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|
Attributes | |
ACN | 794956 |
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 | |
Controlling Facilities | tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet 700 ER&LR |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | other |
Function | maintenance : technician |
ASRS Report | 794956 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : stall messages |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : briefing performance deficiency : testing performance deficiency : inspection performance deficiency : scheduled maintenance performance deficiency : non compliance with legal requirements performance deficiency : installation |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
On jul/xa/08; third shift; I was assigned to aircraft to right&right an APU fire extinguisher bottle for hydrostatic testing. After completing the fire bottle task; I moved over to help P2 do an air data computer functional test on the same aircraft. I proceeded to do step a(5-7) adjusting the angle of attack vanes to read less than 11 degrees on the mdc called out on work card 34. I could not get the angle of attack vane on the right side of the aircraft to stay stationary so I applied a 2 inch piece of speed tape to the forward side of the vane and cupped it around to hold the vane in position. Note that I was unaware of the lockout device procedure outlined in the gpm. I also failed to tell P2 that a piece of tape was attached to the angle of attack vane and did not document the lockout or mark the lockout where it would easily be seen by anyone else. The plane left out that morning and the tape was missed by the taxi and flight crew. In-flight; the crew received cautions for stall but still made it to ZZZ where the tape was removed. In-flight; the crew received what I believe to be a stall disagreement message on the EICAS. After landing in ZZZ; maintenance ran a test on the stall protection system which checked good but found the 2 inch piece of tape on the r-hand angle of attack vane. Maintenance then removed the tape from the angle of attach vane. The event occurred because I did not mark the taped angle of attack with a visible streamer. I ailed to mention the tape being on the vane to P2 and was not aware of the lockout procedures in the gpm. Also; there were complications with the test and the aircraft was rescheduled to an earlier flight; to the best of my knowledge; which made the task a little more time-pressed. I forgot about the taped vane in the mix of the things trying to get the job finished. I suggest following lockout procedures; better communication with co-workers and marking the vane with a streamer. Also annotating the lockout in the logbook or non-routine work card; which I plan to do in the future.callback conversation with reporter revealed the following information: reporter stated there is not a specific lockout tool for the aoa vane on the crj-700; at least he's never seen one. The reference to a lockout was meant to mean; whenever one is securing the aoa vane; to keep it from moving; while performing a test procedure; to always attach a streamer to the aoa or material used as a lockout.
Original NASA ASRS Text
Title: A CRJ-700 FLT CREW RECEIVED CAUTIONS FOR STALL AND STALL DISAGREE MESSAGE ON THEIR EICAS DISPLAYS. MECHANIC HAD TAPED THE RH AOA VANE DURING A TEST ON THE ADC; BUT DID NOT ATTACH A STREAMER OR DOCUMENT TAPE.
Narrative: ON JUL/XA/08; THIRD SHIFT; I WAS ASSIGNED TO ACFT TO R&R AN APU FIRE EXTINGUISHER BOTTLE FOR HYDROSTATIC TESTING. AFTER COMPLETING THE FIRE BOTTLE TASK; I MOVED OVER TO HELP P2 DO AN ADC FUNCTIONAL TEST ON THE SAME ACFT. I PROCEEDED TO DO STEP A(5-7) ADJUSTING THE ANGLE OF ATTACK VANES TO READ LESS THAN 11 DEGS ON THE MDC CALLED OUT ON WORK CARD 34. I COULD NOT GET THE ANGLE OF ATTACK VANE ON THE R SIDE OF THE ACFT TO STAY STATIONARY SO I APPLIED A 2 INCH PIECE OF SPD TAPE TO THE FORWARD SIDE OF THE VANE AND CUPPED IT AROUND TO HOLD THE VANE IN POS. NOTE THAT I WAS UNAWARE OF THE LOCKOUT DEVICE PROC OUTLINED IN THE GPM. I ALSO FAILED TO TELL P2 THAT A PIECE OF TAPE WAS ATTACHED TO THE ANGLE OF ATTACK VANE AND DID NOT DOCUMENT THE LOCKOUT OR MARK THE LOCKOUT WHERE IT WOULD EASILY BE SEEN BY ANYONE ELSE. THE PLANE LEFT OUT THAT MORNING AND THE TAPE WAS MISSED BY THE TAXI AND FLT CREW. INFLT; THE CREW RECEIVED CAUTIONS FOR STALL BUT STILL MADE IT TO ZZZ WHERE THE TAPE WAS REMOVED. INFLT; THE CREW RECEIVED WHAT I BELIEVE TO BE A STALL DISAGREEMENT MESSAGE ON THE EICAS. AFTER LNDG IN ZZZ; MAINT RAN A TEST ON THE STALL PROTECTION SYS WHICH CHKED GOOD BUT FOUND THE 2 INCH PIECE OF TAPE ON THE R-HAND ANGLE OF ATTACK VANE. MAINT THEN REMOVED THE TAPE FROM THE ANGLE OF ATTACH VANE. THE EVENT OCCURRED BECAUSE I DID NOT MARK THE TAPED ANGLE OF ATTACK WITH A VISIBLE STREAMER. I AILED TO MENTION THE TAPE BEING ON THE VANE TO P2 AND WAS NOT AWARE OF THE LOCKOUT PROCS IN THE GPM. ALSO; THERE WERE COMPLICATIONS WITH THE TEST AND THE ACFT WAS RESCHEDULED TO AN EARLIER FLT; TO THE BEST OF MY KNOWLEDGE; WHICH MADE THE TASK A LITTLE MORE TIME-PRESSED. I FORGOT ABOUT THE TAPED VANE IN THE MIX OF THE THINGS TRYING TO GET THE JOB FINISHED. I SUGGEST FOLLOWING LOCKOUT PROCS; BETTER COM WITH CO-WORKERS AND MARKING THE VANE WITH A STREAMER. ALSO ANNOTATING THE LOCKOUT IN THE LOGBOOK OR NON-ROUTINE WORK CARD; WHICH I PLAN TO DO IN THE FUTURE.CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED THERE IS NOT A SPECIFIC LOCKOUT TOOL FOR THE AOA VANE ON THE CRJ-700; AT LEAST HE'S NEVER SEEN ONE. THE REFERENCE TO A LOCKOUT WAS MEANT TO MEAN; WHENEVER ONE IS SECURING THE AOA VANE; TO KEEP IT FROM MOVING; WHILE PERFORMING A TEST PROCEDURE; TO ALWAYS ATTACH A STREAMER TO THE AOA OR MATERIAL USED AS A LOCKOUT.
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.