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|
Attributes | |
ACN | 801732 |
Time | |
Date | 200807 |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Flight Phase | ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
ASRS Report | 801732 |
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 other |
Factors | |
Maintenance | contributing factor : briefing performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
The night began with my assignment to aircraft 1SV; log 1 (lavatory will not hold water). Borescope inspection #1 engine. L-hand overwing slide replacement flight arrived at XA20. I accomplished the 1SV; log 1; and had the borescope 95% accomplished. Only the cowlings to close. After the l-hand slide replacement; during retracting of the flaps; the trailing edge l-hand flap was damaged by the belt loader. The maintenance manual 25-65-01 had no reference on how to get the slide in place. I had a lot of work at that time of night and too many things going on at once. The last and only step I missed was to find a guide man to clear the flaps. 20 yrs with airline and it only took 1 second to miss a major step. Always think of any things that are in place; and always get clearance from a second set of eyes. Callback conversation with reporter revealed the following information: reporter stated after reaching in and pulling out a big diaper from the lav dump chute and accomplishing a #1 engine borescope inspection; he completed the lh overwing slide replacement by using a cargo belt loader and protective pad. The belt loader helped him move the slide to the upper inboard wing surface and also position the slide pack onto the swing-out slide support tray; mounted inside the external fuselage. Reporter stated he did move the belt loader away from the aircraft; although there was another truck directly behind the belt loader; limiting his backup area. He left the belt loader platform itself in a raised slanted position; believing he probably had enough clearance to raise the flaps. Because he didn't get a guide man to verify flap clearance as they were retracted; the upper surface of the flap struck the lower surface of the raised belt loader platform.
Original NASA ASRS Text
Title: AFTER CHANGING A LH OVERWING SLIDE ON A B757-200; A MECHANIC DESCRIBES THE EVENTS THAT LED TO THE LH TRAILING EDGE FLAP BEING DAMAGED BY CONTACT WITH A CARGO BELT LOADER.
Narrative: THE NIGHT BEGAN WITH MY ASSIGNMENT TO ACFT 1SV; LOG 1 (LAVATORY WILL NOT HOLD WATER). BORESCOPE INSPECTION #1 ENG. L-HAND OVERWING SLIDE REPLACEMENT FLT ARRIVED AT XA20. I ACCOMPLISHED THE 1SV; LOG 1; AND HAD THE BORESCOPE 95% ACCOMPLISHED. ONLY THE COWLINGS TO CLOSE. AFTER THE L-HAND SLIDE REPLACEMENT; DURING RETRACTING OF THE FLAPS; THE TRAILING EDGE L-HAND FLAP WAS DAMAGED BY THE BELT LOADER. THE MAINT MANUAL 25-65-01 HAD NO REF ON HOW TO GET THE SLIDE IN PLACE. I HAD A LOT OF WORK AT THAT TIME OF NIGHT AND TOO MANY THINGS GOING ON AT ONCE. THE LAST AND ONLY STEP I MISSED WAS TO FIND A GUIDE MAN TO CLR THE FLAPS. 20 YRS WITH AIRLINE AND IT ONLY TOOK 1 SECOND TO MISS A MAJOR STEP. ALWAYS THINK OF ANY THINGS THAT ARE IN PLACE; AND ALWAYS GET CLRNC FROM A SECOND SET OF EYES. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED AFTER REACHING IN AND PULLING OUT A BIG DIAPER FROM THE LAV DUMP CHUTE AND ACCOMPLISHING A #1 ENGINE BORESCOPE INSPECTION; HE COMPLETED THE LH OVERWING SLIDE REPLACEMENT BY USING A CARGO BELT LOADER AND PROTECTIVE PAD. THE BELT LOADER HELPED HIM MOVE THE SLIDE TO THE UPPER INBOARD WING SURFACE AND ALSO POSITION THE SLIDE PACK ONTO THE SWING-OUT SLIDE SUPPORT TRAY; MOUNTED INSIDE THE EXTERNAL FUSELAGE. REPORTER STATED HE DID MOVE THE BELT LOADER AWAY FROM THE ACFT; ALTHOUGH THERE WAS ANOTHER TRUCK DIRECTLY BEHIND THE BELT LOADER; LIMITING HIS BACKUP AREA. HE LEFT THE BELT LOADER PLATFORM ITSELF IN A RAISED SLANTED POSITION; BELIEVING HE PROBABLY HAD ENOUGH CLEARANCE TO RAISE THE FLAPS. BECAUSE HE DIDN'T GET A GUIDE MAN TO VERIFY FLAP CLEARANCE AS THEY WERE RETRACTED; THE UPPER SURFACE OF THE FLAP STRUCK THE LOWER SURFACE OF THE RAISED BELT LOADER PLATFORM.
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.