37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 938958 |
Time | |
Date | 201103 |
Local Time Of Day | 0001-0600 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Light | Night |
Aircraft 1 | |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | Parked |
Component | |
Aircraft Component | AC Generator/Alternator |
Person 1 | |
Function | Technician |
Qualification | Maintenance Airframe Maintenance Powerplant |
Events | |
Anomaly | Aircraft Equipment Problem Critical Deviation - Procedural Published Material / Policy |
Narrative:
During an operational check of an aircraft air driven generator (air driven generator); the hydraulic mule used to power the air driven generator; had a hydraulic return line come disconnected; and sprayed high pressure hydraulic fluid on personnel and aircraft. Mechanic X was operating the hydraulic mule. He was unaware at the time that heavy maintenance visit (hmv) personnel had just used the mule in a different configuration to flush an aircraft hydraulic system.mechanic X was using his approved task card to perform the operational check; however the card failed to direct him to another card located on the mule about the proper positioning of the valves on the mule for his task. These valves are located on the other side of the mule from the normal operational controls. When mechanic X started the mule and began to apply pressure to the system; a hydraulic return line separated from it's connection spraying both personnel and aircraft. The mule's hydraulic return line has been reattached using substandard radiator clamps; and a 'splash shield' installed by company personnel. The reason given for using the weak radiator clamps is so that the line separates there; and not somewhere else; making it sound like there is a safety device on the equipment that is inoperable and the clamp is a substandard workaround.this is the third time in approximately a year that this exact [type of] incident has happened at least once; sending multiple personnel to the hospital.there needs to be clear procedures laid out in the task card for the air driven generator operational check to [include] checking positions of all [hydraulic mule] valves prior to powering up the mule. The instructions should be in one place and clearly written; by the manufacture of the mule; and not company personnel who [only] just have experience with the equipment. A complete check of the mule needs to be performed on the mule; to ensure all the manufactures safety devices are in proper working order. If the hose is designed th pop-off its connection (I doubt); then there needs to be a better method to contain the spray of fluid.
Original NASA ASRS Text
Title: During a hangar Operational Check of an aircraft's Air Driven Generator (ADG); the Hydraulic Mule [external hydraulic pressure source] used to power the ADG; had a hydraulic return line come disconnected and sprayed high pressure hydraulic fluid on personnel and aircraft. Lack of clear operating procedures for the ADG in their ADG Task Card also a factor.
Narrative: During an Operational Check of an aircraft Air Driven Generator (ADG); the Hydraulic Mule used to power the ADG; had a hydraulic return line come disconnected; and sprayed high pressure hydraulic fluid on personnel and aircraft. Mechanic X was operating the Hydraulic Mule. He was unaware at the time that Heavy Maintenance Visit (HMV) personnel had just used the Mule in a different configuration to flush an aircraft hydraulic system.Mechanic X was using his approved Task Card to perform the Operational Check; however the card failed to direct him to another card located on the Mule about the proper positioning of the valves on the Mule for his task. These valves are located on the other side of the Mule from the normal operational controls. When Mechanic X started the Mule and began to apply pressure to the system; a hydraulic return line separated from it's connection spraying both personnel and aircraft. The Mule's hydraulic return line has been reattached using substandard radiator clamps; and a 'splash shield' installed by company personnel. The reason given for using the weak radiator clamps is so that the line separates there; and not somewhere else; making it sound like there is a safety device on the equipment that is inoperable and the clamp is a substandard workaround.This is the third time in approximately a year that this exact [type of] incident has happened at least once; sending multiple personnel to the hospital.There needs to be clear procedures laid out in the Task Card for the ADG Operational Check to [include] checking positions of all [Hydraulic Mule] valves prior to powering up the Mule. The instructions should be in one place and clearly written; by the Manufacture of the Mule; and not company personnel who [only] just have experience with the equipment. A complete check of the Mule needs to be performed on the Mule; to ensure all the manufactures safety devices are in proper working order. If the hose is designed th pop-off its connection (I doubt); then there needs to be a better method to contain the spray of fluid.
Data retrieved from NASA's ASRS site as of April 2012 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.