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Attributes | |
ACN | 816117 |
Time | |
Date | 200811 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : airframe technician : powerplant |
ASRS Report | 816117 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : airframe |
ASRS Report | 815546 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : far |
Independent Detector | aircraft equipment other aircraft equipment : nose uplock indication failure |
Resolutory Action | flight crew : diverted to another airport |
Consequence | other |
Factors | |
Maintenance | contributing factor : work cards contributing factor : manuals contributing factor : briefing performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : testing performance deficiency : fault isolation performance deficiency : installation performance deficiency : inspection |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Narrative:
I worked the torque link on the nose gear that was out of limits so I had to install more shims. Going back together; I ran out of time and the job was not completed and I signed for 'C) adjust the play at 'J1' and/or 'J2' on the nose landing gear torque.' supplemental information from acn 815546: I was sent on emergency field service to accomplish nose landing gear strut seal replacement according to management. On initial inspection of nose gear; found no evidence of seal leakage of fluid. Contacted maintenance control and was directed to accomplish airbus maintenance tip procedure and a nose gear normal extension and retraction test. Test indications were good. Maintenance control directed to check target condition and security referencing ipc 32-21-11 page 13 item 50. Item 50 as suspected of not being there. Maintenance control faxed copies of this item in question and facsimile was of poor quality and hard to make sense of. Also by conversation with maintenance control it seemed that they knew from previous incidents of this problem; why else would they be specific to look for specific items. I was only told to look for one specific item. After completion of work done; called maintenance control and was told work was sufficient to return aircraft to service. Aircraft flew and returned back to ZZZ with no landing gear uplock indication. Aircraft ferried to maintenance control for repair. Maintenance control found bolt missing item 15 of ipc 32-21-11 page 8B-1. This bolt was never pointed out to me by maintenance clt in any conversation or facsimile sent to me. Callback conversation with reporter acn 816117 revealed the following information: reporter stated the problem appears to have started after he signed for the side play gap adjustment of the nose landing gear upper torque link to the landing gear attach lugs. Normally the centering pin with a 'dishpan' or cup is installed after the side play gap shims are installed and to secure and prevent the upper torque link attach bolt from migrating out and detaching from the nose gear strut. But his supervisor told him not to install the pin and cup assembly at that time; because the nose gear strut seals needed to be replaced which would require disconnection of at least; the lower torque link from the upper link. Reporter stated the centering pin and cup were never reinstalled. The nose gear job cards were not properly reviewed for completion after the strut seals had been replaced and the centering pin and cup were never reinstalled. The aircraft departed; only to have numerous flight faults that eventually ended up with an air turnback. Reporter stated the job cards need to be revised for better flow of the different work being accomplished on the nose gear during the aircraft's maintenance visit; but his carrier seems reluctant to make those changes.
Original NASA ASRS Text
Title: THREE MECHANICS REPORT ON THEIR INVOLVEMENT AND TROUBLE SHOOTING OF AN AIRBUS A320 THAT WAS FOUND WITH AN INCOMPLETE REASSEMBLY OF THE NOSE GEAR UPPER TORQUE LINK; CAUSING FAULTS ON NUMEROUS FLIGHTS; AN AIR TURNBACK AND A FERRY FLIGHT FOR MAINTENANCE REPAIRS.
Narrative: I WORKED THE TORQUE LINK ON THE NOSE GEAR THAT WAS OUT OF LIMITS SO I HAD TO INSTALL MORE SHIMS. GOING BACK TOGETHER; I RAN OUT OF TIME AND THE JOB WAS NOT COMPLETED AND I SIGNED FOR 'C) ADJUST THE PLAY AT 'J1' AND/OR 'J2' ON THE NOSE LNDG GEAR TORQUE.' SUPPLEMENTAL INFO FROM ACN 815546: I WAS SENT ON EMER FIELD SVC TO ACCOMPLISH NOSE LNDG GEAR STRUT SEAL REPLACEMENT ACCORDING TO MGMNT. ON INITIAL INSPECTION OF NOSE GEAR; FOUND NO EVIDENCE OF SEAL LEAKAGE OF FLUID. CONTACTED MAINT CTL AND WAS DIRECTED TO ACCOMPLISH AIRBUS MAINT TIP PROC AND A NOSE GEAR NORMAL EXTENSION AND RETRACTION TEST. TEST INDICATIONS WERE GOOD. MAINT CTL DIRECTED TO CHK TARGET CONDITION AND SECURITY REFING IPC 32-21-11 PAGE 13 ITEM 50. ITEM 50 AS SUSPECTED OF NOT BEING THERE. MAINT CTL FAXED COPIES OF THIS ITEM IN QUESTION AND FAX WAS OF POOR QUALITY AND HARD TO MAKE SENSE OF. ALSO BY CONVERSATION WITH MAINT CTL IT SEEMED THAT THEY KNEW FROM PREVIOUS INCIDENTS OF THIS PROB; WHY ELSE WOULD THEY BE SPECIFIC TO LOOK FOR SPECIFIC ITEMS. I WAS ONLY TOLD TO LOOK FOR ONE SPECIFIC ITEM. AFTER COMPLETION OF WORK DONE; CALLED MAINT CTL AND WAS TOLD WORK WAS SUFFICIENT TO RETURN ACFT TO SVC. ACFT FLEW AND RETURNED BACK TO ZZZ WITH NO LNDG GEAR UPLOCK INDICATION. ACFT FERRIED TO MAINT CTL FOR REPAIR. MAINT CTL FOUND BOLT MISSING ITEM 15 OF IPC 32-21-11 PAGE 8B-1. THIS BOLT WAS NEVER POINTED OUT TO ME BY MAINT CLT IN ANY CONVERSATION OR FAX SENT TO ME. CALLBACK CONVERSATION WITH RPTR ACN 816117 REVEALED THE FOLLOWING INFO: REPORTER STATED THE PROBLEM APPEARS TO HAVE STARTED AFTER HE SIGNED FOR THE SIDE PLAY GAP ADJUSTMENT OF THE NOSE LANDING GEAR UPPER TORQUE LINK TO THE LANDING GEAR ATTACH LUGS. NORMALLY THE CENTERING PIN WITH A 'DISHPAN' OR CUP IS INSTALLED AFTER THE SIDE PLAY GAP SHIMS ARE INSTALLED AND TO SECURE AND PREVENT THE UPPER TORQUE LINK ATTACH BOLT FROM MIGRATING OUT AND DETACHING FROM THE NOSE GEAR STRUT. BUT HIS SUPERVISOR TOLD HIM NOT TO INSTALL THE PIN AND CUP ASSEMBLY AT THAT TIME; BECAUSE THE NOSE GEAR STRUT SEALS NEEDED TO BE REPLACED WHICH WOULD REQUIRE DISCONNECTION OF AT LEAST; THE LOWER TORQUE LINK FROM THE UPPER LINK. REPORTER STATED THE CENTERING PIN AND CUP WERE NEVER REINSTALLED. THE NOSE GEAR JOB CARDS WERE NOT PROPERLY REVIEWED FOR COMPLETION AFTER THE STRUT SEALS HAD BEEN REPLACED AND THE CENTERING PIN AND CUP WERE NEVER REINSTALLED. THE AIRCRAFT DEPARTED; ONLY TO HAVE NUMEROUS FLIGHT FAULTS THAT EVENTUALLY ENDED UP WITH AN AIR TURNBACK. REPORTER STATED THE JOB CARDS NEED TO BE REVISED FOR BETTER FLOW OF THE DIFFERENT WORK BEING ACCOMPLISHED ON THE NOSE GEAR DURING THE AIRCRAFT'S MAINTENANCE VISIT; BUT HIS CARRIER SEEMS RELUCTANT TO MAKE THOSE CHANGES.
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.