37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 803983 |
Time | |
Date | 200809 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B717 (Formerly MD-95) |
Operating Under FAR Part | Part 121 |
Flight Phase | landing : roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
ASRS Report | 803987 |
Person 2 | |
Affiliation | other |
Function | flight attendant : on duty |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : left rev did not deploy other flight crewa |
Consequence | other |
Factors | |
Maintenance | performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
Sep 08; flight #ab ZZZ1-ZZZ; aircraft X. Upon landing in ZZZ; our left thrust reverser did not deploy and we got the level 1 alert -- reverser left fault; with a consequence of 'thrust reverser may not deploy.' we landed without incident and taxied to the gate. Contract maintenance was called and they discovered that the left thrust reverser hydraulic shutoff lever (which is located behind the thrust reverser hydraulic servicing access panel) was positioned incorrectly causing the thrust reverser fault. Contract maintenance coordination with maintenance control and the left thrust reverser hydraulic shutoff lever was positioned correctly. After checking both the current and previous aircraft logbooks; no entries were found that would indicate any hydraulic or thrust reverser malfunctions that would require the movement of the left thrust reverser hydraulic shutoff lever. Aircraft X had just been released to service earlier that morning; after the completion of an airworthiness inspection. Maintenance personnel should review their procedures before releasing an aircraft into service. Callback conversation with reporter revealed the following information: reporter stated the left engine reverser control is accessed through the left side of the fuselage tail section below the left engine strut. Reporter asked the contract maintenance mechanic to visually point out the control handle and the correct; or 'normal'; position the handle should be in. Handle lever in the horizontal position was the 'normal' mode. But also noticed; was how little movement of the handle; perhaps 45 degrees or less of handle rotation would position the control valve to abnormal or lockout mode. Reporter stated the difference in handle position between 'normal' and 'abnormal' was barely noticeable and believed this could easily be missed by anyone. The unused lockout safety pin did not appear to have a safety streamer attached. Currently their flight crews are only using idle reverse during landing due to fuel costs. Reporter also stated part of their required security safety walkaround checks include looking inside certain access panel areas of the external fuselage.
Original NASA ASRS Text
Title: UPON LANDING A B717-200 (MD-95); PILOT REPORTS THE LEFT THRUST REVERSER DID NOT DEPLOY WITH A LEVEL ONE ALERT FAULT. THIS WAS FIRST FLIGHT FOR ACFT OUT OF MAINT CHECK.
Narrative: SEP 08; FLT #AB ZZZ1-ZZZ; ACFT X. UPON LNDG IN ZZZ; OUR L THRUST REVERSER DID NOT DEPLOY AND WE GOT THE LEVEL 1 ALERT -- REVERSER L FAULT; WITH A CONSEQUENCE OF 'THRUST REVERSER MAY NOT DEPLOY.' WE LANDED WITHOUT INCIDENT AND TAXIED TO THE GATE. CONTRACT MAINT WAS CALLED AND THEY DISCOVERED THAT THE L THRUST REVERSER HYD SHUTOFF LEVER (WHICH IS LOCATED BEHIND THE THRUST REVERSER HYD SVCING ACCESS PANEL) WAS POSITIONED INCORRECTLY CAUSING THE THRUST REVERSER FAULT. CONTRACT MAINT COORD WITH MAINT CTL AND THE L THRUST REVERSER HYD SHUTOFF LEVER WAS POSITIONED CORRECTLY. AFTER CHKING BOTH THE CURRENT AND PREVIOUS ACFT LOGBOOKS; NO ENTRIES WERE FOUND THAT WOULD INDICATE ANY HYD OR THRUST REVERSER MALFUNCTIONS THAT WOULD REQUIRE THE MOVEMENT OF THE L THRUST REVERSER HYD SHUTOFF LEVER. ACFT X HAD JUST BEEN RELEASED TO SVC EARLIER THAT MORNING; AFTER THE COMPLETION OF AN AIRWORTHINESS INSPECTION. MAINT PERSONNEL SHOULD REVIEW THEIR PROCS BEFORE RELEASING AN ACFT INTO SVC. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER STATED THE LEFT ENGINE REVERSER CONTROL IS ACCESSED THROUGH THE LEFT SIDE OF THE FUSELAGE TAIL SECTION BELOW THE LEFT ENG STRUT. REPORTER ASKED THE CONTRACT MAINT MECHANIC TO VISUALLY POINT OUT THE CONTROL HANDLE AND THE CORRECT; OR 'NORMAL'; POSITION THE HANDLE SHOULD BE IN. HANDLE LEVER IN THE HORIZ POSITION WAS THE 'NORMAL' MODE. BUT ALSO NOTICED; WAS HOW LITTLE MOVEMENT OF THE HANDLE; PERHAPS 45 DEGREES OR LESS OF HANDLE ROTATION WOULD POSITION THE CONTROL VALVE TO ABNORMAL OR LOCKOUT MODE. REPORTER STATED THE DIFFERENCE IN HANDLE POSITION BETWEEN 'NORMAL' AND 'ABNORMAL' WAS BARELY NOTICEABLE AND BELIEVED THIS COULD EASILY BE MISSED BY ANYONE. THE UNUSED LOCKOUT SAFETY PIN DID NOT APPEAR TO HAVE A SAFETY STREAMER ATTACHED. CURRENTLY THEIR FLIGHT CREWS ARE ONLY USING IDLE REVERSE DURING LANDING DUE TO FUEL COSTS. REPORTER ALSO STATED PART OF THEIR REQUIRED SECURITY SAFETY WALKAROUND CHECKS INCLUDE LOOKING INSIDE CERTAIN ACCESS PANEL AREAS OF THE EXTERNAL FUSELAGE.
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.