGHT' STREAMER HANGING OUT OF THE THRUST REVERSER CONTROL PANEL.
Narrative: IN THE EARLY MORNING; ACFT X'S MAINT LOGBOOK WAS BEING CLOSED OUT AND THE MAINT WORK WAS BEING COMPLETED. THERE HAD BEEN LOG DISCREPANCIES FOR THE R THRUST REVERSER BEING LOCKED OUT; THOSE DISCREPANCIES WERE SIGNED OFF. AN ADDITIONAL BLOCK IN THE LOGBOOK HAD BEEN INITIALED THAT THE THRUST REVERSERS WERE LOCKED OUT. ASSUMING THAT IT HAD BEEN USED AS AN ADDITIONAL LOG FOR THE R; I SIGNED THEM OFF NOT AWARE THAT IT HAD ALSO BEEN USED TO LOCK OUT THE L THRUST REVERSER. UPON LNDG; THE THRUST REVERSER DID NOT DEPLOY. MAINT CTL WAS NOTIFIED AND THE THRUST REVERSER WAS UN-BYPASSED. THE THRUST REVERSER DID NOT HAVE THE LOCKOUT 'REMOVE BEFORE FLT' STREAMER HANGING OUT OF THE DOOR. THIS WOULD HAVE CAUGHT THE ATTN OF THE MAINT CREW WORKING ON THE ACFT THAT MORNING AS WELL AS THE FLT CREW DURING PREFLT. MAINT PERSONNEL SHOULD ENSURE THAT ANY STREAMERS ATTACHED TO LOCKOUT PINS SHOULD BE VISIBLE WHEN COMPONENTS ARE LOCKED OUT AND ALL MAINT ACTIONS SHOULD BE INVESTIGATED BEFORE SIGNING THEM OFF AND NOT ASSUMED THAT THEY WERE A PART OF OTHER MAINT THAT WAS CLOSED OUT.
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.